Bulletin of the World Health Organization

Tuberculosis in Rwanda: challenges to reaching the targets

Michel Gasanaa, Greet Vandebrielb, Gaspard Kabandaa, Jules Mugaboc, Simon J Tsiourisd, Aliou Ayabae, Alyssa Finlayf, Jessica Justmand, Ruben Sahabob, Wafaa El-Sadrd

Introduction

Rwanda has a generalized HIV epidemic: 3.1% of adults are living with HIV/AIDS.1 Care, treatment and prevention services for the approximately 183 558 adults and 13 901 children living with HIV/AIDS have been rapidly scaled up over the past three years under the guidance of the Rwandan Ministry of Health’s Treatment Research for AIDS Center. By November 2006, almost 33 000 HIV-infected adults and children were receiving antiretroviral therapy.2

Expansion and enhancement of DOTS in the six-point Stop TB Strategy described by Laserson & Wells have been implemented in Rwanda by the health ministry’s national integrated programme to combat leprosy and TB since 1990. Through recent programme improvements, treatment success rates have increased from 58% in 2003 to 81% by the third quarter of 2006; however, case detection was an estimated 24% in 2005.3–5 Thus, Rwanda is close to achieving the WHO target for treatment success, but is below the target for case detection. Concerted efforts are being made to ensure that effective smear microscopy and directly-observed therapy are available nationwide. Further efforts are needed to reach the goals, especially for case detection. A recent national survey showing that the prevalence of multidrug resistance among new TB patients is 3.9% gives cause for concern.6

TB/HIV collaborative activities

Addressing TB/HIV coinfection (another component of the Stop TB Strategy) through collaboration between programmes and integration of services is a priority for the Rwandan government. Implementation of TB/HIV collaborative activities began with the placement of a TB/HIV technical advisor and coordinators at the national programme to combat leprosy and TB and at the Treatment Research for AIDS Center, to establish coordination at a central level. In February 2005, key stakeholders from the health ministry and partner organizations held a workshop to jointly prioritize collaborative activities and establish a national TB/HIV integration working group. In October 2005, the health ministry approved a national policy on TB/HIV collaborative activities based on WHO interim policy.7,8

The technical manual for the programme to combat leprosy and TB was revised to include a chapter containing standards of care for patients with TB and HIV. Provider-initiated HIV counselling and testing for all TB patients have been adopted. TB treatment cards and case registers now include information on HIV status, care and treatment; these data are regularly reported by all TB diagnostic and treatment facilities.

In August 2005, two TB/HIV integration model centres were established at one rural and one urban health facility. The purpose of these centres is to develop best practices and innovative strategies for TB/HIV integrated care, including evaluating strategies to enhance early diagnosis of TB among people with HIV/AIDS as well as developing methods to improve HIV testing of TB patients, to increase enrolment of TB/HIV coinfected patients into HIV care, and to provide cotrimoxazole and antiretroviral therapy through the TB services.

A TB symptom checklist developed to screen people with HIV/AIDS for TB was piloted at the two model centres and adopted as a national standard. Standardized paper-based registers (which include information on results of routine TB screening and treatment for TB disease) of patients before and after initiation of antiretrovirals have been developed, and complete roll-out is expected by the end of 2006. As of June 2006, preliminary data from 27 of 120 sites providing antiretrovirals report that 138 of 1581 (9%) people receiving care and treatment for HIV/AIDS are also receiving treatment for TB.

In 2005, a baseline evaluation of access to and acceptance of HIV counselling and testing among TB patients was conducted at 23 geographically representative sites. Of 482 patients registered for treatment in the fourth quarter of 2004, 52% had a documented HIV test result. Other HIV-related information was poorly documented. When interviewed, TB patients reported high acceptance of HIV testing if offered (198 out of 207, or 96%). These results were used to inform policy-makers and providers, and to modify national guidelines to promote TB/HIV activities. This evaluation also revealed that mortality among HIV-infected TB patients in Rwanda was six times higher than among non-infected TB patients, supporting the case made by Laserson & Wells that TB is the leading killer of people with HIV/AIDS.

Implementation of the national TB/HIV policy and guidelines has resulted in a nation-wide increase in HIV counselling and testing of TB patients from 46% in 2004 to 81% by the third quarter of 2006. In that quarter, 49% of HIV-infected TB patients had initiated cotrimoxazole preventive therapy and 34% were receiving antiretrovirals.

Conclusion

Rwanda’s experience has demonstrated that it is possible to achieve rapid and successful implementation of TB/HIV collaborative activities as part of the Stop TB Strategy in the setting of a generalized HIV epidemic. This additional effort did not involve substantial additional costs and did not interfere with other TB control efforts. Indeed, it has enhanced case detection among people with HIV/AIDS, who are at the highest risk for TB. Challenges remain for sustained political commitment to support TB/HIV collaborative activities in the context of recent trends. These include decentralization of health services, expansion of HIV counselling and testing in settings other than TB outpatient facilities, provision of cotrimoxazole at all sites offering TB services, effective referrals between TB and HIV programmes, accurate recording and reporting of TB/HIV data, and establishing adequate human resources to supervise and monitor programme outcomes. ■

References

Affiliations

  • Programme National Intégré de lutte contre la Lèpre et la Tuberculose, Rwanda Ministry of Health, Kigali, Rwanda.
  • International Center for AIDS Care and Treatment Programs — Rwanda, Mailman School of Public Health, Columbia University, Kigali, Rwanda.
  • Treatment Research AIDS Center, Rwanda Ministry of Health, Kigali, Rwanda.
  • International Center for AIDS Care and Treatment Programs — New York, Mailman School of Public Health, Columbia University, New York, USA.
  • Global AIDS Program, Centers for Disease Control and Prevention, Kigali, Rwanda.
  • International Research and Programs Branch, Division of Tuberculosis Elimination, Centers for Disease Control and Prevention, Atlanta, USA.
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