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Objectives: Cervical cancer is the major cause of death from cancer in Africa. We wanted to assess the prevalence of human papillomavirus (HPV) infections and associated risk factors and to determine whether HPV testing could serve as a screening method for squamous intraepithelial lesions (SILs) in Rwanda. We also wanted to obtain a broader understanding of the underlying risk factors for the establishment of HPV infection in Rwanda. Methods: A total of 206 HIV‐positive women, 172 HIV‐negative women and 22 women with unknown HIV status were recruited at the University Teaching Hospitals of Kigali (UTHK) and of Butare (UTHB) in Rwanda. Participants underwent an interview, cervical sampling for a Thinprep Pap test and a screening test analysing 37 HPV strains. Results: Only 27% of HIV‐positive women and 7% of HIV‐negative women had been screened for cervical cancer before. HPV16 and HPV52 were the most common HPV strains. HIV‐positive women were more commonly infected with high‐risk (HR) HPV and multitype HPV than HIV‐negative women. The sensitivity was 78% and the specificity 87% to detect high‐grade SIL (HSIL) with HPV screening. Among HIV‐negative women, being divorced was positively associated with HR‐HPV infection, while hepatitis B, Trichomonas vaginalis infection and HR‐HPV infection were factors positively associated with SILs. Ever having had gonorrhoea was positively associated with HR‐HPV infection among HIV‐positive women. HR‐HPV infection and the number of live births were positively associated with SILs. Conclusions: The currently used quadrivalent vaccine may be insufficient to give satisfactory HPV coverage in Rwanda. HPV Screening may be effective to identify women at risk of developing cervical cancer, particularly if provided to high‐risk patients. [ABSTRACT FROM AUTHOR]

The diagnosis of pulmonary tuberculosis (TB) is challenging among patients infected with HIV. This study aimed to assess the incremental yield of bronchoalveolar lavage (BAL) and postbronchoscopy sputum (PBS) in the diagnosis of pulmonary TB among HIV-infected patients whose sputum smear microscopy was negative for TB or who were unable to produce sputum for analysis. The study was a prospective study conducted between March 2013 and December 2014 and all patients willing to participate were recruited. They underwent bronchoscopy and bronchoalveolar lavage and when possible a sample of postbronchoscopy sputum was taken within 5 days after the bronchoscopy. Of the 115 HIV-infected patients who underwent bronchoscopy, pulmonary TB was diagnosed in 56 (48.6%) patients. Among 56 patients confirmed with positive cultures, 34/56 (57.1%) were positive both in PBS and BAL, 13/56 (23.2 %) cultures were positive only in PBS and 9/56 (16%) were positive only in BAL. The culture yield of Mycobacterium tuberculosis was increased by 12% using PBS samples and by 7.8% using BAL. The difference between BAL and PBS was not statistically significant. The study concluded that BAL and PBS are very useful methods in the diagnosis of pulmonary TB among HIV-infected patients who are smear negative or have dry cough. Strengthening bronchoscopy can reduced empirical treatment of TB especially among HIV patients. [ABSTRACT FROM AUTHOR]

Background: Adolescents living with HIV have elevated mental distress and suboptimal antiretroviral therapy (ART) adherence., Setting: Two urban clinics in Kigali, Rwanda., Methods: A 2-arm individual randomized controlled trial compared Trauma-Informed Cognitive Behavioral Therapy enhanced to address HIV (TI-CBTe) with usual care (time-matched, long-standing, unstructured support groups) with 356 12- to 21-year-old (M = 16.78) Rwandans living with HIV. TI-CBTe included 6 group-based 2-hour sessions led by trained and supervised 21- to 25-year-old Rwandans living with HIV. Participants reported their ART adherence, depression/anxiety, and Post-Traumatic Stress Disorder symptoms at baseline, 6, 12, and 18 months., Results: ART adherence was relatively high at baseline, and youth reported elevated rates of depression/anxiety and trauma symptoms. There were no differential treatment effects on adherence, but depression/anxiety improved over time. Youth with lower depression/anxiety at baseline seemed to benefit more from TI-CBTe than usual care, whereas women with high baseline distress seemed to benefit more from usual care. Youth were less likely to score in high Post-Traumatic Stress Disorder symptom categories at the follow-up, with no differential treatment effects., Conclusions: TI-CBTe did not outperform usual care on ART adherence, possibly reflecting relatively high adherence at baseline, simplified medication regimens over time, a strong comparison condition, or because youth assigned to TI-CBTe returned to their support groups after the intervention. TI-CBTe was more effective for youth with lower depression/anxiety symptoms, whereas youth with high distress benefitted more from the support groups. TI-CBTe was feasible and acceptable, and young adults living with HIV were able to deliver a mental health intervention with fidelity. The powerful nature of the comparison group, ongoing support groups, points to the potential value of locally crafted interventions in low-resource settings., Competing Interests: The authors have no conflicts of interest to disclose., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Health workers (HWs) in Africa face challenges accessing and learning from existing online training opportunities. To address these challenges, we developed a modular, self-paced, mobile-ready and work-relevant online course covering foundational infection prevention and control (IPC) concepts. Here, we evaluate the first pilot of this course, conducted with HWs in Nigeria., Methods: We used a learner-centered design and prototyping process to create a new approach to delivering online training for HWs. The resulting course comprised 10 self-paced modules optimized for use on mobile devices. Modules presented IPC vignettes in which learning was driven by short assessment questions with feedback. Learners were recruited by distributing a link to the training through Nigeria-based email lists, WhatsApp groups and similar networks of HWs, managers and allied professionals. The course was open to learners for 8 weeks. We tracked question responses and time on task with platform analytics and assessed learning gains with pre- and post-testing. Significance was evaluated with the Wilcoxon signed-rank test, and effect size was calculated using Cohen's d., Results: Three hundred seventy-two learners, with roles across the health system, enrolled in the training; 59% completed all 10 modules and earned a certificate. Baseline knowledge of foundational IPC concepts was low, as measured by pre-test scores (29%). Post-test scores were significantly higher at 54% (effect size 1.22, 95% confidence interval 1.00-1.44). Learning gains were significant both among learners with low pre-test scores and among those who scored higher on the pre-test. We used the Net Promoter Score (NPS), a common user experience metric, to evaluate the training. The NPS was + 62, which is slightly higher than published scores of other self-paced online learning experiences., Conclusions: High completion rates, significant learning gains and positive feedback indicate that self-paced, mobile-ready training that emphasizes short, low-stakes assessment questions can be an effective, scalable way to train HWs who choose to enroll. Low pre-test scores suggest that there are gaps in IPC knowledge among this learner population., (© 2022. The Author(s).)

Background: Proper hand hygiene (HH) practices have been shown to reduce healthcare-acquired infections. Several potential challenges in low-income countries might limit the feasibility of effective HH, including preexisting knowledge gaps and staffing., Aim: We sought to evaluate the feasibility of the implementation of effective HH practice at a teaching hospital in Rwanda., Methods: We conducted a prospective quality improvement project in the intensive care unit (ICU) at the Kigali University Teaching Hospital. We collected data before and after an intervention focused on HH adherence as defined by the World Health Organization '5 Moments for Hand Hygiene' and assuring availability of HH supplies. Pre-intervention data were collected throughout July 2019, and HH measures were implemented in August 2019. Post-implementation data were collected following a 3-month wash-in., Results: In total, 902 HH observations were performed to assess pre-intervention adherence and 903 observations post-intervention adherence. Overall, HH adherence increased from 25% (222 of 902 moments) before intervention to 75% (677 of 903 moments) after intervention ( P < 0.001). Improvement was seen among all health professionals (nurses: 19-74%, residents: 23-74%, consultants: 29-76%)., Conclusions: Effective HH measures are feasible in an ICU in a low-income country. Ensuring availability of supplies and training appears key to effective HH practices., Competing Interests: The authors report no conflicts of interest. This work was supported by the UVA Global Infectious Diseases Institute, National Institutes of Health Center for Advancing Translational Science (UL1TR003015/KL2TR003016), and National Institute Of Allergy And Infectious Diseases (K23AI163368).

Background: Sub-Saharan African adolescents living with HIV face challenges to antiretroviral therapy (ART) adherence. Poor mental health drives nonadherence but can be improved with cognitive behavioral therapy (CBT). CBT delivered by peers may strengthen effects while building capacity for sustainment in low-income countries. This case study retrospectively applied the Exploration Preparation Implementation Sustainment framework to characterize the execution of the Kigali Imbereheza Project, a 2-arm individually randomized group controlled trial of Trauma-Informed Adherence-Enhanced CBT (TI-CBTe) delivered by Rwandan youth leaders (YLs) to adolescents living with HIV., Methods: YL (n = 14, 43% female, M = 22.71 years) had confirmed HIV and self-reported ART adherence >95%. Participants (n = 356, 51% female, M = 16.78 years) living with HIV were randomized to TI-CBTe or usual care. Two YLs co-led TI-CBTe sessions over 2 months for a total of 12 hours, while other YL observed and rated fidelity. Participants reported on YL competence. Additional data evaluated feasibility, acceptability, uptake, and fidelity., Results: In the Exploration phase, focus groups, stakeholder meetings, and individual interviews revealed strong consensus for delivering TI-CBT to reduce adolescent depression and trauma and improve ART adherence. In the Preparation phase, curriculum revisions were made, YLs were successfully trained, and a cascading supervision model was established. In the Implementation phase, YL delivered TI-CBTe with close monitoring and supervision. Findings revealed strong feasibility, acceptability, uptake, and fidelity, increasing the likelihood of Sustainment., Conclusions: Exploration Preparation Implementation Sustainment can guide implementation planning and delivery and evaluate implementation outcomes.

Objective: We evaluated post-vaccination immunity status and describe potential risk factors associated with the lack of response among healthcare workers (HCWs) at a tertiary care hospital in Kigali, Rwanda., Results: Of 373 HCWs, 291 (78.2%) were female and 81 (21.8%) were male. The mean age of the study participants was 40.2 years (standard deviation [SD], 7.7 years), within a range of 24-41 years. Participants' mean BMI was 25.4 ± 6.6 kg/m 2 , with more than half of patients (60.3%) being overweight. 96% received all three doses of vaccination. A total of 36 participants (9.6%) were considered non responders as they did not develop a sufficient anti-HBs response post vaccination. The anti-HBs response was significantly higher in females when compared to males (p = 0.02). Interestingly, there was no significant association between decline in antibody levels with age (p = 0.242) and BMI (p = 0.516) of the participants. The anti-HBs titers were similar in the group of participants who had received two doses and those who had received three doses of the HBV vaccination. Overall the findings of our study provide a basis for testing for anti-HBs in all HCWs post vaccination in Rwanda.

Antimicrobial resistance (AMR) is a serious public health threat in both developed and developing countries. Many developing countries, including Rwanda, lack adequate surveillance systems, and therefore, the prevalence of AMR is not well-known. We conducted a prospective observational study to assess the prevalence of AMR among common bacterial isolates from clinical specimens obtained from patients on the medical wards of Kigali University Teaching Hospital (KUTH). We evaluated the antibiotic sensitivity patterns of bacterial pathogens cultured from urine, blood, sputum, and wound swab specimens obtained over a 6-month period (July 1 to December 30, 2013). There were 154 positive cultures from specimens obtained from 141 unique patients over the study period. Urine, blood, wound swab, and sputum cultures comprised 55.2%, 25.3%, 16.2%, and 3.3% of the total specimens evaluated; 31.4% and 58.7% of Escherichia coli and Klebsiella isolates, respectively, were resistant to at least one of the third generation cephalosporins. Eight percent of E. coli isolates were resistant to imipenem; 82% and 6% of Staphylococcus aureus strains were oxacillin- and vancomycin-resistant respectively. Antimicrobial resistance rates are high in Rwanda and pose a serious therapeutic challenge to the management of common infections., (© The American Society of Tropical Medicine and Hygiene.)