Linkage to HIV care before and after the introduction of provider-initiated testing and counselling in six Rwandan health facilities.

HIV testing and counselling forms the gateway to the HIV care and treatment continuum. Therefore, the World Health Organization recommends provider-initiated testing and counselling (PITC) in countries with a generalized HIV epidemic. Few studies have investigated linkage-to-HIV-care among out-patients after PITC. Our objective was to study timely linkage-to-HIV-care in six Rwandan health facilities (HFs) before and after the introduction of PITC in the out-patient departments (OPDs). Information from patients diagnosed with HIV was abstracted from voluntary counselling and testing, OPD and laboratory registers of six Rwandan HFs during three-month periods before (March-May 2009) and after (December 2009-February 2010) the introduction of PITC in the OPDs of these facilities. Information on patients' subsequent linkage-to-pre-antiretroviral therapy (ART) care and ART was abstracted from ART clinic registers of each HF. To triangulate the findings from HF routine, a survey was held among patients to assess reasons for non-enrolment. Of 635 patients with an HIV diagnosis, 232 (36.5%) enrolled at the ART clinic within 90 days of diagnosis. Enrolment among out-patients decreased after the introduction of PITC (adjusted odds ratio, 2.0; 95% confidence interval, 1.0-4.2; p = .051). Survey findings showed that retesting for HIV among patients already diagnosed and enrolled into care was not uncommon. Patients reported non-acceptance of disease status, stigma and problems with healthcare services as main barriers for enrolment. Timely linkage-to-HIV-care was suboptimal in this Rwandan study before and after the introduction of PITC; the introduction of PITC in the OPD may have had a negative impact on linkage-to-HIV-care. Healthier patients tested through PITC might be less ready to engage in HIV care. Fear of HIV stigma and mistrust of test results appear to be at the root of these problems

Community-based accompaniment and psychosocial health outcomes in HIV-infected adults in Rwanda: a prospective study

We examined whether the addition of community-based accompaniment to Rwanda’s national model for antiretroviral treatment (ART) was associated with greater improvements in patients’ psychosocial health outcomes during the first year of therapy. We enrolled 610 HIV-infected adults with CD4 cell counts under 350 cells/?L initiating ART in one of two programs. Both programs provided ART and required patients to identify a treatment buddy per national protocols. Patients in one program additionally received nutritional and socioeconomic supplements, and daily home-visits by a community health worker (“accompagnateur”) who provided social support and directly-observed ingestion of medication. The addition of community-based accompaniment was associated with an additional 44.3 % reduction in prevalence of depression, more than twice the gains in perceived physical and mental health quality of life, and increased perceived social support in the first year of treatment. Community-based accompaniment may represent an important intervention in HIV-infected populations with prevalent mental health morbidity

Provider-initiated HIV testing and counselling in Rwanda: acceptability among clinic attendees and workers, reasons for testing and predictors of testing.

INTRODUCTION: Routine provider-initiated HIV testing and counselling (PITC) may increase HIV testing rates, but whether PITC is acceptable to health facility (HF) attendees is unclear. In the course of a PITC intervention study in Rwanda, we assessed the acceptability of PITC, reasons for being or not being tested and factors associated with HIV testing. METHODS: Attendees were systematically interviewed in March 2009 as they left the HF, regarding knowledge and acceptability of PITC, history of testing and reasons for being tested or not. Subsequently, PITC was introduced in 6 of the 8 HFs and a second round of interviews was conducted. Independent factors associated with testing were analysed using logistic regression. Randomly selected health care workers (HCWs) were also interviewed. RESULTS: 1772 attendees were interviewed. Over 95% agreed with the PITC policy, both prior to and after implementation of PITC policy. The most common reasons for testing were the desire to know one's HIV status and having been offered an HIV test by an HCW. The most frequent reasons for not being tested were known HIV status and test not being offered. In multivariable analysis, PITC, age ≥15 years, and not having been previously tested were factors significantly associated with testing. Although workload was increased by PITC, HIV testing rates increased and HCWs overwhelmingly supported the policy. CONCLUSION: Among attendees and HCWs in Rwandan clinics, the acceptability of PITC was very high. PITC appeared to increase testing rates and may be helpful in prevention and early access to treatment

Does provider-initiated HIV testing and counselling lead to higher HIV testing rate and HIV case finding in Rwandan clinics?

Provider-initiated HIV testing and counselling (PITC) is promoted as a means to increase HIV case finding. We assessed the effectiveness of PITC to increase HIV testing rate and HIV case finding among outpatients in Rwandan health facilities (HF). PITC was introduced in six HFs in 2009-2010. HIV testing rate and case finding were compared between phase 1 (pre-PITC) and phase 3 (PITC period) for outpatient-department (OPD) attendees only, and for OPD and voluntary counseling & testing (VCT) departments combined. Out of 26,367 adult OPD attendees in phase 1, 4.7% were tested and out of 29,864 attendees in phase 3, 17.0% were tested (p  < 0.001). The proportion of HIV cases diagnosed was 0.25% (67/26,367) in phase 1 and 0.46% (136/29864) in phase 3 (p  < 0.001). In multivariable analysis, both testing rate and case finding were significantly higher in phase 3 for OPD attendees. In phase 1 most of the HIV testing was done in VCT departments rather than at the OPD (78.6% vs 21.4% respectively); in phase 3 this was reversed (40.0% vs 60.0%; p  < 0.001). In a combined analysis of VCT and OPD attendees, testing rate increased from 18.7% in phase 1 to 25.4% in phase 3, but case finding did not increase. In multivariable analysis, testing rate was significantly higher in phase 3 (OR 1.67; 95% CI 1.60-1.73), but case finding remained stable (OR 1.09; 95% CI 0.93-1.27). PITC led to a shift of HIV testing from VCT department to the OPD, a higher testing rate, but no additional HIV case findin

Discordant Treatment Responses to Combination Antiretroviral Therapy in Rwanda: A Prospective Cohort Study

Introduction: Some antiretroviral therapy naïve patients starting combination antiretroviral therapy (cART) experience a limited CD4 count rise despite virological suppression, or vice versa. We assessed the prevalence and determinants of discordant treatment responses in a Rwandan cohort. Methods: A discordant immunological cART response was defined as an increase of <100 CD4 cells/mm3 at 12 months compared to baseline despite virological suppression (viral load [VL] <40 copies/mL). A discordant virological cART response was defined as detectable VL at 12 months with an increase in CD4 count ≥100 cells/mm3. The prevalence of, and independent predictors for these two types of discordant responses were analysed in two cohorts nested in a 12-month prospective study of cART-naïve HIV patients treated at nine rural health facilities in two regions in Rwanda. Results: Among 382 patients with an undetectable VL at 12 months, 112 (29%) had a CD4 rise of <100 cells/mm3. Age ≥35 years and longer travel to the clinic were independent determinants of an immunological discordant response, but sex, baseline CD4 count, body mass index and WHO HIV clinical stage were not. Among 326 patients with a CD4 rise of ≥100 cells/mm3, 56 (17%) had a detectable viral load at 12 months. Male sex was associated with a virological discordant treatment response (P = 0.05), but age, baseline CD4 count, BMI, WHO HIV clinical stage, and travel time to the clinic were not. Conclusions: Discordant treatment responses were common in cART-naïve HIV patients in Rwanda. Small CD4 increases could be misinterpreted as a (virological) treatment failure and lead to unnecessary treatment changes

Characteristics of clinic attendees interviewed at intervention and control sites, PITC study, Rwanda, 2009–10.

<p>PITC: provider initiated testing and counselling; IQR: Inter-quartile range; OPD: out-patient department; FP: family planning; VCT: Voluntary counseling and testing; ANC: Antenatal care; TB: tuberculosis.</p><p>P values are based on the chi-squared test, except comparison of age (based on rank sum test).</p><p>Phase 1: before PITC was implemented; Phase 3: after PITC was implemented (at the intervention sites).</p

Proportions of health care facility attendees who were tested on day of interview, tested for HIV before and had ever been tested”, by clinic department for the intervention and control sites, PITC study, Rwanda, 2009–10.

<p>Intervention: intervention sites; Control: control sites; PITC: provider initiated testing and counselling; Phase 1: before PITC; Phase 3: PITC phase; OPD: outpatient department; FP: family planning; VCT: voluntary counseling and testing; ANC: antenatal care; TB: tuberculosis. Note: for this table we assumed that the patients of whom information on HIV testing on date of interview (n = 61; 56 from OPD and 5 from FP) or ever before (n = 4; all from OPD) was lacking, had not been tested. “Ever tested for HIV” means being tested for HIV on day of interview, or having been tested for HIV before, or both.</p

Outcomes from interviews of clinic attendees at intervention and control sites, PITC study, Rwanda, 2009–10.

<p>PITC: provider initiated testing and counselling; Phase 1: before PITC; Phase 3: PITC phase;</p><p>*the results reflect the perceptions from the interviews.</p

Characteristics of intervention and control sites, PITC study, Rwanda, 2009–10.

<p>Option 1: a rapid test by the HCW using a finger-prick blood sample in the consultation department was done; Option 2: a venous blood sample was drawn by the HCW and sent to the laboratory for rapid testing; Option 3: the HCW offered the test upon consent, and sent the attendee to the laboratory for a venous blood draw and rapid testing.</p

Additional file 1: Table S1. of Does provider-initiated HIV testing and counselling lead to higher HIV testing rate and HIV case finding in Rwandan clinics?

Characteristics of 65,716 clinic attendees of outpatient departments in eight health facilities by study phase and site, PITC study, Rwanda 2009–2010. Table S2. Multivariable logistic regression to determine the association of study phase with HIV testing rate and HIV case finding in the outpatient department of 2 control health facilities in Rwanda, 2009–2010. Table S3. Characteristics of 77,389 clinic attendees of outpatient and voluntary counseling and testing departments in eight health facilities by study phase and site, PITC study, Rwanda 2009–2010. Table S4. Multivariable logistic regression to determine the association of study phase with HIV testing rate and HIV case finding in the outpatient and voluntary counseling and testing departments of 2 control health facilities in Rwanda, 2009–2010. Figure S1. HIV testing rate and testing cascade in OPD in phase 3 at intervention sites, Rwanda, 2009–10. Figure S2. Reasons for refusing an HIV test in phase 3 at intervention sites, Rwanda, 2009–10. (DOC 311 kb