To start and to maintain an HIV-clinic in a rural district hospital of Tanzania

The HIV pandemic is hitting the African continent hardest. The majority of people living with HIV/AIDS live on the African continent. Thanks to efforts of many institutions and initiatives of developed countries the price of antiretroviral drugs (ARVs) could be reduced substantially. Simultaneously, the problem got the (adequate) high priority on the political agenda of African countries. This allowed the start of national programmes to care for patients infected with HIV and to dispense ARVs free of charge in many countries. Hence people got a good reason to go for HIV-testing, as a treatment in case of a positive result could make a change to their future. In this sense dispensing ARVs is a very important part of HIV prevention.

Tanzania started ARV dispensing in 2004 and as in most countries, the activities concentrated in the beginning mainly in the urban setting, where the percentage of HIV-positive people among the general population is higher than in rural. Still the majority of people living with HIV live in rural areas. It was the aim of our mutual project of Ifakara Health Research and Development Center (IHRDC), St. Francis Designated District Hospital (SFDDH), Swiss Tropical Institute (STI) and the University Hospital Basel (UHBS) to establish an HIV clinic at SFDDH, a rural district hospital in Ifakara, Kilombero district, Tanzania. We incorporated the HIV clinic with a high standard of care into the hospital organization, to treat patients according the Tanzanian National AIDS control programme (NACP), to train our Tanzanian colleagues in HIV medicine, to strengthen the general medical service at SFDDH and to avert the risk, that resources needed for the hospital in general would be drained to HIV medicine.

In spring 2005 the Chronic Diseases Clinic Ifakara (CDCI) was opened. At this out-patient clinic, we treat patients with chronic diseases like hypertension, diabetes, HIV, TB, and leprosy. With this concept we were able to overcome the fear of HIV-patients to attend the clinic. Since March 2005 we enrolled over 1850 patients into the NACP, around fifty percent of them are in need of ARVs and receive the drugs at our clinic for free. We introduced the concept of an adherence assistant (AA) successfully into the district. Every patient starting ARVs has to bring a person of his choice to the clinic. The duty of this person is to support the patient in adhering to the therapy and to collect the next batch of drugs at CDCI, in case the patient is not able to do so. This concept is very helpful in a setting, where patients live up to 150 km away from the clinic and most of them do not have any means of modern communication. The concept of AA is very well accepted by the patients and gives us the possibility to teach relatives and friends of our patients about HIV and to answer their questions.

At our clinic, we trained seven clinicians in HIV medicine; half of them are working in other departments of the hospital and thereby disseminate the knowledge of HIV medicine into the general hospital. Teaching and training sessions for hospital staff, lectures at the nearby Assistant Medical Officer School and during National and International courses help to spread the knowledge in HIV medicine within the hospital, the district, the country and even beyond.

We established a cohort of HIV patients attending our clinic to monitor adherence to ARVs and clinical out-come of patients treated in rural Tanzania.

At the laboratory of IHRDC we run CD4 cell counts, a very important tool to decide when to start with ARVs and to monitor the success of the therapy. This service is not only offered to patients of CDCI, but to patients from three other hospitals in our and neighboring districts as well. Our experience and expertise in HIV medicine let to the invitation of CDCI and IHRDC staff to participate in the National HIV drug resistance monitoring working group.

In conclusion, we can say that with CDCI, SFDDH has a well functioning HIV clinic, which offers care and treatment to people living with HIV/AIDS at a high standard. With the support of the above mentioned institutions and the financial support of the Canton Basel-Stadt, the project does not drain staff and resources from other department of SFDDH, in contrary, the hospital profits from financial support to and knowledge of CDCI.

The good adherence to therapy and the trust of the patients of our clinic into our work is motivation to all CDCI staff members to work extra-hours on a daily basis in order to meet the needs and expectations of our patients. HIV-therapy is feasible and well accepted in rural Tanzania. The next step forward is to bring ARVs closer to the people living in very remote areas of our districts as they often do not have the financial means to come on a regular basis to our clinic. In this context we see our responsibility in the training of clinicians, who will dispense ARVs at health center level and to conduct supportive supervisions of to assure a high quality of care at each level in our districts.

Marcel Stoeckle, MD
Chronic Diseases Clinic Ifakara and
Swiss Tropical Institute

 

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Photos: please click on them to enlarge
Photo top left: Chronic Diseases Clinic Ifakara
Photo top right: Explanation of ARVs
Photo bottom left: Teaching at CDCI
Photo bottom right: Patient files at CDCI