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, 6]. 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.

HIV activities began with HIV counseling and testing in Kinkala in March 2005 and in Mindouli in February 2006. All HIV activities were transferred from Kinkala to Mindouli in May 2006 as MSF withdrew its support in Kinkala, and in Mindouli were handed over to the MoH in February 2008.

Overall, 1058 HIV tests were performed of which 388 (37%) were positive. Of those HIV positive, 352 (91%) accepted medical care; 95% were ≥ 15 years of age and 71% were female. By the end of December 2007, 236 (76% of those in medical care) people had commenced ART in the Kinkala/Mindouli program; 222 (94%) adults and 12 (5%) children<15 years of age (age unknown for 2 people).

Thus ART has been commenced for a significant number of patients (especially for an integrated rural-based program) and the outcomes have been good with important individual benefits.

One of the greatest challenges was to convince staff (both expatriate and national) working under basic conditions with high medical needs and limited resources of the need and capability to introduce HIV care. It was essential to promote and/or develop a sense of ownership and motivation within the field teams to make HIV integration work. Some staff felt that there were greater medical priorities; malaria, diarrhea, respiratory illnesses, malnutrition and maternal and infant health. Staff were also unfamiliar and uncomfortable with HIV management and there was a fear that HIV care, through its perceived complexity and time demands on already overworked staff, would turn the focus of care too much towards HIV and detract from the ability to provide for these other needs. Concerns were addressed through education and discussions, including explaining that although there may appear to be higher priority health care needs, most of the major morbidities confronted occur more frequently and have a higher mortality in the presence of underlying HIV. Thus addressing HIV would substantially contribute to addressing these other health care needs. In addition, the introduction of HIV activities allowed the justification to program managers of extra resources that were in fact already needed (e.g. an extra doctor, extra laboratory resources). Thus rather than draining resources from other services, staff discovered that introducing HIV care led to a strengthening of medical activities in other areas. Overall, the experience was that introducing HIV services led to minimal disruption to other activities while providing additional, much needed resources.

One of the challenges of introducing HIV care into an area with minimal HIV knowledge or awareness is a concern over stigma and negative consequences from health staff, families and community for those diagnosed as HIV positive[12]. This may lead to excessive confidentiality measures being instituted that lead to secrecy rather than appropriate practice. Early in this program medical practices that were potentially dangerous were instituted such as not writing patient's HIV drugs on the medication chart or recording their HIV status in their medical history, and not informing health staff providing direct patient care – for instance the TB nurse – of a patient's HIV status. To overcome this, an approach was needed where openness around HIV testing and treatment was promoted. For example that it is normal and beneficial for people to know their HIV status and that all people for whom HIV infection would complicate their illness should be encouraged to be tested (e.g. all patients on medical, TB and therapeutic feeding wards were given group counselling and offered HIV testing). In addition normal codes of medical confidentiality were instituted with efforts to ensure that HIV results and medications were entered into the medical files and drug charts, and that a patient's HIV status was appropriately shared by staff caring for patients.

As care was targeted towards patient groups with high levels of immunosuppression (e.g. medical inpatients, those with symptoms) and TB co-infected patients, teams were confronted with the significant early mortality rates on ART frequently described from African programs[5], especially in the early phases of integration. This had the effect of initially reducing the confidence of the inexperienced medical staff in managing ART, and reinforced fears around safety of ART amongst patients. In this situation, efforts were required to reassure staff and patients of the reasons for the high mortality, and to promote initiation of treatment for eligible but asymptomatic patients to simplify patient management and demonstrate success.

In a region where both patients and staff were unfamiliar with HIV, there were many debates within health staff regarding the 'ethics' of offering HIV testing, especially with the lack of guaranteed long-term availability of ART. For example, there were understandable concerns that people tested for HIV could face serious negative consequences if tested positive (e.g. abandonment, physical violence, discrimination), and people were often not convinced that the benefits of testing outweighed these concerns. Thus teams were often reluctant or actively opposed to offering CT; this was most evidenced by a reluctance to offer HIV testing in the antenatal clinic for mainly asymptomatic pregnant women. To address these concerns, careful and repeated discussions from staff experienced in HIV management outlining the benefits and the means of minimising the risks of testing were required.

The integrated HIV programme in Pool is faced with a number of challenges. Most significantly, the numbers of people living with HIV (PLHA) accessing care will steadily increase, and this will place increasing demands on the costs and workload of HIV care. However, as most PLHA will become well on treatment, this workload will be compensated by reduced needs for hospitalization and palliative care of AIDS sufferers, particularly as access to care expands and more people start ART before they are sick.

Another challenge is the prevention of mother to child HIV transmission (PMTCT). These activities have not yet been introduced mainly due to a lack of motivation from the field teams related to a combination of failing to understand the importance and benefits of PMTCT, a fear of harm to women being diagnosed HIV positive, lack of experience with PMTCT, and busy workload. In addition, the number of children diagnosed and treated has been suboptimal due to inexperience and fear of testing and treating children with HIV, but also because of a lack of diagnostic tools and adapted medications for young children [16]. Designing effective PMTCT interventions and increasing the number of children diagnosed and treated for HIV, especially as infants, [17] is an urgent priority for the future.

Finally, as the cohort of patients on ART matures, there will be an increasing need for second-line ARVs for those failing treatment [10]. This will place increasing strains on the project in terms of cost, complexity and sustainability, and access to second-line ARVs will need to be made available through the NACP.

Integrating HIV care activities into basic health programs in conflict affected areas is possible with good individual outcomes and benefits to communities and health care systems. Nevertheless there are many challenges and dilemmas in implementation. Our experience in RoC, which adds to the growing evidence that ART delivery is effective in conflict settings[8, 18], has yielded a number of important lessons that could benefit actors considering similar interventions. Integrated HIV programs have a role to play in rural and remote settings where they have the potential to save lives and play a key role in helping to achieve universal access to ART in Africa.