The Republic of Congo (RoC), situated in central Africa, has 3.8 million inhabitants [1
] of whom about 70% live in the cities of Brazzaville and Pointe-Noire. RoC is rich in natural resources (e.g. petroleum and natural gas, timber, minerals, hydro-power). It was one of the most developed sub-Saharan African countries in the early 1980s, but began to decline by the end of that decade, the situation exacerbated by three civil wars between 1993 and 1999 and further civil conflict in 2002–3. A ceasefire was signed in March 2003, but fighting has continued in some areas. Corruption, arms spending and excessive borrowing against future oil production has left the country with one of the largest per-capita debts in the world.
The RoC health system operates using a cost recovery mechanism where patients pay a significant proportion of the care costs (e.g. around 2–3 EUR for a consultation and 30 EUR for a caesarean section). Access to health care is generally poor, either due to geographic distance or cost of services, leading many people to turn to traditional healers. Most health services outside the main cities are poorly staffed and lack basic drugs and equipment. In RoC life expectancy is 54 years, with an infant mortality rate of 108 deaths/1,000 live births [2
]. The leading causes of morbidity and mortality are malaria (30–38%), respiratory tract infections (15–22%) and diarrhoeal diseases (7–15%). Tuberculosis (TB) is common (estimated incidence; 377/100,000 pop/yr) [3
] and the reported prevalence of HIV is 4.2%. [4
The 'Pool' region of RoC was significantly affected during the 1998 and 2002 civil wars by fighting between three political factions and their accompanying militias (Ninjas, Cocoyes and Cobras). Pool is one of nine departments in RoC, and was known for its serenity and natural beauty before the war; today it is a devastated area. Between 2003–2008 Médecins Sans Frontières (MSF) supported the hospitals and surrounding health centres in the administrative centre of Kinkala and 2 other towns Mindouli and Kindamba. Roads were very poor: the 90 km trip from Brazzaville to Kinkala which took one hour before the war, took over six hours in 2005 when the HIV project was started; Mindouli (70 km further) took another 4 hours. Security incidents on the road were common, and during the wet season the roads at times were impassable. Since 2006 the security situation in the region improved allowing the local economy to grow, but access remains difficult.
Kinkala hospital is an 80-bed referral hospital for the western part of the Pool region for an estimated population of 30,000. Mindouli hospital is a regional, 60-bed hospital serving a population of around 50,000. MSF's support to these hospitals comprised general medical, surgical, maternity, paediatric and mental health care (war trauma counselling), as well as nutritional and TB interventions. All health care services were provided free of charge.
Up to 2005 there was no capacity for HIV care in the region, and antiretroviral care was not available outside of the main urban centers of Brazzaville and Pointe Noire (where access was limited due to user fees). In addition, there was minimal knowledge of HIV and its treatment among health staff and the local population. However, health services in Kinkala and Mindouli were faced with large numbers of patients presenting to the health-care facilities with significant mortality and morbidity from HIV related illnesses, especially TB. Antiretroviral treatment (ART) programmes in developing countries, particularly in sub-Saharan Africa, have mainly been delivered through vertical programmes [5
]. However in this rural and remote setting, with high basic medical needs and limited resources, it was considered that a vertical approach was unsuitable. Instead, a programme was established to offer HIV services as part of existing health services.