Roll-out of Intensified TB Case Finding in Rwanda Greet Vandebriel, MD, MPH Track 1.0 Meeting Washington DC August 11 –

1. 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

2. 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

3. 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

4. ICF Questionnaire and Operational Protocol

5. HIV Patient File

6. Pre-ART and ART Registers

7. 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

8. 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

9. … 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

10. 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

11. 85% 15% 17% (268) The prevalence of TB in newly enrolled patients was 268/12179 (2.2%)

12. 59% 8% 189 (13%) The incidence of TB among pts enrolled into care for > 6 months was 189/31959 (0.6%)

13. 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%)

14. 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

15. 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

16. 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

17. 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

18. 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

19. 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

20. Additional slides

21. New Smear Positive TB Case Detection and Treatment Outcome, Rwanda, 2001 - 2007

22. 2004 2006 2005 HIV testing of patients with TB, 2004-2007 91% 45% 2007

24. TB Registers

25. Which model for collaboration? TB HIV ‘One stop service’ for TB patients with HIV Reference HIV TB Partial integration TB/HIV TB HIV Reference