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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 –

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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
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

> 55 000 on anti-retroviral therapy (ART)

38% of TB patients are HIV-infected

Rwanda
intensified tb case finding icf at national level
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
icf at facility level
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
rolling out icf to sites nationwide
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
to sites nationwide
… 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
indicators for evaluation of icf
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
slide11
85%

15%

17% (268)

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

slide12
59%

8%

189 (13%)

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

community based tb screening pilot project
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%)
program challenges
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
program challenges 2
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
future programmatic directions
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
next steps
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
conclusion
Conclusion
  • 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
acknowledgements
CIDC/TRAC-Plus

PNILT

TRAC

NRL

UPDC

CNLS

Gisenyi, Kicukiro teams

Acknowledgements
  • WHO
  • GFATM
  • PEPFAR
    • CDC
    • USAID
    • USG partners
  • Columbia U/ICAP

Supported by PEPFAR

which model for collaboration
Which model for collaboration?

TB

HIV

‘One stop service’ for TB patients with HIV

Reference

HIV

TB

Partial integration

TB/HIV

TB

HIV

Reference

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