Democratic Republic of Congo

The Union collaborated with the National Tuberculosis Programme (NTP) and the National AIDS Programme (NAP) of the Democratic Republic of Congo (DRC) to develop and implement a programme of Integrated HIV Care for Tuberculosis Patients Living with HIV/AIDS (IHC) from 2006 to 2012.

The IHC programme introduced HIV screening and management of co-infected TB patients by health care paramedics in charge of TB services. Co-infected patients were started on cotrimoxazole preventive therapy (CPT) and, if eligible, on antiretroviral treatment (ART). IHC also introduced CD4 cell count measurement at all sites, with the microscopes used for sputum smear microscopy (using the Dynabeads ® technique). Patients CD4 counts were measured to assess ART eligibility.

The first phase of the European Commission-funded IHC Programme was implemented in 23 TB diagnostic and treatment centres (DTCs) in two provinces: 13 in North Kivu, East DRC, and 10 in Bas Congo, West DRC, from 2006 to 2008. Activities in Bas Congo integrated the National Aids Programme at the end of 2008, while research continued in North Kivu until end 2012, in a second phase of the IHC programme also funded by the European Commission. A key feature of the IHC approach was that all centres were operated by the public (civilian or military), private, or NGO sectors that are involved in the day-to-day provision of health care in DRC. It is the vision of The Union that partner countries are empowered to develop and manage services through the systems in place, rather than creating new ones.

From July 2008 to September 2012 (when project reporting stopped), 7,809 cases of TB were diagnosed at the 13 pilot health centres, and 87% were tested for HIV and registered into care. By documenting precisely the trends in TB-HIV coinfection, IHC contributed significantly to documenting the epidemiology of AIDS in DRC. Integrating these results, the World Health Organization (WHO) corrected its prevalence estimates for HIV-TB coinfection. IHC also validated a model for the management of AIDS built on the existing TB care infrastructure, piloted by the national programme, and implemented through the network of regular public and private health facilities. Although services are provided by non-physicians, results compare favourably to others observed in DRC in terms of retention into care and development of resistance to ARVs. They also compare favourably with data from Sub-Saharan Africa, which, given the constraints related to the context, is an achievement per se. Results confirm that it is possible to implement national programmes in this type of environment. Unexpectedly, IHC also showed that implementing major national programmes through regular country settings may contribute to state building in politically challenged areas.

In terms of human resources, IHC developed a training and re-training mechanism for staff involved in implementing national programmes, which combines classroom and in-service training in centres of excellence. This mechanism is in line with the principles of the country's Health System Strengthening Strategy and rests on the contractual approach followed by the Ministry of Health. IHC also highlighted the importance, under the current configuration of the Congolese health system, of maintaining a specific supervision structure for TB and AIDS. Complete integration of supervision in health zones can only be contemplated when a sufficient level of operational and technical maturity has been achieved.

In terms of financing, IHC specified the cost of the various components of the TB and HIV care packages, and demonstrated that prices paid by the Health Services Purchasing Funds do not cover the real cost of the services, leaving gap funding to other users of the health system through cost sharing. In addition, the current arrangement does not cover the very catastrophic costs of TB and HIV care. IHC showed that TB control may benefit from lowered economic barriers to access to care, as achieved by general care subsidization. Benefits vary though depending on the epidemiology of the disease (TB or AIDS) considered. Finally, IHC stressed three important systemic risks: a) financing mechanisms based on performance that target too many indicators are inefficient for lack of specificity; b) financing additional interventions (such as involving community based organisation into service provision, or implementing new technologies) on top of the basic package, when financing essential TB and HIV control services is not secured, undermines attempts to set up a sustainable health financing mechanism; c) failing to adequately fund services provided free-of-charge to patients is a major threat for the health system in a context of cost recovery.

In terms of health technologies, IHC2 finalized the preliminary findings of IHC1 and demonstrated the feasibility of measuring HIV viral load at the point of care using dried blood spots. Combined with Dynabeads ® CD4 count, the whole set of technologies that allow evidence based care to AIDS sufferers can equally benefit patients in remote rural areas. This important component also made it possible to monitor ART resistance, and clarified the needs for reference laboratory services to support the provision of the package of services to patients. The validation of the GeneXpert® MDR/RIF by WHO has made possible the assessment of this technology for intensified TB case finding among People Living with HIV (PLH). In the epidemiological context of Eastern DRC results showed limited feasibility and prohibitive cost-effectiveness. They also highlighted the interest of chest radiology for TB screening in PLHs.

Overall, IHC provided DRC with a coherent and integrated strategy for the management of AIDS and TB within regular health facilities, and with a strategy for scaling up HIV care countrywide. These strategies have been adopted by the National AIDS Programme. The Union confirmed the relevance of the DOTS strategy for HIV care, and clarified the priority of its components within a health system. The coordination of different financing mechanisms, either within an organization like the European Commission, between donors, or between the latter and the government, remains a considerable challenge.