Does Provider-Initiated HIV Testing & Counselling Lead to Higher HIV Testing Rate & HIV Case Finding in Rwandan Clinics?

BACKGROUND:

Provider-initiated HIV testing and counselling (PITC) is promoted as a means to increase HIV case finding. We assessed the effectiveness of PITC to increase HIV testing rate and HIV case finding among outpatients in Rwandan health facilities (HF).

METHODS:

PITC was introduced in six HFs in 2009-2010. HIV testing rate and case finding were compared between phase 1 (pre-PITC) and phase 3 (PITC period) for outpatient-department (OPD) attendees only, and for OPD and voluntary counseling & testing (VCT) departments combined.

RESULTS:

Out of 26,367 adult OPD attendees in phase 1, 4.7 % were tested and out of 29,864 attendees in phase 3, 17.0 % were tested (p < 0.001). The proportion of HIV cases diagnosed was 0.25 % (67/26,367) in phase 1 and 0.46 % (136/29864) in phase 3 (p < 0.001). In multivariable analysis, both testing rate and case finding were significantly higher in phase 3 for OPD attendees. In phase 1 most of the HIV testing was done in VCT departments rather than at the OPD (78.6 % vs 21.4 % respectively); in phase 3 this was reversed (40.0 % vs 60.0 %; p < 0.001). In a combined analysis of VCT and OPD attendees, testing rate increased from 18.7 % in phase 1 to 25.4 % in phase 3, but case finding did not increase. In multivariable analysis, testing rate was significantly higher in phase 3 (OR 1.67; 95 % CI 1.60-1.73), but case finding remained stable (OR 1.09; 95 % CI 0.93-1.27).

CONCLUSION:

PITC led to a shift of HIV testing from VCT department to the OPD, a higher testing rate, but no additional HIV case finding.

Below: a. HIV testing rate at OPD. b. HIV case finding at OPD

Full article at:   http://goo.gl/uXYkdc

By:  Kayigamba FR1, Van Santen D2,3, Bakker MI4, Lammers J5, Mugisha V6, Bagiruwigize E7, De Naeyer L8, Asiimwe A9, Schim Van Der Loeff MF10,11,12.

• 1INTERACT, Kigali, Rwanda. fkaigamba@gmail.com.
• 2KIT Biomedical Research, Royal Tropical Institute (KIT), Amsterdam, The Netherlands. dvsanten@ggd.amsterdam.nl.
• 3Public Health Service of Amsterdam (GGD), Amsterdam, The Netherlands. dvsanten@ggd.amsterdam.nl.
• 4KIT Biomedical Research, Royal Tropical Institute (KIT), Amsterdam, The Netherlands. M.Bakker@kit.nl.
• 5Academic Medical Center (AMC), Amsterdam, The Netherlands. judith.lammers@amc.uva.nl.
• 6ICAP, Mailman School of Public Health, Columbia University, Kigali, Rwanda. vm2208@columbia.edu.
• 7Ruhengeri hospital, Ministry of Health, Kigali, Rwanda. emmanuelb@theaccessproject.com.
• 8INTERACT, Kigali, Rwanda. ldnaeyer@yahoo.com.
• 9University of Rwanda, Kigali, Rwanda. anita.asiimwe@gmail.com.
• 10Amsterdam Institute of Global Health and Development (AIGHD), Academic Medical Center (AMC), Amsterdam, The Netherlands. mschimvdloeff@ggd.amsterdam.nl.
• 11Center for Infection and Immunity Amsterdam (CINIMA), AMC, Amsterdam, The Netherlands. mschimvdloeff@ggd.amsterdam.nl.
• 12Public Health Service of Amsterdam (GGD), Amsterdam, The Netherlands. mschimvdloeff@ggd.amsterdam.nl. 

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Ten-Year Trends of Syphilis in Sero-Surveillance of Pregnant Women in Rwanda & Correlates of Syphilis-HIV Co-Infection

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 and urban areas. 
• Older participants (25-49 years) residing in urban areas and women with secondary or high education were less likely to screen positive for syphilis. 
• HIV-syphilis co-infection was more likely in women residing in urban areas, but less likely in women with secondary/high education. 

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.

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By:   Mutagoma M1, Balisanga H2, Remera E2, Gupta N3, Malamba SS4, Riedel DJ5, Nsanzimana S6.

• 1Rwanda Biomedical Center, Ministry of Health, Kigali, Rwanda mutagoma@gmail.com.
• 2Rwanda Biomedical Center, Ministry of Health, Kigali, Rwanda.
• 3Global Health Equity, Brigham & Women's Hospital, Boston, MA, USA Partners in Health / Inshuti Mu Buzima, Rwinkwavu, Rwanda.
• 4U.S. Centers for Disease Control and Prevention (CDC), Center for Global Health (CGH), Division of Global HIV/AIDS (DGHA), Rwanda.
• 5Institute of Human Virology and Division of Infectious Diseases, University of Maryland School of Medicine, Baltimore, Maryland, MD, USA.
• 6Rwanda Biomedical Center, Ministry of Health, Kigali, Rwanda Swiss Tropical and Public Health Institute, University of Basel, Basel, Switzerland. 

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Factors Associated with Dropout in a Long Term Observational Cohort of Fishing Communities Around Lake Victoria, Uganda

Background

Fishing communities are potentially suitable for Human immunodeficiency virus (HIV) efficacy trials due to their high risk profile. However, high mobility and attrition could decrease statistical power to detect the impact of a given intervention. We report dropout and associated factors in a fisher-folk observational cohort in Uganda.

Methods

Human immunodeficiency virus-uninfected high-risk volunteers aged 13–49 years living in five fishing communities around Lake Victoria were enrolled and followed every 6 months for 18 months at clinics located within each community. Volunteers from two of the five communities had their follow-up periods extended to 30 months and were invited to attend clinics 10–40 km (km) away from their communities. Human immunodeficiency virus counseling and testing was provided, and data on sexual behaviour collected at all study visits. Study completion was defined as completion of 18 or 30 months or visits up to the date of sero-conversion and dropout as missing one or more visits. Discrete time survival models were fitted to find factors independently associated with dropout.

Results

A total of 1000 volunteers (55 % men) were enrolled. Of these, 91.9 % completed 6 months, 85.2 % completed 12 months and 76.0 % completed 18 months of follow-up. In the two communities with additional follow-up, 76.9 % completed 30 months. In total 299 (29.9 %) volunteers missed at least one visit (dropped out). Dropout was independently associated with age (volunteers aged 13–24 being most likely to dropout), gender [men being more likely to dropout than women [adjusted hazard ratio (aHR) 1.4; 95 % confidence interval (CI) 1.1–1.8)], time spent in the fishing community (those who stayed <1 year being most likely to dropout), History of marijuana use (users being more likely to dropout than non-users [1.7; (1.2–2.5)], ethnicity (non-Baganda being more likely to dropout than Baganda [1.5; (1.2–1.9)], dropout varied between the five fishing communities, having a new sexual partner in the previous 3 months [1.3 (1.0–1.7)] and being away from home for ≥2 nights in the month preceding the interview [1.4 (1.1–1.8)].

Conclusion

Despite a substantial proportion dropping out, retention was sufficient to suggest that by incorporating retention strategies it will be possible to conduct HIV prevention efficacy trials in this community.

...The results suggest a number of factors that are associated with dropout from the fisher-folk cohort including young age, male gender, ethnicity, having a new sexual partner, time spent in the fishing communities, being away from home for ≥2 nights and marijuana use. Consistent with other studies in the neighbouring fishing [8] and non-fishing communities [9, 10], USA [15] and Brazil [16], study dropout was associated with age, with those in the youngest age group (13–24) being most likely to dropout. Since there were nearly equal proportions of men (49 %) and women (51 %) in this age group, this could be due to both looking for work and new relationships.

Dropping out was associated with the ethnicity of the volunteers, with non-Baganda being more likely to dropout. This has been indicated in the previous study further North of Lake Victoria [8]. The majority of non-Baganda volunteers come from further afield, including neighbouring countries (Kenya, Tanzania and Rwanda) and some are traders and transporters who might spend relatively long periods away from the fishing communities. These were more likely to be involved in fishing or related activities compared to the Baganda who were likely to be engaged in small scale businesses. Furthermore, number of years spent in the fishing site was independently associated with study dropout, with those who have spent more than 1 year in the fishing communities being less likely to dropout. This further demonstrates that individuals who have lived in a community for a long time are more likely to be available for recruitment in prevention studies. Additionally these could easily be retained in study follow up. The finding that dropout was associated with use of marijuana is consistent with findings from cohorts in the USA [17] and Japan [18], where similar dropout rates were observed among illicit drug users.

In this cohort we ascertained the frequency of reporting a new sexual partner for both men and women and this was independently associated with cohort dropout. This is consistent with the results from the inland non-fishing community in which the reported number of lifetime partners was higher in those who changed residence to other neighboring villages and there was also more risky sexual behavior reported among those who changed residence [14]. The fact that higher risk volunteers were more likely to drop out could lead to underestimation of HIV incidence in a prevention trial...

Full article at:   http://goo.gl/fzVnth

By:   Andrew Abaasa, Gershim Asiki, Juliet Mpendo, Jonathan Levin, Janet Seeley, Leslie Nielsen, Ali Ssetaala, Annet Nanvubya, Jan De Bont, Pontiano Kaleebu, and Anatoli Kamali

Uganda Research Unit on AIDS, Medical Research Council/Uganda Virus Research Institute (MRC/UVRI), P.O Box 49, Entebbe, Uganda

Uganda Virus Research Institute/International AIDS Vaccine Initiative (UVRI/IAVI)-HIV Vaccine Program, Entebbe, Uganda

London School of Hygiene and Tropical Medicine, London, UK

International AIDS Vaccine Initiative, New York, USA

Faculty of Health Sciences, School of Public Health, University of the Witwatersrand, Johannesburg, South Africa

Andrew Abaasa, Phone: 256 (0)417 704000, Email: gro.adnagucrm@asaabA.werdnA, Email: moc.oohay@asaaba.werdna.

  

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HIV Knowledge and Risky Sexual Behavior among Men in Rwanda

Introduction: 

New infections of Human Immunodeficiency Virus (HIV) remain a big problem in many countries. Different interventions have been implemented to improve the general knowledge of HIV, with the hypothesis that increasing HIV knowledge will reduce risky sexual behavior (RSB). However, HIV knowledge may not necessarily reduce RSB. This study explores HIV knowledge and its effect on RSB.

Methods: 

The study used data from the 2005 and 2010 Rwanda Demographic and Health Surveys to analyze the association between HIV risk factors and two types of RSB (having two or more partners in the past 12 months; and among those with two or more partners, not using a condom at last sex) and the association between HIV knowledge and those RSB. Multivariate logistic regression was used to determine predictors of RSB.

Results: 

Among 2,773 men in 2005 and 3,772 men in 2010, 5% and 7% respectively reported having two or more sexual partners. Among them, 93% in 2005 and 74% in 2010 did not use a condom at the last sex. Between 2005 and 2010, knowledge of the protective effect of having just one uninfected faithful partner, and basic knowledge of HIV decreased. Knowledge of the protective effect of using condoms increased from 90% to 94%. However, HIV knowledge was not associated with either type of RSB.

Conclusion: 

In setting up policies and strategies related to HIV prevention, policymakers should consider that focusing on HIV knowledge is not sufficient in itself.

Below: Factors model for predicting risky sexual behavior among men

Below:  Percentage of men who had two types of risky sexual behavior

Full article at:   http://goo.gl/jw0E4X

By:   Etienne Rugigana¹, Francine Birungi¹, Manassé Nzayirambaho^1,&

¹School of Public Health, College of Medicine and Health Sciences, University of Rwanda

Manassé Nzayirambaho, School of Public Health, College of Medicine and Health Sciences, University of Rwanda

 

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Exposure to Genocide as a Risk Factor for Homicide Perpetration in Rwanda

A population-based case-control study was conducted to assess the relationship between genocide exposure and homicide perpetration in Rwanda. 

A sample of 150 homicide perpetrators who were charged with and confessed to having committed homicide between 1 May 2011 and 31 May 2013 and 450 controls were enrolled. Cases were matched to controls by neighborhood, age and sex. Socio-demographic, background and genocide-related information was collected from study subjects’ next of kin. Four characteristics of genocide exposure were: genocide survivor, genocide perpetrator, having lost a first-degree relative to genocide and having a first-degree relative convicted of genocide. 

We assessed the impact of each genocide-exposure variable using conditional logistic regression. Of the 150 cases, 124 (82.7%) were male and 26 (17.3%) were female. The mean age of the alleged homicide perpetrators was 33 years, with a peak in the age group 20-29 years (39.3%). After adjusting for socio-demographic characteristics and past common criminal records, having a first-degree relative who had been convicted of genocide crimes was a significant predictor for homicide perpetration (odds ratio [OR] = 14.4, 95% confidence interval [CI] = 1.6-129.4). Being a genocide perpetrator, a genocide survivor and having lost a first-degree family member to genocide were not identified as risk factors for homicide perpetration. 

In Rwanda, young people who experienced early exposure to trauma by witnessing their first-degree relatives’ active participation in the genocide, are more likely to commit homicide. Socio-economic and psychotherapeutic programs targeting this population group are needed to rehabilitate these young people for violent behavior change.

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By:   Wilson Rubanzana, MD1,2, Bethany L. Hedt-Gauthier, PhD1,3, Joseph Ntaganira, PhD1, Michael D. Freeman, MedDr, PhD4,5,6

1. ¹University of Rwanda College of Medicine and Health Sciences, Kigali, Rwanda
2. ²Rwanda National Police, Forensic Medicine and Coordination Office of “Isange” One Stop Centers for Victims of Gender Based Violence and Victims of Child Abuse, Kigali, Rwanda
3. ³Harvard Medical School, Boston, MA, USA
4. ⁴Oregon Health & Science University, Portland, OR, USA
5. ⁵Umeå University, Sweden
6. ⁶Aarhus University, Denmark

1. Wilson Rubanzana, Department of Epidemiology and Biostatistics, School of Public Health, University of Rwanda College of Medicine and Health Sciences, Kicukiro, Kigali, P.O. Box 5229, Rwanda. Email: wrubanzana@nursph.org

 

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HPV Vaccine Introduction in Rwanda: Impacts on the Broader Health System

Highlights

• Rwanda was the first country in Africa to introduce the HPV vaccine.
• It is the first vaccine in Rwanda to be delivered in school-based campaigns.
• The new vaccine integrated well into the national immunisation programme.
• New services to school children were co-delivered as part of the campaigns.
• Continuity of routine services was preserved during the HPV campaign activities.

Abstract

Objectives

Rwanda was the first country in Africa to introduce the human papillomavirus (HPV) vaccine. This was achieved through multi-year school-based campaigns. Our study evaluated the impact of the HPV vaccine introduction on the country's immunisation programme and health system.

Methods

Thirty key informants were interviewed at national and district levels, and in participating schools. Twenty-seven health facilities completed a questionnaire exploring the effects of the new vaccine introduction on six health system building blocks, as defined by the World Health Organization. Routine service activity data were collected during a 90-day period around the introduction.

Results

Routine vaccination activities were not disrupted during the delivery, likely due to a strong Expanded Program on Immunization, appropriate planning and a well-resourced operation. Opportunities were seized to co-deliver other interventions targeted at children and adolescents, such as health promotion. Collaboration with the Ministry of Education was strengthened at national level. Although there were some temporary increases in staff workload, no major negative effects were reported.

Conclusion

Despite its delivery through school-based campaigns, the HPV vaccine integrated well into the immunisation programme and health system. The introduction had no major negative effects. Some opportunities were seized to expand services and collaborations.

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By:  Sergio Torres-Rueda, Stephen Rulisa, Helen E.D. Burchett, N. Victor Mivumbi, Sandra Mounier-Jack

Affiliations

• London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London WC1H 9SH, UK

Correspondence

• Corresponding author. Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London WC1H 9SH, UK. Tel.: +44 (0)207 958 8310.

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Association of Sexual Risk Behavior with Previous HIV Testing among VCT Clients in Kigali, Rwanda

With increased coverage of voluntary HIV counselling and testing (VCT) in Rwanda and a greater focus on repeat testing of key populations, it is important to understand whether the right clients are returning for repeat testing and if repeat testing is effective at reducing risk. 

We assessed the association between repeat testing and recent sexual risk behaviours among 1852 first time or repeat HIV testing clients in Kigali who had had sex, using data from a cross-sectional survey. Repeat testing was associated with being female, older and type of occupation. Multivariable analyses indicate that individuals who tested for HIV 1-2 times and 3+ times previously were more likely to have recent unprotected sex. Those with 3+ previous tests were more likely to have recently had multiple sexual partners. However, a significant decrease in HIV prevalence is shown as individuals receive more HIV tests in their lifetime (p < 0.001). 

These findings show that individuals who report high-risk behaviours are returning for repeat tests. However, VCT may not be successful at addressing certain sexual risk behaviours. Therefore more intensive counselling or additional HIV prevention services may be needed.

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By:  Stalter R1, Chen M2, Uwizeye G3, Mutunge E4, Ahayo A4, Mugwaneza P4, Shumbusho F5, Wesson J6.

• 1FHI 360, Durham, North Carolina, USA rstalter@fhi360.org.
• 2FHI 360, Durham, North Carolina, USA.
• 3FHI 360, Kigali, Rwanda Human Resources for Health (HRH) Program, Ministry of Health, Kigali, Rwanda.
• 4Institute of HIV/AIDS, Disease Prevention and Control, Rwanda Biomedical Center, Kigali, Rwanda.
• 5FHI 360, Kigali, Rwanda Rwanda Healthcare Federation (RHF), Kigali, Rwanda.
• 6FHI 360, Kigali, Rwanda IntraHealth International, Chapel Hill, North Carolina, USA. 

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The Missing Men: HIV Treatment Scale-Up and Life Expectancy in Sub-Saharan Africa

Delivery of effective HIV antiretroviral therapy (ART) to the more than 6 million persons with HIV in South Africa is well underway, with early data on the impact of this massive public health effort demonstrating a reversal of the previous decade’s precipitous decline in population life expectancy [1]. Although South Africa’s age and sex disparities in HIV acquisition have traditionally been described as disadvantaging young women [2], accumulating evidence now suggests a reverse disparity: although HIV care is available to both men and women and is nominally free of charge, women are more likely to be tested for HIV, engage in pre-treatment care, initiate treatment earlier, stay on treatment, and survive [3–6]. To adopt the classic Eisenberg and Power [7] analogy of health care as current flowing through an electric circuit, the voltage drops along the entire circuit of HIV care, from HIV infection to AIDS-free survival, are larger for men compared with women (Fig 1). There are simply too many missing men.

Below:  The cascade of “voltage drops” from HIV infection to AIDS-free survival.

In order for the goal of AIDS-free survival to be achieved, (1) HIV testing, care, and treatment services must be available, and persons with HIV must (2) be enrolled in care, (3) initiate antiretroviral therapy, (4) achieve suppression of HIV-1 RNA viral load, and (5) be retained in care.

Below:  Gender gaps in life expectancy among men and women with HIV initiating antiretroviral therapy at 20 years of age.

This figure summarizes the findings of studies from Rwanda [9], South Africa [8], and Uganda [10]. Estimates and associated 95% confidence intervals are shown as the number of additional years of life expected for men and women with HIV initiating antiretroviral therapy at 20 years of age.

Full article at:  http://goo.gl/BC93rj

By:   Alexander C. Tsai

Department of Psychiatry, Massachusetts General Hospital, Boston, Massachusetts, United States of America

Alexander C. Tsai

Mbarara University of Science and Technology, Mbarara, Uganda

Alexander C. Tsai, Mark J. Siedner

Harvard Medical School, Boston, Massachusetts, United States of America

Mark J. Siedner

Division of Infectious Diseases, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, United States of America

 

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Children Living with HIV-Infected Adults: Estimates for 23 Countries in Sub-Saharan Africa

Background

In sub-Saharan Africa many children live in extreme poverty and experience a burden of illness and disease that is disproportionately high. The emergence of HIV and AIDS has only exacerbated long-standing challenges to improving children’s health in the region, with recent cohorts experiencing pediatric AIDS and high levels of orphan status, situations which are monitored globally and receive much policy and research attention. Children’s health, however, can be affected also by living with HIV-infected adults, through associated exposure to infectious diseases and the diversion of household resources away from them. While long recognized, far less research has focused on characterizing this distinct and vulnerable population of HIV-affected children.

Methods

Using Demographic and Health Survey data from 23 countries collected between 2003 and 2011, we estimate the percentage of children living in a household with at least one HIV-infected adult. We assess overlaps with orphan status and investigate the relationship between children and the adults who are infected in their households.

Results

The population of children living in a household with at least one HIV-infected adult is substantial where HIV prevalence is high; in Southern Africa, the percentage exceeded 10% in all countries and reached as high as 36%. This population is largely distinct from the orphan population. Among children living in households with tested, HIV-infected adults, most live with parents, often mothers, who are infected; nonetheless, in most countries over 20% live in households with at least one infected adult who is not a parent.

Conclusion

Until new infections contract significantly, improvements in HIV/AIDS treatment suggest that the population of children living with HIV-infected adults will remain substantial. It is vital to on-going efforts to reduce childhood morbidity and mortality to consider whether current care and outreach sufficiently address the distinct vulnerabilities of these children.

Below: Co-residence of Children 0–17 with HIV-infected Adults and Adult HIV Prevalence (15–49), by Country

Below:  Among Children 0–17 Living with at Least One HIV-infected Adult, Percent Living with HIV-infected Mothers, Fathers, and Others, by Country

Full article at:  http://goo.gl/IAtHln

By:  

Susan E. Short

Department of Sociology and Population Studies and Training Center, Brown University, Providence, RI, United States of America

Rachel E. Goldberg

Department of Sociology, University of California Irvine, Irvine, CA, United States of America

 

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HIV Incidence Prior To, During, and After Violent Conflict in 36 Sub-Saharan African Nations, 1990-2012: An Ecological Study

The aim of this study was to determine the association between violent conflict and HIV incidence within and across 36 sub-Saharan Africa countries between 1990 and 2012.

We used generalized linear mixed effect modeling to estimate the effect of conflict periods on country-level HIV incidence. We specified random intercepts and slopes to account for across and within country variation over time. We also conducted a sub-analysis of countries who experienced conflict to assess the effect of conflict intensity on country-level HIV incidence. All models controlled for level of economic development, number of refugees present in the country, and year.

We found that, compared to times of peace, the HIV incidence rate increased by 2.1 per 1000 infections per year (95%CI: 0.39, 3.87) in the 5 years prior to conflict. Additionally, we found a decrease of 0.7 new infections per 1000 people per year (95%CI: -1.44, -0.01) in conflicts with 25 to 1000 battle-related deaths and a decrease of 1.5 new infections per 1000 people per year (95%CI:-2.50, -0.52) for conflict with more than 1000 battle-related deaths, compared to conflicts with less than 25 battle-related deaths

Our results demonstrate that HIV infection rates increase in the years immediately prior to times of conflict; however, we did not identify a significant increase during and immediately following periods of violent conflict. Further investigation, including more rigorous data collection, is needed, as is increased aid to nations at risk of violent conflict to help in the fight against HIV/AIDS in sub-Saharan Africa.

Below: Annual Minimum, Maximum, and Mean HIV Incidence in 36 Countries in sub-Saharan Africa, 1990–2012

Full article at:  http://goo.gl/JbyPdU

By:  Brady W. Bennett, Brandon D. L. Marshall, Annie Gjelsvik, Stephen T. McGarvey, Mark N. Lurie

Department of Epidemiology, Brown University School of Public Health, Providence, RI, United States of America

 

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