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As lifelong antiretroviral therapy (ART) for pregnant women is implemented, it is important to understand the attitudes and norms affecting women's postpartum ART adherence. This is a qualitative cross-sectional study of HIV-positive postpartum women (n = 112) enrolled in a 2-year observational prospective cohort in Rwanda. Informed by the Theory of Reasoned Action (TRA), we conducted in-depth interviews with women whose children were 0-6, 7-12, 13-18, or 21-24 months of age to describe factors contributing to adherence and changes over time. Positive ART attitudes reported by women included mothers' health promotion, prevention of infant HIV infection, higher CD4 count, and improved physical appearance. Negative attitudes were few, but included side effects and the lifelong nature of treatment. Learning from people living with HIV (PLHIV) was identified as a norm facilitating adherence; ART adherence was inhibited by fear of disclosure or stigmatization in communities and clinics. Poor adherence behaviors were common immediately after HIV diagnosis, not necessarily during prevention of mother-to-child transmission (PMTCT). Women with older children, most of whom stopped breastfeeding by 13-18 months, reported more barriers and missed doses than women with younger children. The TRA was useful in identifying the collective influence of attitudes, norms, and intentions on behavior. Findings suggest that HIV-positive women are vulnerable to poor adherence following HIV diagnosis and around the time of breastfeeding cessation. Lifelong treatment adherence can be supported through PLHIV exemplifying long-term ART use, fewer and less stigmatizing clinic visits, and counseling messages highlighting the benefits of drugs on appearance and illness prevention and incorporating biological feedback.

Purpose The health of infants that are HIV-exposed and -uninfected (HEU) is a major public health concern as HIV becomes a chronic condition. We investigate the interrelationship between maternal viral suppression, maternal weight status, breastfeeding, and infants that are HEU. Methods The Kabeho study followed 502 HEU infants in Kigali, Rwanda, for 24 months from 2013 to 2014. We use a structural equation modeling approach to investigate the dynamic relationships between viral suppression, maternal weight change, breastfeeding, and infant length-for-age z-score (LAZ) as defined by the WHO. Results Older mothers are more likely to be virally suppressed and to breastfeed. Viral suppression and the mother being on antiretroviral treatment for longer were related to lower infant LAZ at three months. A more positive maternal weight change was related to higher infant LAZ at the end of each period. At 12 months, a higher infant LAZ was related to increased probability of continued breastfeeding. At 18 months, continued breastfeeding was related to lower LAZ, and food shortages were related to higher LAZ. Conclusion There is a complex interrelationship between viral suppression, maternal weight change, breastfeeding, and infant LAZ. These relationships demonstrate the link between maternal and infant health in the context of HIV.

The authors discuss the Human Resources for Health Program, which is working to improve the quality and quantity of health professionals in Rwanda by means of sustained collaborations with U.S. schools of medicine, nursing, dentistry, and public health.

OBJECTIVE: To assess the safety and efficacy of the PrePex device for nonsurgical circumcision in adult males as part of a comprehensive HIV prevention program in Rwanda. METHODS: Single-center 6-week noncontrolled study in which healthy men underwent circumcision using the PrePex device which employs fitted rings to clamp the foreskin leading to distal necrosis. In the first phase of the study the feasibility of the procedure was tested on 5 subjects in a sterile environment; in the main phase an additional 50 subjects were circumcised in a nonsterile setting by physicians or a nurse. Outcome measures included the rate of successful circumcision time to complete healing pain and adverse events. RESULTS: In the feasibility phase all 5 subjects achieved complete circumcision without adverse events. In the main phase all 50 subjects achieved circumcision with 1 case of diffuse edema after device removal which resolved with minimal intervention. Pain was minimal except briefly during device removal (day 7 after placement in most cases). The entire procedure was bloodless requiring no anesthesia no suturing and no sterile settings. Subjects had no sick/absent days associated with the procedure. Median time for complete healing was 21 days after device removal. There were no instances of erroneous placement and no mechanical problems with the device. CONCLUSION: The PrePex device was safe and effective for nonsurgical adult male circumcision without anesthesia or sterile settings and may be useful in mass circumcision programs to reduce the risk of HIV infection particularly in resource-limited settings.

The creation and implementation of national cancer control plans is becoming increasingly necessary for countries in Africa, with the number of new cancer cases per year in the continent expected to reach up to 1·5 million by 2020. Examples from South Africa, Egypt, Nigeria, Ghana, and Rwanda describe the state of national cancer control plans and their implementation. Whereas in Rwanda the emphasis is on development of basic facilities needed for cancer care, in those countries with more developed economies, such as South Africa and Nigeria, the political will to fund national cancer control plans is limited, even though the plans exist and are otherwise well conceived. Improved awareness of the increasing burden of cancer and increased advocacy are needed to put pressure on governments to develop, fund, and implement national cancer control plans across the continent.

BACKGROUND: Generalizable data are needed on the magnitude and determinants of adherence and virological suppression among patients on antiretroviral therapy (ART) in Africa. METHODS: We conducted a cross-sectional survey with chart abstraction, patient interviews and site assessments in a nationally representative sample of adults on ART for 6, 12 and 18 months at 20 sites in Rwanda. Adherence was assessed using 3- and 30-day patient recall. A systematically selected sub-sample had viral load (VL) measurements. Multivariable logistic regression examined predictors of non-perfect (40 copies/ml). RESULTS: Overall, 1,417 adults were interviewed and 837 had VL measures. Ninety-four percent and 78% reported perfect adherence for the last 3 and 30 days, respectively. Eighty-three percent had undetectable VL. In adjusted models, characteristics independently associated with higher odds of non-perfect 30-day adherence were: being on ART for 18 months (vs. 6 months); younger age; reporting severe (vs. no or few) side effects in the prior 30 days; having no documentation of CD4 cell count at ART initiation (vs. having a CD4 cell count of

Not the final published version, Objectives: To describe experiences, and identify factors associated with nonadherence to a single-dose nevirapine (SD-NVP) regimen for the prevention of mother-to-child transmission (PMTCT) of HIV in Rwanda. Methods: In April to May 2006, using a case-control design at 12 PMTCT sites, we interviewed HIV-infected women who did not adhere (n = 111) and who adhered (n = 125) to the PMTCT prophylaxis regimen. Nonadherence was defined as mother and/or infant not ingesting SD-NVP at the recommended time or not at all and adherence as mother-infant pairs who ingested it as recommended. Results: Only 61% of nonadherent women had received SD-NVP during pregnancy or delivery. Among nonadherent women who received SD-NVP, 80% ingested it at the recommended time, representing 49% of all nonadherent women. Only 7% of their newborns ingested SD-NVP. Multivariate logistic regression showed that unmarried women, less educated women, women who made 2 or less antenatal care visits, and those offered HIV testing after their first antenatal care visit were more likely to be nonadherent to PMTCT prophylaxis. Not disclosing one's HIV status to someone aside from a partner was also associated with nonadherence in mother-infant pairs. Conclusions: Sociodemographic factors, health services delivery factors, and a lack of communication and social support contributed to nonadherence to PMTCT prophylaxis in Rwanda.

Introduction: Routine provider-initiated HIV testing and counselling (PITC) may increase HIV testing rates, but whether PITC is acceptable to health facility (HF) attendees is unclear. In the course of a PITC intervention study in Rwanda, we assessed the acceptability of PITC, reasons for being or not being tested and factors associated with HIV testing. Methods: Attendees were systematically interviewed in March 2009 as they left the HF, regarding knowledge and acceptability of PITC, history of testing and reasons for being tested or not. Subsequently, PITC was introduced in 6 of the 8 HFs and a second round of interviews was conducted. Independent factors associated with testing were analysed using logistic regression. Randomly selected health care workers (HCWs) were also interviewed. Results: 1772 attendees were interviewed. Over 95% agreed with the PITC policy, both prior to and after implementation of PITC policy. The most common reasons for testing were the desire to know one’s HIV status and having been offered an HIV test by an HCW. The most frequent reasons for not being tested were known HIV status and test not being offered. In multivariable analysis, PITC, age ≥15 years, and not having been previously tested were factors significantly associated with testing. Although workload was increased by PITC, HIV testing rates increased and HCWs overwhelmingly supported the policy. Conclusion: Among attendees and HCWs in Rwandan clinics, the acceptability of PITC was very high. PITC appeared to increase testing rates and may be helpful in prevention and early access to treatment.

In their Policy Forum “Global HIV/AIDS policy in transition” (11 June, p. [1359][1]), J. Bongaarts and M. Over conclude that antiretroviral therapy for AIDS is not a cost-effective use of donor funding for global health. We believe that Bongaarts and Over omitted key aspects of a complete cost-effectiveness assessment: numerous positive spinoffs to other services, the effect on increased attention on global health, and the ability to mobilize resources that would not otherwise have been available for global health. The situation in Rwanda serves as an example. Rwanda's total health expenditure declined from 1998 through 2002, but because of advocacy for HIV resources, total health expenditure doubled between 2002 and 2003 ([ 1 ][2]). HIV funding, even before the current focus on integration, provided resources for the renovation of health facilities, equipment, training, and management, as well as a culture of openness for best practices. With integration of HIV services into other health services, resources have had an even wider benefit, especially for maternal health services. Integration is still in progress, but successful steps have been made ([ 2 ][3], [ 3 ][4]). Rwanda's 2006 National Health Accounts reported that although reproductive health spending did not grow as rapidly as overall spending, it increased by 15% between 2002 and 2006 ([ 4 ][5]), and maternal mortality rate decreased from 1071 (in 2000) to 750 per 100,000 births (in 2005) and is expected to fall to about 350 in 2010. Rates of assisted deliveries, use of family planning, and receipt of four standard prenatal care services have seen a marked increase ([ 4 ][5]–[ 6 ][6]). Consistent with the results in Rwanda, a recent Lancet article correlated maternal mortality with HIV mortality in women ([ 7 ][7]). These improvements cannot be attributed to reproductive health spending alone; major health initiatives made possible by HIV funding are largely responsible. HIV resources also paid for the community-based health insurance premiums of many of the poorest segments of the population; the funding thus contributed to the increase in community-based health insurance enrollment rate from 7% in 2003 to 85% in 2008. The literature cited by Bongaarts and Over failed to consider all benefits gained beyond direct HIV services, including the value of saving a mother and its contribution to quality of life for her children and family and societal productivity. In doing so, Bongaarts and Over have greatly underestimated the impact of HIV funding on both HIV and non-HIV health results. 1. [↵][8] Rwanda Ministry of Health, “National health accounts 2006” (2008). 2. [↵][9] National AIDS Commission, “National strategic plan 2009–2012” (2009). 3. [↵][10] UNAIDS, “Rwanda country progress report 2008–2009” (UNAIDS, Geneva, 2010). 4. [↵][11] Rwanda Ministry of Health, “Rwanda demographic and health survey 2000” (2001). 5. Rwanda Ministry of Health, “Rwanda demographic and health survey 2005” (2006). 6. [↵][12] Rwanda Ministry of Health, “Rwanda demographic and health survey 2007–2008” (2009). 7. [↵][13] 1. M. C. Hogan 2. et al ., Lancet 375, 1967 (2010). [OpenUrl][14][CrossRef][15][PubMed][16][Web of Science][17] [1]: /lookup/doi/10.1126/science.1191804 [2]: #ref-1 [3]: #ref-2 [4]: #ref-3 [5]: #ref-4 [6]: #ref-6 [7]: #ref-7 [8]: #xref-ref-1-1 "View reference 1 in text" [9]: #xref-ref-2-1 "View reference 2 in text" [10]: #xref-ref-3-1 "View reference 3 in text" [11]: #xref-ref-4-1 "View reference 4 in text" [12]: #xref-ref-6-1 "View reference 6 in text" [13]: #xref-ref-7-1 "View reference 7 in text" [14]: {openurl}?query=rft.jtitle%253DLancet%26rft.stitle%253DLancet%26rft.aulast%253DMcCaw-Binns%26rft.auinit1%253DA.%26rft.volume%253D375%26rft.issue%253D9730%26rft.spage%253D1967%26rft.epage%253D1968%26rft.atitle%253DNew%2Bmodelled%2Bestimates%2Bof%2Bmaternal%2Bmortality.%26rft_id%253Dinfo%253Adoi%252F10.1016%252FS0140-6736%252810%252960924-5%26rft_id%253Dinfo%253Apmid%252F20569839%26rft.genre%253Darticle%26rft_val_fmt%253Dinfo%253Aofi%252Ffmt%253Akev%253Amtx%253Ajournal%26ctx_ver%253DZ39.88-2004%26url_ver%253DZ39.88-2004%26url_ctx_fmt%253Dinfo%253Aofi%252Ffmt%253Akev%253Amtx%253Actx [15]: /lookup/external-ref?access_num=10.1016/S0140-6736(10)60924-5&link_type=DOI [16]: /lookup/external-ref?access_num=20569839&link_type=MED&atom=%2Fsci%2F330%2F6001%2F176.1.atom [17]: /lookup/external-ref?access_num=000278689600024&link_type=ISI