Eye on Rwanda – successes and challenges in HIV testing and treatment

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Anita Asiimwe, MD, MPH, of the Rwanda Biomedica Center in Kigali, presents to an audience at the 19th Conference on Retroviruses and Opportunistic Infections Tuesday afternoon in Seattle.

In many ways, Rwanda is a success story in terms of provision of services to people with HIV — just 18 years after 800,000 people were massacred in the country’s 1994 genocide. Anita Asiimwe, MD, MPH, of the Rwanda Biomedica Center in Kigali, drew a picture of what is seen on the ground for an audience at the 19th Conference on Retroviruses and Opportunistic Infections Tuesday afternoon in Seattle.  The small sub-Saharan African country has three percent HIV prevalence among the general population aged 15 to 49 – 3.7 percent among females, 2.2 percent among males – and prevalence is three times as high in urban areas (7.1 percent) as in rural areas (2.3 percent).

Of Rwanda’s 484 health facilities, 93 percent offered HIV testing and counseling in 2011; 85 percent offered prevention of mother-to-child transmission (PMTCT) services; and 81 percent offered antiretroviral therapy (ART). Through those services, 94 percent of HIV infected persons in Rwanda with a CD4 count less than 350 were receiving ART in 2011 and 78 percent of HIV infected pregnant women were receiving ART in 2010.  Eighty-five percent of the male partners of women in the PMTCT programs were tested for HIV, and 90 percent of women in the program were retained on care.

What could be behind the successes they are seeing? Asiimwe had several answers. “A number of evaluators will note – and this is something that means a lot to us in Rwanda — is the commitment politically from very high levels to making HIV a priority, and getting people care no matter what they can or cannot afford,” she said.

Other thoughts included efforts to coordinate strategic decisions making sure that all stakeholders are involved from planning to implementation; integration of HIV programs into health care system – so they are not on their own; decentralizing care and services provision to empower local care centers; keeping care and treatment equitable for all Rwandans – regardless of gender or geography; and incorporation of task shifting to empower non-doctors to handle ARV administration.

Asiimwe also mentioned their National HIV Monitoring System (TRACnet) that allows them to monitor several indicators in HIV care – including number in therapy, how many people are on which regimen, how many have been lost to follow up, etc. – in order to target improvement efforts.

The country is not without its challenges, however. HIV testing coverage is low, Asiimwe said. Only 39 percent of females and 38 percent of males were tested in the 12 months preceding data collection in 2010 and received results. The country also reported low condom use – only 29 percent of women and 28 percent men who had two or more partners reported using a condom during their last sexual encounter.

They also have a problem of extremely high HIV prevalence among female sex workers. – 51 percent in 2010, versus three percent prevalence in the general population. “If we’re going to be able to respond to our population’s HIV risk we have to look at services available to this population,” Asiimwe said. This population also reported low consistent condom use (33 percent). The country also has little knowledge of the homosexual population and consequently poor service provision, but they are working on this with a focus on the MSM population in the country’s major city, Kigali. Prompted by a question from a man from Uganda, she also noted that the country’s leadership had resisted calls to criminalize homosexuality as an action that would undermine the country’s AIDS response.

Asiimwe also presented data on a huge disparity between people who knew where to get an HIV test (96 to 99 percent across all age groups) versus the percentage that had been tested and received results from their last HIV test taken in the past 12 months (ranging from 27 to 47 percent across all age groups).

She also presented evidence of patient enrolment into HIV care and treatment in 2009, where less than 50 percent of diagnosed HIV patients had enrolled into care and treatment within 90 days of receiving their HIV diagnosis. She postulated that in 2009 linkage was poor because although there were various health centers able to offer testing, not many were able to offer access to treatment at that time.

Asiimwe called out the need to efficiently identify greater numbers of HIV infected people earlier in the course of their disease through HIV testing programs, and linking those patients in a timely manner to appropriate care and antiretroviral treatment. To do that, she mentioned focusing efforts to test on groups in the population thought to be the source of most new infections or geographical locations with the highest prevalence considered sources of most new infections.

As the final panelist in a symposium devoted largely to research and development activity related to pre-exposure prophylaxis or PrEP, Asiimwe underscored the work in the epidemic left still undone, including the millions in Africa who still need ART to save their own lives and the current threat to resources available to fight the epidemic.


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