Evaluation of a case management program for HIV clients in Rwanda.

Case management is a standard practice in the United States for the effective care of people living with HIV and AIDS (PLHA); however, application of this approach in developing countries has not been demonstrated. Although great advances have been made in Africa to increase PLHA's access to HIV services, care and support systems often remain fragmented. In September 2004, CARE International initiated a case management program in health facilities in Rwanda designed to enhance linkages between clinical and non-clinical services for PLHA. This paper presents findings from an evaluation of the program conducted in 2006 focusing on its implementation, specifically the responsibilities of case managers, community linkages, and integration within the health facility. Program outcomes of antiretroviral treatment adherence and quality of life among PLHA also were explored. Qualitative data were collected from case managers, clients, health care providers, and CARE staff. A survey was conducted among 75% of the 149 case managers. Results indicate the case management program strengthened linkages between health facility and community service providers for PLHA. However, most case managers (79%) reported inadequate resources to carry out their duties and high client loads, averaging 55 clients each. They also had limited referral networks. Nonetheless, case managers were highly regarded and appreciated by health professionals, who reported that the program helped to enhance patient-doctor relationships and ensure follow-up of patients' needs. Respondents further highlighted benefits of improved psychosocial well-being and better adherence to antiretroviral medications among clients. Issues remain in terms of case management efficacy in developing country environments, notably the availability and accessibility of needed ancillary services. Despite some limitations, data suggest case management is a viable strategy for providing comprehensive support to PLHA in Rwanda and its implementation elsewhere in Africa should be explored. Considerations in replicating this approach are discussed.