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Rwanda has prioritized the decentralization and integration of HIV services over the past decade to ensure universal access to HIV services throughout the nation. Improving the capacity of healthcare providers to provide high-quality HIV prevention and treatment services was a crucial component of this process. In partnership with the authors, Rwanda's national health implementation agency developed a national clinical mentorship program from 2011 to 2017 to facilitate this transition. The Rwanda Clinical Mentorship Model aims to effectively manage HIV-infected patients across all levels of healthcare delivery, implement task shifting, and adhere to national guidelines. The clinical care of HIV-positive individuals was transferred from HIV specialists to family physicians and nurses. The facility team was trained, supervised, and mentored by a multidisciplinary team. Mentorship consisted of routine site visits during which clinical case reviews, clinical supervision teaching, and data reviews were conducted to assess the facility's performance and identify obstacles. Between 2012 and 2020, 5,774 healthcare professionals across the country received HIV testing and treatment training. This clinical mentoring has demonstrated a pragmatic, data-driven, and enduring strategy for enhancing clinical practice at all levels of care. A dedicated cadre of mentors is required to ensure the coordination and sustainability of this approach, according to one finding. The authors participated in accelerating the geographic and scope expansion of clinical mentoring in Rwanda. Developing a sustainable HIV clinical mentorship program in Rwanda requires longterm partnerships and evolving technical assistance. [ABSTRACT FROM AUTHOR]

Female sex workers (FSWs) frequently face violence in their working place. This study assessed the physical and sexual violence and associated factors among FSWs in Rwanda. A cross-sectional study was conducted among FSWs in Rwanda in 2015. Venue-Day-Time sampling method was used for recruitment. Descriptive analyses and logistic regression models were computed to assess factors associated with violence. In total, 1978 FSWs were recruited. A large proportion (18.3%) had been sexually abused outside of the family circle, and 37.8% had faced physical violence before 15 years of age. Clients were most often reported (67.0%) as perpetrators of physical violence in sex work. Being aged 25 years old and above, and having sexually transmitted infections (STIs) were positively associated with sexual violence (aOR = 2.1[95%CI: 1.80-2.39]) and (aOR = 3.0[95%CI: 1.01-2.14], respectively). Being aged 25 years old and above (aOR = 0.8[95%CI: 0.76-0.89]) and drinking alcohol every day (aOR = 0.6[95%CI: 0.42-0.87]) were negatively associated with physical violence. Sexual and physical violence was common among FSWs in Rwanda. Single FSWs are the most vulnerable to sexual violence. Alcohol consumption and having STIs are associated with violence against FSWs. Human rights and social protection as well as health promotion among FSWs is needed. [ABSTRACT FROM AUTHOR]

Female sex workers (FSWs) are at high risk for HIV. Cross-sectional surveys using a venue–day–time approach for recruitment were conducted among FSWs in Rwanda in 2006, 2010 and 2015. Chi square test for trends was computed to determine behavior changes. Logistic regression models were computed to determine risk factors associated with consistent condom use for the 2015 survey. There were 1041, 1338, and 1978 FSWs surveyed in 2006, 2010, and 2015, respectively. Condom use at the last sexual encounter with a client was similar in all surveys: 84.2%, 64.1%, and 83.3% (p = 1.0), respectively. Comprehensive HIV knowledge among FSWs was higher in 2015 than in 2006: 18.4%, 53.1%, and 71.1% (p = 0.00), respectively. Living in Kigali City and the Western province (aOR = 1.9 [95% CI: 1.3–2.8] and aOR = 2.0 [95% CI: 1.4–2.9], respectively) and higher level of education (OR = 2.0 [95% CI: 1.4–2.9]) were positively associated with consistent condom use with a client. Street-based FSWs (aOR = 0.7 [95% CI: 0.6–0.9]); FSWs with sex work as sole occupation (aOR = 0.6 [95% CI: 0.5–0.7]); FSWs who experienced sexually transmitted infections in the last year (aOR = 0.7 [95% CI: 0.5–0.8]) and HIV-positive FSWs (aOR = 0.8 [95% CI: 0.6–0.9]) were less likely to report consistent condom use. HIV prevention methods have evolved among FSWs in RWanda over the last decade, but HIV prevalence remains high. Condom use among many FSWs is inconsistent. New approaches for behavior change and income-generating activities are needed to reduce the vulnerability of FSWs in Rwanda. [ABSTRACT FROM AUTHOR]

The Rwanda national HIV program has been successful at scaling up antiretroviral therapy (ART) to achieve universal access. The AIDSRelief Model of Care focuses on four key principles: (1) earlier initiation of ART; (2) use of durable, highly-potent, and sequence-friendly first-line ART regimens; (3) early detection of treatment failure; and (4) provision of community-based care and support to ensure optimal adherence and follow up/engagement in care. We conducted a retrospective cohort study of randomly-selected HIV-infected patients at AIDSRelief-supported sites using a stratified, random sample of 583 adults (>15 years) who initiated ART from 30 June 2008 to 1 February 2010. At ART initiation, the median patient age was 38 years, and 67% were female. The baseline median CD4+ cell count was 309 cells/mm3. Overall virologic suppression was 91%. Married/ever married status (adjusted prevalence odds ratio [aPOR] 3.75, 95% confidence interval [CI] 1.30-10.78) and self-reported adherence ≥95% in the past month (aPOR 2.76, 95% CI 1.00-7.62) were significantly associated with viral suppression in the multivariable model. Excellent virologic outcomes were achieved in Rwandan AIDSRelief sites utilizing the AIDSRelief Model of Care during the scale-up of ART in the country. [ABSTRACT FROM AUTHOR]

Background: Human Immunodeficiency Virus (HIV), syphilis, Hepatitis B Virus (HBV) and Hepatitis C Virus (HCV) are sexually transmitted infections (STIs) and share modes of transmission. These infections are generally more prevalent among female sex workers (FSWs).Methods: This is a cross-sectional study conducted among female sex workers (FSWs) in Rwanda in 2015. Venue-Day-Time (VDT) sampling method was used in recruiting participants. HIV, syphilis, HBV, and HCV testing were performed. Descriptive analyses and logistic regression models were computed.Results: In total, 1978 FSWs were recruited. The majority (58.5%) was aged between 20 and 29 years old. Up to 63.9% of FSWs were single, 62.3% attained primary school, and 68.0% had no additional occupation beside sex work. Almost all FSWs (81.2%) had children. The majority of FSWs (68.4%) were venue-based, and most (53.5%) had spent less than five years in sex work. The overall prevalence of syphilis was 51.1%; it was 2.5% for HBV, 1.4% for HCV, 42.9% for HIV and 27.4% for syphilis/HIV co-infection. The prevalence of syphilis, HIV, and syphilis + HIV co-infection was increasing with age and decreasing with the level of education. A positive association with syphilis/HIV co-infection was found in: 25 years and older (aOR = 1.82 [95% CI:1.33-2.50]), having had a genital sore in the last 12 months (aOR = 1.34 [95% CI:1.05-1.71]), and having HBsAg-positive test (aOR = 2.09 [1.08-4.08]).Conclusion: The prevalence of HIV and syphilis infections and HIV/syphilis co-infection are very high among FSWs in Rwanda. A strong, specific prevention program for FSWs and to avert HIV infection and other STIs transmission to their clients is needed. [ABSTRACT FROM AUTHOR]

Syphilis can be transmitted by pregnant women to their children and is a public health problem in Africa. A cross-sectional survey was conducted in 24 antenatal clinics from 2002 to 2003 and increased to 30 sites from 2005 to 2011. Participants were tested for syphilis and HIV. Multi-variate logistic regression was performed to identify risks associated with syphilis and its co-infection with HIV. Results showed that syphilis decreased from 3.8% in 2002 to 2.0% in 2011. Syphilis in the HIV-infected participants increased from 6.0% in 2002 to 10.8% in 2011, but decreased from 3.7% to 1.7% in the HIV-negative participants. In 2011, syphilis in urban participants was 2.7% and 1.4% in rural ones. HIV-infected participants screened positive for syphilis more frequently in both rural (aOR = 3.64 [95% CI: 1.56%-8.51%]) and urban areas (aOR = 7.26 [95% CI: 5.04%-10.46%]). Older participants (25-49 years) residing in urban areas (aOR = 0.43[95% CI: 0.32%-0.58%]) and women with secondary or high education (aOR = 0.35[95% CI: 0.20%-0.62%]) were less likely to screen positive for syphilis. HIV-syphilis co-infection was more likely in women residing in urban areas (aOR = 8.32[95% CI: 3.54%-19.56%]), but less likely in women with secondary/high education (aOR = 0.11[95% CI: 0.01%-0.77%]). In conclusion, syphilis increased in HIV-positive pregnant women, but decreased in HIV-negative women. Positive HIV status and young age were associated risks for syphilis. HIV-syphilis co-infection was associated with a lower level of education and urban residence. [ABSTRACT FROM AUTHOR]

Objective: To evaluate HIV drug resistance (HIVDR) and determinants of virological failure in a large cohort of patients receiving first-line tenofovir-based antiretroviral therapy (ART) regimens.Methods: A nationwide retrospective cohort from 42 health facilities was assessed for virological failure and development of HIVDR mutations. Data were collected at ART initiation and at 12 months of ART on patients with available HIV-1 viral load (VL) and ART adherence measurements. HIV resistance genotyping was performed on patients with VL ≥1000 copies/ml. Multiple logistic regression was used to determine factors associated with treatment failure.Results: Of 828 patients, 66% were women, and the median age was 37 years. Of the 597 patients from whom blood samples were collected, 86.9% were virologically suppressed, while 11.9% were not. Virological failure was strongly associated with age <25 years (adjusted odds ratio [aOR]: 6.4; 95% confidence interval [CI]: 3.2-12.9), low adherence (aOR: 2.87; 95% CI: 1.5-5.0) and baseline CD4 counts <200 cells/μl (aOR 3.4; 95% CI: 1.9-6.2). Overall, 9.1% of all patients on ART had drug resistance mutations after 1 year of ART; 27% of the patients who failed treatment had no evidence of HIVDR mutations. HIVDR mutations were not observed in patients on the recommended second-line ART regimen in Rwanda.Conclusions: The last step of the UNAIDS 90-90-90 target appears within grasp, with some viral failures still due to non-adherence. Nonetheless, youth and late initiators are at higher risk of virological failure. Youth-focused programmes could help prevent further drug HIVDR development. [ABSTRACT FROM AUTHOR]

Background: Hepatitis C virus (HCV) treatment data in sub-Saharan Africa are limited. This study was to determine HCV sustained virologic response(SVR) at 24 weeks in patients undergoing HCV therapy in Kigali, Rwanda. Methods: The paper presents data for all patients treated for HCV with ribavirin/interferon at King Faisal Hospital in Kigali, Rwanda, from 1 January 2007 to 31 December 2014. Results and Conclusions: There were 69 evaluable patients. HCV genotype 4(61%, 42/69) predominated. 24-week SVR was 70%(26/37) by per-protocol and 32%(26/69) by intention-to-treat analysis. HCV treatment in Rwanda is feasible. SVR with interferon/ribavirin was acceptable in the per-protocol analysis. Transition to newer direct acting antivirals is urgently needed in Rwanda and sub-Saharan Africa more generally to improve treatment outcomes. [ABSTRACT FROM AUTHOR]

Tuberculosis (TB) is the leading cause of morbidity and mortality among people living with HIV (PLHIV) in sub-Saharan Africa. Early TB detection and treatment is key to saving lives of PLHIV. Rwanda began implementing intensified TB case finding (ICF) in 2005 in line with World Health Organization policy on TB/HIV collaborative activities. We aimed to describe trends of ICF in PLHIV newly enrolled into HIV clinics.We used routinely collected program data on ICF from facility-based pre-antiretroviral therapy/antiretroviral therapy registers in Rwandan HIV clinics from 2006 to 2011. Semiannual, active data collection for PLHIV newly enrolled into HIV care included proportion screened for TB, proportion screened positive, and percentage with active TB and started anti-TB drugs.The number of health facilities reporting TB screening indicators increased 16-fold, from 20 facilities in the first semester of 2006 to 328 facilities by the end of 2011. The proportion of patients screened increased progressively from 77% of newly enrolled patients in first semester of 2006 to 94% at the end of 2011 (P < 0.001). The proportion of patients who screened positive decreased over time, from 23% in the first semester of 2006 to 10% at the end of 2011 (P < 0.001). The proportion of active TB cases remained relatively constant over time at 2.2%.Rwanda has increased the proportion of newly enrolled PLHIV screened for TB using a simple screening protocol. Countries with limited resources but high HIV and TB disease prevalence should implement ICF as part of their integrated HIV-TB treatment programs. [ABSTRACT FROM AUTHOR]

Background: Voluntary assisted partner notification (VAPN) services that use contract, provider, or dual referral modalities may be efficient to identify individuals with undiagnosed HIV infection. We aimed to assess the relative effectiveness of VAPN modalities in identifying undiagnosed HIV infections. Setting: VAPN was piloted in 23 health facilities in Kigali, Rwanda. Methods: We identified individuals with a new HIV diagnosis before antiretroviral therapy initiation or individuals on antiretroviral therapy (index cases), who reported having had sexual partners with unknown HIV status, to assess the association between referral modalities and the odds of identifying HIV-positive partners using a Bayesian hierarchical logistic regression model. We adjusted our model for important factors identified through a Bayesian variable selection. Results: Between October 2018 and December 2019, 6336 index cases were recruited, leading to the testing of 7690 partners. HIV positivity rate was 7.1% (546/7690). We found no association between the different referral modalities and the odds of identifying HIV-positive partners. Notified partners of male individuals (adjusted odds ratio 1.84; 95% credible interval: 1.50 to 2.28) and index cases with a new HIV diagnosis (adjusted odds ratio 1.82; 95% credible interval: 1.45 to 2.30) were more likely to be infected with HIV. Conclusion: All 3 VAPN modalities were comparable in identifying partners with HIV. Male individuals and newly diagnosed index cases were more likely to have partners with HIV. HIV-positive yield from index testing was higher than the national average and should be scaled up to reach the first UNAIDS-95 target by 2030. [ABSTRACT FROM AUTHOR]

Monitoring and evaluation of antiretroviral treatment (ART) scale-up has been challenging in resource-limited settings. We describe an innovative cell-phone-based and internet-based reporting system (TRACnet) utilized in Rwanda.From January 2004 to June 30, 2010, all health facilities with ART services submitted standardized monthly aggregate reports of key indicators. National cohort data were analyzed to examine trends in characteristics of patients initiating ART and cumulative cohort outcomes. Estimates of HIV-infected patients eligible for ART were obtained from Joint United Nations Program on HIV/AIDS (Estimation and Projection Package-Spectrum, 2010).By June 30, 2010, 295 (65%) of 451 health centers, District and referral hospitals provided ART services; of these, 255 (86%) were located outside Kigali, the capital. Cell phone-based and internet-based reporting was used by 253 (86%) and 42 (14%), respectively. As of June 30, 2010, 83,041 patients were alive on ART, 6171 (6%) had died, and 9621 (10%) were lost-to-follow-up. Of those alive on ART, 7111 (8.6%) were children, 50,971 (61.4%) were female, and 1823 (2.2%) were on a second-line regimen. The proportion of all patients initiating ART at World Health Organization clinical stages 3 and 4 declined from 65% in 2005 to 27% in 2010. National ART coverage of eligible patients increased from 13% in 2005 to 79% in 2010.Rwanda has successfully expanded ART access and achieved high national ART coverage among eligible patients. TRACnet captured essential data about the ART program during rapid scale-up. Cell phone-based and internet-based reporting may be useful for monitoring and evaluation of similar public health initiatives in other resource-limited settings. [ABSTRACT FROM AUTHOR]