Excellent clinical outcomes and high retention in care among adults in a community-based HIV treatment program in rural Rwanda

BACKGROUND

Access to antiretroviral therapy (ART) has rapidly expanded; as of the end of 2010, an estimated 6.6 million people are receiving ART in low-income and middle-income countries. Few reports have focused on the experiences of rural health centers or the use of community health workers. We report clinical and programatic outcomes at 24 months for a cohort of patients enrolled in a community-based ART program in southeastern Rwanda under collaboration between Partners In Health and the Rwandan Ministry of Health.

METHODS AND FINDINGS

A retrospective medical record review was performed for a cohort of 1041 HIV+ adult patients initiating community-based ART between June 1, 2005, and April 30, 2006. Key programatic elements included free ART with direct observation by community health worker, tuberculosis screening and treatment, nutritional support, a transportation allowance, and social support. Among 1041 patients who initiated community-based ART, 961 (92.3%) were retained in care, 52 (5%) died and 28 (2.7%) were lost to follow-up. Median CD4 T-cell count increase was 336 cells per microliter [interquartile range: (IQR): 212-493] from median 190 cells per microliter (IQR: 116-270) at initiation.

CONCLUSIONS

A program of intensive community-based treatment support for ART in rural Rwanda had excellent outcomes in 24-month retention in care. Having committed to improving access to HIV treatment in sub-Saharan Africa, the international community, including country HIV programs, should set high programmatic outcome benchmarks.

Mentoring and quality improvement strengthen integrated management of childhood illness implementation in rural Rwanda

OBJECTIVE

Integrated Management of Childhood Illness (IMCI) is the leading clinical protocol designed to decrease under-five mortality globally. However, impact is threatened by gaps in IMCI quality of care (QOC). In 2010, Partners In Health and the Rwanda Ministry of Health implemented a nurse mentorship intervention Mentoring and Enhanced Supervision at Health Centres (MESH) in two rural districts. This study measures change in QOC following the addition of MESH to didactic training.

DESIGN

Prepost intervention study of change in QOC after 12 months of MESH support measured by case observation using a standardised checklist. Study sample was children age 2 months to 5 years presenting on the days of data collection (292 baseline, 413 endpoint).

SETTING

21 rural health centres in Rwanda.

OUTCOMES

Primary outcome was a validated index of key IMCI assessments. Secondary outcomes included assessment, classification and treatment indicators, and QOC variability across providers. A mixed-effects regression model of the index was created.

RESULTS

In multivariate analyses, the index significantly improved in southern Kayonza (β-coefficient 0.17, 95% CI 0.12 to 0.22) and Kirehe (β-coefficient 0.29, 95% CI 0.23 to 0.34) districts. Children seen by IMCI-trained nurses increased from 83.2% to 100% (p<0.001) and use of IMCI case recording forms improved from 65.9% to 97.1% (p<0.001). Correct classification improved (56.0% to 91.5%, p<0.001), as did correct treatment (78.3% to 98.2%, p<0.001). Variability in QOC decreased (intracluster correlation coefficient 0.613-0.346).

CONCLUSIONS

MESH was associated with significant improvements in all domains of IMCI quality. MESH could be an innovative strategy to improve IMCI implementation in resource-limited settings working to decrease under-five mortality.

Improving district facility readiness: a 12-month evaluation of a data-driven health systems strengthening intervention in rural Rwanda

Background

While health systems strengthening (HSS) interventions are recommended by global health policy experts to improve population health in resource-limited settings, few examples exist of evaluations of HSS interventions conducted at the district level. In 2009, a partnership between Partners In Health (PIH), a non-governmental organization, and the Rwandan Ministry of Health (RMOH) was provided funds to implement and evaluate a district-level HSS intervention in two rural districts of Rwanda.

Design

The partnership provided limited funds to 14 health centers for targeted systems support in 2010; six others received support prior to the intervention (reference). RMOH health systems norms were mapped across the WHO HSS framework, scored from 0 to 10 and incorporated into a rapid survey assessing 11 domains of facility readiness. Stakeholder meetings allowed partnership leaders to review results, set priorities, and allocate resources. Investments included salary support, infrastructure improvements, medical equipment, and social support for patients. We compared facility domain scores from the start of the intervention to 12 months and tested for correlation between change in score and change in funding allocation to assess equity in our approach.

Results

We found significant improvements among intervention facilities from baseline to 12 months across several domains [infrastructure (+4, p=0.0001), clinical services (+1.2, p=0.03), infection and sanitation control (+0.6, p=0.03), medical equipment (+1.0, p=0.02), information use (+2, p=0.002)]. Composite score across domains improved from 6.2 at baseline to 7.4 at 12 months (p=0.002). Across facilities, 50% had composite scores greater than the average score among reference facilities (7.4) at 12 months compared to none at baseline.

Conclusions

Rapid facility surveys, stakeholder engagement, and information feedback can be used for gap analysis and resource allocation. This approach can achieve effective use of limited resources, improve facility readiness, and ensure consistency of facility capacity to provide quality care at the district level.