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Roll-out of Intensified TB Case Finding in Rwanda Greet Vandebriel, MD, MPH Track 1.0 Meeting Washington DC August 11 – 12, 2008 CIDC Rwanda 9 million people 83% rural Adult HIV prevalence = 3.1% 193,000 people living with HIV/AIDS By May 2008 >100 000 receiving HIV care

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Roll-out of Intensified TB Case Finding in Rwanda

Greet Vandebriel, MD, MPH

Track 1.0 Meeting

Washington DC

August 11 – 12, 2008

  • CIDC

  • Rwanda

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9 million people

83% rural

Adult HIV prevalence = 3.1%

193,000 people living with HIV/AIDS

By May 2008

>100 000 receiving HIV care

> 55 000 on anti-retroviral therapy (ART)

38% of TB patients are HIV-infected


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Intensified TB Case Finding (ICF) at National Level

  • National policy on TB/HIV collaboration approved in 2005

    • Including systematic screening of all HIV-infected patients for active TB disease and to link all suspects to TB diagnosis and therapy

  • National TB/HIV working group established

  • Program guidelines, tools and training materials revised to incorporate ICF

  • Standardized recording and reporting system on ICF developed

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ICF at Facility Level

  • HIV care and treatment Clinic

    • TB screening by use of 5 question checklist

    • Transfer/Accompany TB cases to TB Clinic for treatment

  • Screening for TB at community level by peer educators

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Rolling out ICF to Sites Nationwide

  • Implementation of ICF as part of the TB/HIV Integration package at 2 model centers

  • TB/HIV national WG adopted the model for TB/HIV Integration as national model

  • Harmonization of the approach between HIV Implementing Partners

  • Visits for Clinical Partners (USG, GF) to Model centers

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… to Sites Nationwide

  • TB/HIV training curriculum developed for TB and HIV nurses and training conducted at district level

  • Practical hands-on training sessions at Model Centers

  • Supervision and mentorship by PNILT, TRAC and Partners

  • Assessment of ICF is currently ongoing at non-USG sites

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Two time points:

Screening at enrollment into HIV care

6 month follow up screening

Data collected every 6 months by facilities and districts and reported to MOH

Indicators for Evaluation of ICF

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17% (268)

The prevalence of TB in newly enrolled patients was 268/12179 (2.2%)

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189 (13%)

The incidence of TB among pts enrolled into care for > 6 months was 189/31959 (0.6%)

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Community Based TB Screening, pilot project

Kabaya District:

  • Nb of families visited by peer educators: 172

  • Nb of people in the families visited: 825

  • Nb of people screened for TB: 570 (68%)

  • Nb of people who screened positive and

    referred for diagnostic work up: 89 (16%)

  • Nb of people received at the health facility: 21 (31%)

  • Nb of people who started TB treatment: 4 (19%)

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Program Challenges

  • TB detection among PLWHA through ICF is lower than expected:

    • TB screening for all HIV-infected patients during follow up visits is not yet part of routine HIV care

      • Some patients come late for 6 month CD4 clinic visit

      • Some patients are not screened for TB

    • Diagnostic workup to confirm or exclude active TB may not follow national guidelines

    • Diagnostic capacity at health facilities is weak

      • Need to strengthen TB lab services and capacity, improve accessibility to CXR

    • Recording and reporting of TB screening process and diagnostic work-up is often inadequate in the patient HIV care and treatment chart

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Program Challenges (2)

  • Ensuring diagnosis, care and treatment of HIV-infected TB patients through effective referrals and improved integration of services between programs

    • Implementing routine TB screening at HIV care and treatment clinics and ensuring timely and accurate TB diagnosis in PLHA

  • Establishing adequate human resources to supervise and monitor program outcomes

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Future Programmatic Directions

  • Expansion of TB screening among HIV-infected to other HIV service sites (VCT/PMTCT/home based care)

  • Full implementation of the HIV M&E system to allow for national program monitoring of intensified TB case-finding

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Next steps

  • Fully scale up implementation of TB screening in PLWH as part of routine care

    • On-site mentoring and supervision of ICF to improve the quality of ICF at implementing sites

    • Initiate ICF activities at remaining sites

  • Implement QI/QA system through evaluation of ICF standards of care in collaboration with district health teams

  • Validate current screening tool against gold standard diagnosis for TB

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  • The Rwandan experience demonstrates that it is feasible to achieve rapid and successful implementation of Intensified TB case Finding but further effort is needed to improve the quality

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Gisenyi, Kicukiro teams


  • WHO



    • CDC

    • USAID

    • USG partners

  • Columbia U/ICAP

Supported by PEPFAR

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2004 Rwanda, 2001 - 2007



HIV testing of patients with TB, 2004-2007




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TB Registers Rwanda, 2001 - 2007

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Which model for collaboration? Rwanda, 2001 - 2007



‘One stop service’ for TB patients with HIV




Partial integration