Following the genocide in 1994, Rwanda was facing an HIV epidemic with almost no capacity to treat patients outside of the capital city. In congruent with the rise of HIV also came high levels of tuberculous, especially among HIV infected patients. When we began working in Rwanda in 2005, our efforts focused on making HIV treatment accessible to rural poor Rwandans because at the time zero rural health facilities were capable of providing HIV treatment. In the years since, the Government of Rwanda has been committed to universal free access to HIV prevention and care. Today around 570 health facilities across the country offer HIV treatment to more than 164,000 who cover 78% of those in need of ART. We work to strengthen Rwanda’s capacity to deliver high quality care of infectious diseases, increase treatment retention rates, virological suppression rates and eliminate mother to child HIV transmission.
COMMUNITY-BASED ACCOMPANIMENT APPROACH
In 2005, we began working in Southern Kayonza district because it lacked the necessary health facilities to serve the population and was routinely reporting some of the worst health outcomes in the country. We began by constructing a district hospital in partnership with the Ministry of Health. We worked to improve the supply chain of essential medicines and hired much needed staff.
We worked to implement a community-based accompaniment approach to HIV and TB care that had proven highly successful in Haiti. We believe it is unaccepted for people to die of treatable diseases just because they don’t have the means to regularly visit a health facility. We hired and trained community health workers to actively find people living with HIV and TB and connect them to health facilities. Community Health workers ensure patients continue treatment by bringing medicine to their patients’ homes and observing adherence. Additionally, community health workers are trained to look for clinical warning signs of side effects to the medicine or other common illnesses.
What makes our program different is the added support provided to patients. In addition to daily home visits from health workers, patients enrolled in the program received nutritional assistance for ten months, a travel allowance for routine clinic visits, and comprehensive integrated medical care. They were also enrolled in support groups and HIV education programs.
The community-based accompaniment approach proved successful in Rwanda. A published study showed that HIV patients in rural Rwanda who were enrolled in our program achieved some of the highest rates recorded anywhere in the world for continuing to take their medications. The study reviewed the records of over 1,000 patients and found that 92 percent of them were still taking their ART medications regularly, two years after they were enrolled in treatment at clinics supported by us. This retention rate far exceeds the average of 70 percent reported in a review of 39 published studies that looked at a combined 225,000 HIV patients across sub-Saharan Africa. And retention rates in North America were even lower, averaging just 55 percent, according to a review of 31 studies published in the Journal of the American Medical Association.
Focusing on the Most Vulnerable Patients
Rwanda has proven extremely successful at decentralizing HIV treatment, promoting early testing, and linking infected people to care quickly. Additionally, ART treatment has improved with single daily dose regiments with decreased side effects now available. After more than a decade of treatment experience, many of our patients are now thriving socially and professionally. They have demonstrated that they are ready to handle a less intense accompaniment model. Nationwide in Rwanda, over 83 percent of patients have demonstrated viral load suppression, which indicated that they can successfully take their medication as prescribed. In order to adapt to this contextual change, we have modified our approach to HIV care to focus on the most vulnerable patients who are in need of daily accompaniment and to provide continued monthly visits to patients who have shown consistent improvement.
IMPROVING QUALITY OF CARE
As Rwanda’s capability to provide treatment for infectious diseases has improved in the last ten years, we have transitioned our support. We now focus on improving the quality of care through trainings, mentorship, and research. We provide regular trainings for physicians and nurses both at the hospital and health center levels. Our mentorship program promotes using data to drive quality improvement. We have implemented the use of electronic medical records to better monitor patient outcomes and aid in decision making. Our mentors identify key areas of care and work with hospital staff to develop and implement quality improvement techniques. Our model of HIV mentors has since been adopted by the Ministry of Health and implemented nationally.
One of our goals is to eliminate mother to child transmission of HIV. We are developing protocols to coordinate the care of pregnant women with HIV and the care of their children. We work to also address the social and economic determinants of health of patients living with HIV or TB. Social workers identify vulnerable patients and families and connect them with our livelihood program to help improve their wellbeing.