A. Programme management
The program focused on providing care to those presenting to the MSF or Ministry of Health (MoH) health facilities. HIV counseling and testing (CT) was targeted to those with an increased likelihood of having HIV and where knowledge of HIV would have an impact on the medical care provided: medical hospital inpatients, severely malnourished children not responding to treatment, patients with TB, sexually transmitted infections or illnesses suggestive of HIV.
A "Clinic for Chronic Diseases" was opened to provide care for patients with HIV as well as a number of chronic conditions including diabetes, epilepsy and hypertension. This was with the dual purpose of providing chronic disease management and limiting possible stigma associated with an "HIV clinic".  Nevertheless, in reality most patients had HIV (and/or TB). The clinics were initially open for only two afternoons a week, but as the number of patients grew they opened on a daily basis. The patient files and HIV-related medications (ARVs and drugs for prophylaxis of opportunistic infections (OIs)) were kept securely in the clinic, but other drugs were obtained from the ward or pharmacy if required.
Rather than wait until everything was in place before starting, the HIV activities were added in a step-wise manner. Initially HIV education and CT were introduced, followed by treatment and prophylaxis of OIs, and eventually ART. In this way patients could benefit from the interventions that logically precede the others whilst allowing for the time and experience required for programme staff to introduce the other activities. Although a cost recovery system operated in RoC, and all other available HIV care in the country required patient co-payments, it was negotiated with the MoH that all HIV services would be provided for free – including consultations, medications, laboratory investigations and nutrition – given the negative impact of user fees on HIV programmes .
At the time HIV activities were introduced, the region was still classified as a conflict area, with no formal peace agreement signed between the parties. In January 2006, prior to the introduction of HIV activities, the expatriate team were evacuated from Mindouli for 2 weeks due to security issues. Based on experience from other conflict settings,  a plan was put in place to deal with the potential of program disruption to minimize the risk that patients would have to interrupt their ART, and thus allow them to access care without greatly endangering their future treatment. Despite the potential for disruption, the program did not suffer from interruption in the three years since ART commenced.
B. Human Resources and training
Two extra doctors and two laboratory technicians were added to the health program to support the introduction of HIV activities. However it was also realised the single medical doctor (MD) previously in the program had been overworked and that HIV had 'justified' the addition of a resource that was already required prior to the addition of HIV activities.
The HIV component was included as part of staff members routine activities rather than having wholly dedicated "HIV" staff. Doctors caring for HIV patients also worked in the adult medical, paediatric, emergency and TB wards, and counsellors undertook general psychosocial counselling for HIV negative people (e.g. post-traumatic counselling) as well as HIV related counselling and education activities. Nevertheless, one MD was made chiefly responsible for HIV activities including direct clinical care.
Initially the health staff (expatriate and national) had no significant HIV care experience, and felt reluctant and fearful to begin. Thus to help plan and commence HIV activities, an MD with experience in treating HIV in resource-limited settings initially provided support in the project by designing care pathways, training staff, clinical mentoring and setting up data collection systems. Staff were also provided with short (i.e.1–2 weeks) practical experience in other large regional HIV programs (e.g. MSF in Kinshasa, DRC; French Red Cross in Brazzaville, RoC), and attending local or external courses.
A strong focus was placed on HIV education and awareness for all health, hospital and MSF program staff through general staff meetings and targeted training sessions. Space was given to discuss misconceptions, stigma and anxieties of health staff related to HIV, and to actively address these through ongoing regular education sessions.
One of the key successes of the integration process was the institution of regular meetings between counsellors, nurses, doctors and all others involved in the HIV/AIDS activities. These were used to discuss difficult patient cases, for education and training, and to share information, but they also served as an opportunity for supervisors to identify misconceptions or negative attitudes among staff. In addition, they helped create a cohesive interdisciplinary team approach to HIV activities which facilitated the implementation of the program across the various health activities.
C. Clinical care
For diagnosis, HIV rapid diagnostic tests (Determine HIV-1/2® and Unigold HIV®) were used on venous blood samples. Testing was done confidentially by laboratory staff, mainly because national regulations prohibit testing by non-medical staff. For ART, generic antiretroviral drugs were used in the form of fixed-dose combinations (FDCs) which facilitated adherence, procurement and stock management, and reduced costs. Eligibility criteria for ART and first-line regimens were standardised and based on WHO recommendations . During the initial phase only first-line drugs and their alternatives were provided (i.e. stavudine, lamivudine, nevirapine, effavirenz, zidovudine and nelfinavir) to allow simplification, based on the fact that almost all patients were ART naïve and thus not likely to need second-line ART for at least 12 months . For treatment of OIs, the simplest effective protocols were used (e.g. fluconazole rather than intravenous amphotericin B for initial treatment of cryptococcosis, and cotrimoxazole rather than sulphadiazine and pyrimethamine for treatment of cerebral toxoplasmosis). Clinical consultations were performed by both doctors and nurses. Monitoring was performed on a clinical and immunological basis (CD4 count) with no viral load monitoring.
It has been argued that monitoring tools such as CD4 machines are too complex for many resource-limited settings.  However we found that a simplification of management was achieved by instituting some 'complex' monitoring tools such as CD4 counts and liver function tests that increased the ease of decision-making by less experienced clinical staff, a process we would describe as 'paradoxical simplification'. Clinical staff found HIV management (e.g. initiation of treatment and prophylaxis, or monitoring effectiveness of treatment) easier if they had a 'number' to follow rather than having to rely on clinical assessments alone. A Sysemex machine capable of performing automated CD4 counts was introduced into the Mindouli laboratory. In the same logic, an automated biochemistry machine was installed to support the monitoring and management of ART related side-effects (e.g. hepatitis, renal dysfunction), which also increased hospital capacity for diagnosis and management of other non-HIV related medical conditions.
In a population with little knowledge of HIV or the benefits of treatment, it was felt that strong efforts were needed to encourage patients to commit fully to ART. Before starting ART patients were required to attend at least 2–3 education and adherence workshops (usually in groups) on HIV and how ART medications work, common side effects and how to overcome them, the importance of adherence, and drug resistance. Counselors had a strong input into decisions regarding a patient's readiness to commence ART, including an assessment of the patient's understanding of the disease and ability to take ART. A patient support group was also created which was facilitated by the counsellors with the presence of a doctor or nurse on occasions.