1
|
Ross J, Anastos K, Hill S, Remera E, Rwibasira GN, Ingabire C, Umwiza F, Munyaneza A, Muhoza B, Zhang C, Nash D, Yotebieng M, Murenzi G. Reducing time to differentiated service delivery for newly-diagnosed people living with HIV in Kigali, Rwanda: a pilot, unblinded, randomized controlled trial. BMC Health Serv Res 2024; 24:555. [PMID: 38693537 PMCID: PMC11062003 DOI: 10.1186/s12913-024-10950-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Accepted: 04/04/2024] [Indexed: 05/03/2024] Open
Abstract
BACKGROUND Differentiated service delivery (DSD) programs for people living with HIV (PWH) limit eligibility to patients established on antiretroviral therapy (ART), yet uncertainty exists regarding the duration on ART necessary for newly-diagnosed PWH to be considered established. We aimed to determine the feasibility, acceptability, and preliminary impact of entry into DSD at six months after ART initiation for newly-diagnosed PWH. METHODS We conducted a pilot randomized controlled trial in three health facilities in Rwanda. Participants were randomized to: (1) entry into DSD at six months after ART initiation after one suppressed viral load (DSD-1VL); (2) entry into DSD at six months after ART initiation after two consecutive suppressed viral loads (DSD-2VL); (3) treatment as usual (TAU). We examined feasibility by examining the proportion of participants assigned to intervention arms who entered DSD, assessed acceptability through patient surveys and by examining instances when clinical staff overrode the study assignment, and evaluated preliminary effectiveness by comparing study arms with respect to 12-month viral suppression. RESULTS Among 90 participants, 31 were randomized to DSD-1VL, 31 to DSD-2VL, and 28 to TAU. Among 62 participants randomized to DSD-1VL or DSD-2VL, 37 (60%) entered DSD at 6 months while 21 (34%) did not enter DSD because they were not virally suppressed. Patient-level acceptability was high for both clinical (mean score: 3.8 out of 5) and non-clinical (mean score: 4.1) elements of care and did not differ significantly across study arms. Viral suppression at 12 months was 81%, 81% and 68% in DSD-1VL, DSD-2VL, and TAU, respectively (p = 0.41). CONCLUSIONS The majority of participants randomized to intervention arms entered DSD and had similar rates of viral suppression compared to TAU. Results suggest that early DSD at six months after ART initiation is feasible for newly-diagnosed PWH, and support current WHO guidelines on DSD. TRIAL REGISTRATION Clinicaltrials.gov NCT04567693; first registered on September 28, 2020.
Collapse
Affiliation(s)
- Jonathan Ross
- Albert Einstein College of Medicine, 3300 Kossuth Avenue, Bronx, NY, 10467, USA.
| | - Kathryn Anastos
- Albert Einstein College of Medicine, 3300 Kossuth Avenue, Bronx, NY, 10467, USA
| | - Sarah Hill
- Albert Einstein College of Medicine, 3300 Kossuth Avenue, Bronx, NY, 10467, USA
| | - Eric Remera
- Division of HIV, STIs and Viral Hepatitis, Rwanda Biomedical Center, Kigali, Rwanda
| | - Gallican N Rwibasira
- Division of HIV, STIs and Viral Hepatitis, Rwanda Biomedical Center, Kigali, Rwanda
| | | | | | | | | | - Chenshu Zhang
- Albert Einstein College of Medicine, 3300 Kossuth Avenue, Bronx, NY, 10467, USA
| | - Denis Nash
- Institute for Implementation Science in Population Health, City University of New York, New York, 10027, USA
| | - Marcel Yotebieng
- Albert Einstein College of Medicine, 3300 Kossuth Avenue, Bronx, NY, 10467, USA
| | - Gad Murenzi
- Research for Development (RD Rwanda), Kigali, Rwanda
| |
Collapse
|
2
|
Hill SE, Zhang C, Remera E, Ingabire C, Umwiza F, Munyaneza A, Muhoza B, Rwibasira G, Yotebieng M, Anastos K, Murenzi G, Ross J. Association Between Clinical Encounter Frequency and HIV-Related Stigma Among Newly-Diagnosed People Living with HIV in Rwanda. AIDS Behav 2024; 28:1390-1400. [PMID: 38112826 PMCID: PMC10947825 DOI: 10.1007/s10461-023-04226-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/15/2023] [Indexed: 12/21/2023]
Abstract
HIV-related stigma in healthcare settings remains a key barrier to engaging people living with HIV (PLHIV) in care. This study investigated the association between clinical encounter frequency and HIV-related anticipated, enacted, and internalized stigma among newly-diagnosed PLHIV in Rwanda. From October 2020 to May 2022, we collected data from adult PLHIV on antiretroviral therapy (ART) in Kigali, Rwanda who were participating in a randomized, controlled trial testing early entry into differentiated care at 6 months after ART initiation. We measured anticipated HIV stigma with five-point Likert HIV Stigma Framework measures, enacted stigma with the four-point Likert HIV/AIDS Stigma Instrument, and internalized stigma with the four-point Likert HIV/AIDS Stigma Instrument. We used multivariable linear regression to test the associations between clinical encounter frequency (average inter-visit interval ≥ 50 days vs. < 50 days) and change in mean anticipated, enacted and internalized HIV stigma over the first 12 months in care. Among 93 individuals enrolled, 76 had complete data on encounter frequency and stigma measurements and were included in the present analysis. Mean internalized stigma scores of all participants decreased over the first 12 months in care. Anticipated and enacted stigma scores were low and did not change significantly over time. There was no association between encounter frequency and change in internalized stigma. In this pilot study of newly-diagnosed Rwandan PLHIV with relatively low levels of HIV-related stigma, clinical encounter frequency was not associated with change in stigma. Additional research in diverse settings and with larger samples is necessary to further explore this relationship.
Collapse
Affiliation(s)
- Sarah E Hill
- Division of General Internal Medicine, Albert Einstein College of Medicine, 1300 Morris Park Avenue, Bronx, NY, 10461, USA.
| | - Chenshu Zhang
- Division of General Internal Medicine, Albert Einstein College of Medicine, 1300 Morris Park Avenue, Bronx, NY, 10461, USA
| | - Eric Remera
- HIV/AIDS and STIs Diseases Division, Rwanda Biomedical Center, Institute of HIV Disease Prevention and Control, Kigali, Rwanda
| | - Charles Ingabire
- Rwanda Military Hospital, Kigali, Rwanda
- Research for Development, Kigali, Rwanda
| | - Francine Umwiza
- Rwanda Military Hospital, Kigali, Rwanda
- Research for Development, Kigali, Rwanda
| | - Athanase Munyaneza
- Rwanda Military Hospital, Kigali, Rwanda
- Research for Development, Kigali, Rwanda
| | - Benjamin Muhoza
- Rwanda Military Hospital, Kigali, Rwanda
- Research for Development, Kigali, Rwanda
| | - Gallican Rwibasira
- HIV/AIDS and STIs Diseases Division, Rwanda Biomedical Center, Institute of HIV Disease Prevention and Control, Kigali, Rwanda
| | - Marcel Yotebieng
- Division of General Internal Medicine, Albert Einstein College of Medicine, 1300 Morris Park Avenue, Bronx, NY, 10461, USA
| | - Kathryn Anastos
- Division of General Internal Medicine, Albert Einstein College of Medicine, 1300 Morris Park Avenue, Bronx, NY, 10461, USA
| | - Gad Murenzi
- Rwanda Military Hospital, Kigali, Rwanda
- Research for Development, Kigali, Rwanda
| | - Jonathan Ross
- Division of General Internal Medicine, Albert Einstein College of Medicine, 1300 Morris Park Avenue, Bronx, NY, 10461, USA
| |
Collapse
|
3
|
Remera E, Tuyishime E, Kayitesi C, Malamba SS, Sangwayire B, Umutesi J, Ruisenor-Escudero H, Oluoch T. HIV and hepatitis B, C co-infection and correlates of HIV infection among men who have sex with men in Rwanda, 2021: a respondent-driven sampling, cross-sectional study. BMC Infect Dis 2024; 24:347. [PMID: 38521947 PMCID: PMC10960483 DOI: 10.1186/s12879-024-09206-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2023] [Accepted: 03/07/2024] [Indexed: 03/25/2024] Open
Abstract
BACKGROUND Men who have sex with men (MSM) are a key population group disproportionately affected by HIV and other sexually transmitted infections (STIs) worldwide. In Rwanda, the HIV epidemic remains a significant public health concern, and understanding the burden of HIV and hepatitis B and C coinfections among MSM is crucial for designing effective prevention and control strategies. This study aims to determine the prevalence of HIV, hepatitis B, and hepatitis C infections among MSM in Rwanda and identify correlates associated with HIV infection within this population. METHODS We used respondent-driven sampling (RDS) to recruit participants between November and December 2021. A face-to-face, structured questionnaire was administered. Testing for HIV infection followed the national algorithm using two rapid tests: Alere Combo and STAT PAK as the first and second screening tests, respectively. Hepatitis B surface antigen (HBsAg) and anti-HCV tests were performed. All statistics were adjusted for RDS design, and a multivariable logistic regression model was constructed to identify factors associated with HIV infection. RESULTS The prevalence of HIV among MSM was 6·9% (95% CI: 5·5-8·6), and among HIV-positive MSM, 12·9% (95% CI: 5·5-27·3) were recently infected. The prevalence of hepatitis B and C was 4·2% (95% CI: 3·0-5·7) and 0·7% (95% CI: 0·4-1·2), respectively. HIV and hepatitis B virus coinfection was 0·5% (95% CI: 0·2-1·1), whereas HIV and hepatitis C coinfection was 0·1% (95% CI: 0·0-0·5), and no coinfection for all three viruses was observed. MSM groups with an increased risk of HIV infection included those who ever suffered violence or abuse because of having sex with other men (AOR: 3·42; 95% CI: 1·87-6·25), those who refused to answer the question asking about 'ever been paid money, goods, or services for sex' (AOR: 10·4; 95% CI: 3·30-32·84), and those not consistently using condoms (AOR: 3·15; 95% CI: 1·31-7·60). CONCLUSION The findings suggest more targeted prevention and treatment approaches and underscore the importance of addressing structural and behavioral factors contributing to HIV vulnerability, setting interventions to reduce violence and abuse against MSM, promoting safe and consensual sexual practices, and expanding access to HIV prevention tools such as condoms and preexposure prophylaxis (PrEP).
Collapse
Affiliation(s)
- Eric Remera
- Institute of HIV Disease Prevention and Control, Rwanda Biomedical Centre (RBC) ), Kigali, Rwanda
| | - Elysee Tuyishime
- Division of Global HIV and TB, Global Health Center (GHC), US Centers for Disease Control and Prevention (CDC), Kigali, Rwanda.
| | - Catherine Kayitesi
- Institute of HIV Disease Prevention and Control, Rwanda Biomedical Centre (RBC) ), Kigali, Rwanda
| | - Samuel S Malamba
- Division of Global HIV and TB, Global Health Center (GHC), US Centers for Disease Control and Prevention (CDC), Kigali, Rwanda
| | - Beata Sangwayire
- Division of Global HIV and TB, Global Health Center (GHC), US Centers for Disease Control and Prevention (CDC), Kigali, Rwanda
| | - Justine Umutesi
- Institute of HIV Disease Prevention and Control, Rwanda Biomedical Centre (RBC) ), Kigali, Rwanda
| | - Horacio Ruisenor-Escudero
- Division of Global HIV and TB, Global Health Center (GHC), US Centers for Disease Control and Prevention (CDC), Atlanta, GA, USA
| | - Tom Oluoch
- Division of Global HIV and TB, Global Health Center (GHC), US Centers for Disease Control and Prevention (CDC), Kigali, Rwanda
| |
Collapse
|
4
|
Tuyishime E, Remera E, Kayitesi C, Malamba S, Sangwayire B, Habimana Kabano I, Ruisenor-Escudero H, Oluoch T, Unna Chukwu A. Estimation of the Population Size of Street- and Venue-Based Female Sex Workers and Sexually Exploited Minors in Rwanda in 2022: 3-Source Capture-Recapture. JMIR Public Health Surveill 2024; 10:e50743. [PMID: 38488847 PMCID: PMC10980986 DOI: 10.2196/50743] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Revised: 11/25/2023] [Accepted: 01/10/2024] [Indexed: 03/19/2024] Open
Abstract
BACKGROUND HIV surveillance among key populations is a priority in all epidemic settings. Female sex workers (FSWs) globally as well as in Rwanda are disproportionately affected by the HIV epidemic; hence, the Rwanda HIV and AIDS National Strategic Plan (2018-2024) has adopted regular surveillance of population size estimation (PSE) of FSWs every 2-3 years. OBJECTIVE We aimed at estimating, for the fourth time, the population size of street- and venue-based FSWs and sexually exploited minors aged ≥15 years in Rwanda. METHODS In August 2022, the 3-source capture-recapture method was used to estimate the population size of FSWs and sexually exploited minors in Rwanda. The field work took 3 weeks to complete, with each capture occasion lasting for a week. The sample size for each capture was calculated using shinyrecap with inputs drawn from previously conducted estimation exercises. In each capture round, a stratified multistage sampling process was used, with administrative provinces as strata and FSW hotspots as the primary sampling unit. Different unique objects were distributed to FSWs in each capture round; acceptance of the unique object was marked as successful capture. Sampled FSWs for the subsequent capture occasions were asked if they had received the previously distributed unique object in order to determine recaptures. Statistical analysis was performed in R (version 4.0.5), and Bayesian Model Averaging was performed to produce the final PSE with a 95% credibility set (CS). RESULTS We sampled 1766, 1848, and 1865 FSWs and sexually exploited minors in each capture round. There were 169 recaptures strictly between captures 1 and 2, 210 recaptures exclusively between captures 2 and 3, and 65 recaptures between captures 1 and 3 only. In all 3 captures, 61 FSWs were captured. The median PSE of street- and venue-based FSWs and sexually exploited minors in Rwanda was 37,647 (95% CS 31,873-43,354), corresponding to 1.1% (95% CI 0.9%-1.3%) of the total adult females in the general population. Relative to the adult females in the general population, the western and northern provinces ranked first and second with a higher concentration of FSWs, respectively. The cities of Kigali and eastern province ranked third and fourth, respectively. The southern province was identified as having a low concentration of FSWs. CONCLUSIONS We provide, for the first time, both the national and provincial level population size estimate of street- and venue-based FSWs in Rwanda. Compared with the previous 2 rounds of FSW PSEs at the national level, we observed differences in the street- and venue-based FSW population size in Rwanda. Our study might not have considered FSWs who do not want anyone to know they are FSWs due to several reasons, leading to a possible underestimation of the true PSE.
Collapse
Affiliation(s)
- Elysee Tuyishime
- African Center of Excellence in Data Science, University of Rwanda, Kigali, Rwanda
- Division of Global HIV and TB, Global Health Center, US Centers for Disease Control and Prevention, Kigali, Rwanda
| | - Eric Remera
- Institute of HIV Disease Prevention and Control, Rwanda Biomedical Centre, Rwanda Ministry of Health, Kigali, Rwanda
| | - Catherine Kayitesi
- Institute of HIV Disease Prevention and Control, Rwanda Biomedical Centre, Rwanda Ministry of Health, Kigali, Rwanda
| | - Samuel Malamba
- Division of Global HIV and TB, Global Health Center, US Centers for Disease Control and Prevention, Kigali, Rwanda
| | - Beata Sangwayire
- Division of Global HIV and TB, Global Health Center, US Centers for Disease Control and Prevention, Kigali, Rwanda
| | | | - Horacio Ruisenor-Escudero
- Key Population Surveillance Team, Epidemiology and Surveillance Branch, Division of Global HIV/TB, Global Health Center, US Centers for Disease Control and Prevention, Atlanta, GA, United States
| | - Tom Oluoch
- Division of Global HIV and TB, Global Health Center, US Centers for Disease Control and Prevention, Kigali, Rwanda
| | - Angela Unna Chukwu
- African Center of Excellence in Data Science, University of Rwanda, Kigali, Rwanda
- Department of Statistics, University of Ibadan, Ibadan, Nigeria
| |
Collapse
|
5
|
Rodriguez VJ, Kendall AD, Cohen MH, Nsanzimana S, Ingabire C, Remera E, Donenberg G. Psychometrics of the Children's Report of Parental Behavior Inventory among caregivers and youth with HIV. J Fam Psychol 2024:2024-60653-001. [PMID: 38451718 DOI: 10.1037/fam0001195] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/09/2024]
Abstract
Parenting has been implicated in a range of youth health outcomes. Positive parenting during adolescence, a critical period of developmental change, may equip youth with the necessary tools for their transition into adulthood and, for youth living with HIV, their transition from pediatric HIV care into adult HIV care. Yet, because few studies have carefully assessed the psychometric properties of parenting instruments applied cross-culturally, the validity of parenting research derived in these contexts remains unclear. This study tested the factor structure of the Children's Report of Parenting Behavior Inventory (CRPBI) in a novel setting (e.g., Rwanda), context (e.g., youth with HIV), and considering multiple informants (caregivers and youth). Youth (N = 330) were on average 16.78 years of age; 51% self-identified as female. Caregivers (N = 330) were on average 44.40 years of age; 80% self-identified as female. The factor structures for youth and caregiver CRPBIs appeared to be indicative of two dimensions: (a) acceptance and positive involvement, and (b) hostile detachment and rejection. The CRPBI worked well for youth reports and showed predictive validity. The CRPBI worked less well for caregivers, necessitating the removal of 10 items, seven of which were related to hostile detachment and rejection. The reliability of both CRPBIs was supported. The CRPBI appears to function well for youth, but not as well for caregivers, in this novel context with this unique population of youth with HIV. The findings support careful assessment of instruments developed in high-resource settings and then used in resource-constrained contexts. (PsycInfo Database Record (c) 2024 APA, all rights reserved).
Collapse
Affiliation(s)
| | | | | | | | | | - Eric Remera
- John H. Stroger, Jr. Hospital of Cook County
| | | |
Collapse
|
6
|
Oluoch T, Byiringiro B, Tuyishime E, Kitema F, Ntwali L, Malamba S, Wilmore S, Remera E. Implementation of an HIV Case Based Surveillance Using Standards-Based Health Information Exchange in Rwanda. Stud Health Technol Inform 2024; 310:875-880. [PMID: 38269934 DOI: 10.3233/shti231090] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2024]
Abstract
As Rwanda approaches the UNAIDS Fast Track goals which recommend that 95% of HIV-infected individuals know their status, of whom 95% should receive treatment and 95% of those on treatment achieve viral suppression, the country currently relies on an inefficient paper, and disjointed electronic, systems for case-based surveillance (CBS). Rwanda has established an ecosystem of interoperable systems based on open standards to support HIV CBS. Data were successfully exchanged between an EMR, a client registry, laboratory information system and DHIS-2 Tracker, and subsequently, a complete analytic dataset was ingested into MS-Power Business Intelligence (MS-PowerBI) for analytics and visualization of the CBS data. Existing challenges included inadequate workforce capacity to support mapping of data elements to HL7 FHIR resources. Interoperability optimization to support CBS is work in progress and rigorous evaluations on the effect on health information exchange on monitoring patient outcomes are needed.
Collapse
Affiliation(s)
- Tom Oluoch
- US Centers for Disease Control and Prevention - Kigali, Rwanda
| | | | | | | | | | - Samuel Malamba
- US Centers for Disease Control and Prevention - Kigali, Rwanda
| | - Sridevi Wilmore
- US Centers for Disease Control and Prevention - Atlanta, GA, USA
| | | |
Collapse
|
7
|
Peck ME, Bronson M, Djomand G, Basile I, Collins K, Kankindi I, Kayirangwa E, Malamba SS, Mugisha V, Nsanzimana S, Remera E, Kazaura KJ, Amuri M, Mmbando S, Mgomella GS, Simbeye D, Colletar Awor A, Biraro S, Kabuye G, Kirungi W, Chituwo O, Hanunka B, Kamboyi R, Mulenga L, Musonda B, Muyunda B, Nkumbula T, Malaba R, Mandisarisa J, Musuka G, Peterson AE, Toledo C. HIV, syphilis, and hepatitis B virus infection and male circumcision in five Sub-Saharan African countries: Findings from the Population-based HIV Impact Assessment surveys, 2015-2019. PLOS Glob Public Health 2023; 3:e0002326. [PMID: 37721926 PMCID: PMC10506706 DOI: 10.1371/journal.pgph.0002326] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Accepted: 08/06/2023] [Indexed: 09/20/2023]
Abstract
Voluntary medical male circumcision (VMMC) has primarily been promoted for HIV prevention. Evidence also supports that male circumcision offers protection against other sexually transmitted infections. This analysis assessed the effect of circumcision on syphilis, hepatitis B virus (HBV) infection and HIV. Data from the 2015 to 2019 Population-based HIV Impact Assessments (PHIAs) surveys from Rwanda, Tanzania, Uganda, Zambia, and Zimbabwe were used for the analysis. The PHIA surveys are cross-sectional, nationally representative household surveys that include biomarking testing for HIV, syphilis and HBV infection. This is a secondary data analysis using publicly available PHIA data. Univariate and multivariable logistic regression models were created using pooled PHIA data across the five countries to assess the effect of male circumcision on HIV, active and ever syphilis, and HBV infection among sexually active males aged 15-59 years. Circumcised men had lower odds of syphilis infection, ever or active infection, and HIV, compared to uncircumcised men, after adjusting for covariates (active syphilis infection = 0.67 adjusted odds ratio (aOR), 95% confidence interval (CI), 0.52-0.87, ever having had a syphilis infection = 0.85 aOR, 95% CI, 0.73-0.98, and HIV = 0.53 aOR, 95% CI, 0.47-0.61). No difference between circumcised and uncircumcised men was identified for HBV infection (P = 0.75). Circumcised men have a reduced likelihood for syphilis and HIV compared to uncircumcised men. However, we found no statistically significant difference between circumcised and uncircumcised men for HBV infection.
Collapse
Affiliation(s)
- Megan E. Peck
- Division of Global HIV & TB, HIV Prevention Branch, Center for Global Health, Centers for Disease Control and Prevention, Atlanta, United States of America
| | - Megan Bronson
- Division of Global HIV & TB, Epidemiology and Surveillance Branch, Center for Global Health, Centers for Disease Control and Prevention, Atlanta, United States of America
| | - Gaston Djomand
- Division of Global HIV & TB, HIV Prevention Branch, Center for Global Health, Centers for Disease Control and Prevention, Atlanta, United States of America
| | - Ikuzo Basile
- Ministry of Health, Rwanda Biomedical Center, Kigali City, Rwanda
| | | | - Ida Kankindi
- Division of Global HIV & TB, Center for Global Health, Centers for Disease Control and Prevention, Kigali, Rwanda
| | - Eugenie Kayirangwa
- Division of Global HIV & TB, Center for Global Health, Centers for Disease Control and Prevention, Kigali, Rwanda
| | - Samuel S. Malamba
- Division of Global HIV & TB, Center for Global Health, Centers for Disease Control and Prevention, Kigali, Rwanda
| | | | - Sabin Nsanzimana
- Ministry of Health, Rwanda Biomedical Center, Kigali City, Rwanda
| | - Eric Remera
- Ministry of Health, Rwanda Biomedical Center, Kigali City, Rwanda
| | - Kokuhumbya J. Kazaura
- Division of Global HIV & TB, Centers for Global Health, Centers for Disease Control and Prevention, Dar-es-Salaam, Tanzania
| | - Mbaraka Amuri
- Division of Global HIV & TB, Centers for Global Health, Centers for Disease Control and Prevention, Dar-es-Salaam, Tanzania
| | - Susan Mmbando
- National AIDS Control Program, Ministry of Health, Dar-es-Salaam, Tanzania
| | - George S. Mgomella
- Division of Global HIV & TB, Centers for Global Health, Centers for Disease Control and Prevention, Dar-es-Salaam, Tanzania
| | - Daimon Simbeye
- Division of Global HIV & TB, Centers for Global Health, Centers for Disease Control and Prevention, Dar-es-Salaam, Tanzania
| | - Anna Colletar Awor
- Division of Global HIV & TB, Centers for Global Health, Centers for Disease Control and Prevention, Kampala, Uganda
| | | | - Geoffrey Kabuye
- Division of Global HIV & TB, Centers for Global Health, Centers for Disease Control and Prevention, Kampala, Uganda
| | | | - Omega Chituwo
- Division of Global HIV & TB, Centers for Global Health, Centers for Disease Control and Prevention, Lusaka, Zambia
| | - Brave Hanunka
- Division of Global HIV & TB, Centers for Global Health, Centers for Disease Control and Prevention, Lusaka, Zambia
| | - Royd Kamboyi
- Department of Public Health, Ministry of Health, Lusaka, Zambia
| | - Lloyd Mulenga
- Department of Public Health, Ministry of Health, Lusaka, Zambia
| | - Bupe Musonda
- Department of Public Health, Ministry of Health, Lusaka, Zambia
| | - Brian Muyunda
- Division of Global HIV & TB, Centers for Global Health, Centers for Disease Control and Prevention, Lusaka, Zambia
| | | | - Rickie Malaba
- Division of Global HIV & TB, Center for Global Health, Centers for Disease Control and Prevention, Harare, Zimbabwe
| | - John Mandisarisa
- Division of Global HIV & TB, Center for Global Health, Centers for Disease Control and Prevention, Harare, Zimbabwe
| | | | - Amy E. Peterson
- Division of Global HIV & TB, Center for Global Health, Centers for Disease Control and Prevention, Harare, Zimbabwe
| | - Carlos Toledo
- Division of Global HIV & TB, HIV Prevention Branch, Center for Global Health, Centers for Disease Control and Prevention, Atlanta, United States of America
| |
Collapse
|
8
|
Semakula M, Niragire F, Nsanzimana S, Remera E, Faes C. Spatio-temporal dynamic of the COVID-19 epidemic and the impact of imported cases in Rwanda. BMC Public Health 2023; 23:930. [PMID: 37221533 DOI: 10.1186/s12889-023-15888-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Accepted: 05/12/2023] [Indexed: 05/25/2023] Open
Abstract
INTRODUCTION Africa was threatened by the coronavirus disease 2019 (COVID-19) due to the limited health care infrastructure. Rwanda has consistently used non-pharmaceutical strategies, such as lockdown, curfew, and enforcement of prevention measures to control the spread of COVID-19. Despite the mitigation measures taken, the country has faced a series of outbreaks in 2020 and 2021. In this paper, we investigate the nature of epidemic phenomena in Rwanda and the impact of imported cases on the spread of COVID-19 using endemic-epidemic spatio-temporal models. Our study provides a framework for understanding the dynamics of the epidemic in Rwanda and monitoring its phenomena to inform public health decision-makers for timely and targeted interventions. RESULTS The findings provide insights into the effects of lockdown and imported infections in Rwanda's COVID-19 outbreaks. The findings showed that imported infections are dominated by locally transmitted cases. The high incidence was predominant in urban areas and at the borders of Rwanda with its neighboring countries. The inter-district spread of COVID-19 was very limited due to mitigation measures taken in Rwanda. CONCLUSION The study recommends using evidence-based decisions in the management of epidemics and integrating statistical models in the analytics component of the health information system.
Collapse
Affiliation(s)
- Muhammed Semakula
- I-BioStat, Hasselt University, Hasselt, Belgium.
- College of Business and Economics, Centre of excellence in Data Science, Bio-statistics, University of Rwanda, Kigali, Kigali, Rwanda.
- Rwanda Biomedical Centre, Ministry of Health, Kigali, Rwanda.
| | - François Niragire
- Department of Applied Statistics, University of Rwanda, Kigali, Kigali, Rwanda
| | | | - Eric Remera
- Rwanda Biomedical Centre, Ministry of Health, Kigali, Rwanda
| | | |
Collapse
|
9
|
Tuyishime E, Kayitesi C, Musengimana G, Malamba S, Moges H, Kankindi I, Escudero HR, Habimana Kabano I, Oluoch T, Remera E, Chukwu A. Population Size Estimation of Men Who Have Sex With Men in Rwanda: Three-Source Capture-Recapture Method. JMIR Public Health Surveill 2023; 9:e43114. [PMID: 36972131 PMCID: PMC10131990 DOI: 10.2196/43114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Revised: 12/24/2022] [Accepted: 02/03/2023] [Indexed: 03/29/2023] Open
Abstract
BACKGROUND Globally, men who have sex with men (MSM) continue to bear a disproportionately high burden of HIV infection. Rwanda experiences a mixed HIV epidemic, which is generalized in the adult population, with aspects of a concentrated epidemic among certain key populations at higher risk of HIV infection, including MSM. Limited data exist to estimate the population size of MSM at a national scale; hence, an important piece is missing in determining the denominators to use in estimates for policy makers, program managers, and planners to effectively monitor HIV epidemic control. OBJECTIVE The aims of this study were to provide the first national population size estimate (PSE) and geographic distribution of MSM in Rwanda. METHODS Between October and December 2021, a three-source capture-recapture method was used to estimate the MSM population size in Rwanda. Unique objects were distributed to MSM through their networks (first capture), who were then tagged according to MSM-friendly service provision (second capture), and a respondent-driven sampling survey was used as the third capture. Capture histories were aggregated in a 2k-1 contingency table, where k indicates the number of capture occasions and "1" and "0" indicate captured and not captured, respectively. Statistical analysis was performed in R (version 4.0.5) and the Bayesian nonparametric latent-class capture-recapture package was used to produce the final PSE with 95% credibility sets (CS). RESULTS We sampled 2465, 1314, and 2211 MSM in capture one, two, and three, respectively. There were 721 recaptures between captures one and two, 415 recaptures between captures two and three, and 422 recaptures between captures one and three. There were 210 MSM captured in all three captures. The total estimated population size of MSM above 18 years old in Rwanda was 18,100 (95% CS 11,300-29,700), corresponding to 0.70% (95% CI 0.4%-1.1%) of total adult males. Most MSM reside in the city of Kigali (7842, 95% CS 4587-13,153), followed by the Western province (2469, 95% CS 1994-3518), Northern province (2375, 95% CS 842-4239), Eastern province (2287, 95% CS 1927-3014), and Southern province (2109, 95% CS 1681-3418). CONCLUSIONS Our study provides, for the first time, a PSE of MSM aged 18 years or older in Rwanda. MSM are concentrated in the city of Kigali and are almost evenly distributed across the other 4 provinces. The national proportion estimate bounds of MSM out of the total adult males includes the World Health Organization's minimum recommended proportion (at least 1.0%) based on 2012 census population projections for 2021. These results will inform denominators to be used for estimating service coverage and fill existing information gaps to enable policy makers and planners to monitor the HIV epidemic among MSM nationally. There is an opportunity for conducting small-area MSM PSEs for subnational-level HIV treatment and prevention interventions.
Collapse
Affiliation(s)
- Elysee Tuyishime
- African Center of Excellence in Data Science, University of Rwanda, Kigali, Rwanda
- Division of Global HIV and Tuberculosis, Center for Global Health, US Centers for Disease Control and Prevention, Kigali, Rwanda
| | - Catherine Kayitesi
- HIV/AIDS, Sexually Transmitted Infections and Viral Hepatitis Division, Rwanda Biomedical Center, Kigali, Rwanda
| | - Gentille Musengimana
- Division of Global HIV and Tuberculosis, Center for Global Health, US Centers for Disease Control and Prevention, Kigali, Rwanda
| | - Samuel Malamba
- Division of Global HIV and Tuberculosis, Center for Global Health, US Centers for Disease Control and Prevention, Kigali, Rwanda
| | - Hailegiorgis Moges
- Division of Global HIV and Tuberculosis, Center for Global Health, US Centers for Disease Control and Prevention, Kigali, Rwanda
| | - Ida Kankindi
- Division of Global HIV and Tuberculosis, Center for Global Health, US Centers for Disease Control and Prevention, Kigali, Rwanda
| | - Horacio Ruisenor Escudero
- Key Population Surveillance Team, Epidemiology and Surveillance Branch, Division of Global HIV and Tuberculosis, Center of Global Health, US Centers for Disease Control and Prevention, Atlanta, GA, United States
| | | | - Tom Oluoch
- Division of Global HIV and Tuberculosis, Center for Global Health, US Centers for Disease Control and Prevention, Kigali, Rwanda
| | - Eric Remera
- HIV/AIDS, Sexually Transmitted Infections and Viral Hepatitis Division, Rwanda Biomedical Center, Kigali, Rwanda
| | - Angela Chukwu
- African Center of Excellence in Data Science, University of Rwanda, Kigali, Rwanda
| |
Collapse
|
10
|
Murenzi G, Kim HY, Shi Q, Muhoza B, Munyaneza A, Kubwimana G, Remera E, Nsanzimana S, Yotebieng M, Nash D, Anastos K, Ross J. Association Between Time to Antiretroviral Therapy and Loss to Care Among Newly Diagnosed Rwandan People Living with Human Immunodeficiency Virus. AIDS Res Hum Retroviruses 2023; 39:253-261. [PMID: 36800896 PMCID: PMC10171964 DOI: 10.1089/aid.2022.0023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/20/2023] Open
Abstract
Despite improved clinical outcomes of initiating antiretroviral therapy (ART) soon after diagnosis, conflicting evidence exists regarding the impact of same-day ART initiation on subsequent clinical outcomes. We aimed to characterize the associations of time to ART initiation with loss to care and viral suppression in a cohort of newly diagnosed people living with HIV (PLHIV) entering care after Rwanda implemented a national "Treat All" policy. We conducted a secondary analysis of routinely collected data of adult PLHIV enrolling in HIV care at 10 health facilities in Kigali, Rwanda. Time from enrollment to ART initiation was categorized as same day, 1-7 days, or >7 days. We examined associations between time to ART and loss to care (>120 days since last health facility visit) using Cox proportional hazards models, and between time to ART and viral suppression using logistic regression. Of 2,524 patients included in this analysis, 1,452 (57.5%) were women and the median age was 32 (interquartile range: 26-39). Loss to care was more frequent among patients who initiated ART on the same day (15.9%), compared with those initiating ART 1-7 days (12.3%) or >7 days (10.1%), p < .001. In multivariable analyses, same-day ART initiation was associated with a greater hazard of loss to care compared with initiating >7 days after enrollment (adjusted hazard ratio 1.39, 95% confidence interval: 1.04-1.85). A total of 1,698 (67.3%) had available data on viral load measured within 455 days after enrollment. Of these, 1,476 (87%) were virally suppressed. A higher proportion of patients initiating ART on the same day were virally suppressed (89%) compared with those initiating 1-7 days (84%) or >7 days (88%) after enrollment. This association was not statistically significant. Our findings suggest that ensuring adequate, early support for PLHIV initiating ART rapidly may be important to improve retention in care for newly diagnosed PLHIV in the era of Treat All.
Collapse
Affiliation(s)
- Gad Murenzi
- Rwanda Military Hospital, Kigali, Rwanda.,Research for Development (RD Rwanda), Kigali, Rwanda
| | | | - Qiuhu Shi
- New York Medical College, Valhalla, New York, USA
| | | | | | - Gallican Kubwimana
- Rwanda Military Hospital, Kigali, Rwanda.,Research for Development (RD Rwanda), Kigali, Rwanda
| | | | | | | | - Denis Nash
- Institute for Implementation Science in Population Health, City University of New York, New York, New York, USA.,School of Public Health, City University of New York, New York, New York, USA
| | | | - Jonathan Ross
- Albert Einstein College of Medicine, Bronx, New York, USA
| |
Collapse
|
11
|
Peck ME, Ong KS, Lucas T, Harvey P, Lekone P, Letebele M, Thomas VT, Maziya V, Mkhontfo M, Gultie T, Mulatu D, Shimelis M, Zegeye T, Juma AW, Odoyo-June E, Musingila PK, Njenga J, Auld A, Kapito M, Maida A, Msungama W, Canda M, Come J, Malimane I, Aupokolo M, Zemburuka B, Kankindi I, Malamba S, Remera E, Tubane E, Machava R, Maphothi N, Vranken P, Amuri M, Kazaura KJ, Simbeye D, Alamo S, Kabuye G, Chituwo O, Kamboyi R, Masiye J, Mandisarisa J, Xaba S, Toledo C. Voluntary Medical Male Circumcisions for HIV Prevention - 13 Countries in Eastern and Southern Africa, 2017-2021. MMWR Morb Mortal Wkly Rep 2023; 72:256-260. [PMID: 36893046 PMCID: PMC10010757 DOI: 10.15585/mmwr.mm7210a2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/10/2023]
Abstract
In 2007, voluntary medical male circumcision (VMMC) was endorsed by the World Health Organization (WHO) and the Joint United Nations Programme on HIV/AIDS after it was found to be associated with approximately a 60% reduction in the risk for female-to-male transmission of HIV (1). As a result of this endorsement, the U.S. President's Emergency Plan for AIDS Relief (PEPFAR), through partnerships with U.S. government agencies, including CDC, the U.S. Department of Defense, and the U.S. Agency for International Development, started supporting VMMCs performed in prioritized countries in southern and eastern Africa. During 2010-2016, CDC supported 5,880,372 VMMCs in 12 countries (2,3). During 2017-2021, CDC supported 8,497,297 VMMCs performed in 13 countries. In 2020, the number of VMMCs performed declined 31.8% compared with the number in 2019, primarily because of COVID-19-related disruptions to VMMC service delivery. PEPFAR 2017-2021 Monitoring, Evaluation, and Reporting data were used to provide an update and describe CDC's contribution to the scale-up of the VMMC program, which is important to meeting the 2025 Joint United Nations Programme on HIV/AIDS (UNAIDS) target of 90% of males aged 15-59 years having access to VMMC services in prioritized countries to help end the AIDS epidemic by 2030 (4).
Collapse
|
12
|
Rwibasira GN, Dzinamarira T, Remera E, Malamba SS, Fazito E, Mathu R, Matreja P, Cai H, Kayirangwa E, Nsanzimana S. Engagement in HIV continuum of care: another step needed to close the gap towards UNAIDS 90-90-90 targets among younger men in Rwanda. J Med Virol 2023; 95:e28619. [PMID: 36840399 PMCID: PMC10076904 DOI: 10.1002/jmv.28619] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2022] [Revised: 02/13/2023] [Accepted: 02/19/2023] [Indexed: 02/26/2023]
Abstract
In this study, we measured Rwandan men's engagement in HIV services based on the UNAIDS 90-90-90 targets and assessed factors associated with linkage to HIV services. We analyzed the Rwanda Population-based HIV Impact Assessment (RPHIA) data for 15-64-year-old males. We conducted bivariate analysis to assess the distribution and association of sociodemographic characteristics with UNAIDS 90-90-90 targets. We adjusted multi-variable models to understand the effect measurement of associated factors and determine the factors that best predict the achievement of UNAIDS 90-90-90. Of 13,780 males aged 15-64 years who participated in the RPHIA and consented to the blood draw and HIV testing, 302 had a positive HIV result while 301 had valid responses to all variables analyzed in this paper and were included in the analysis. We found that age group was an explanatory and predictive factor for achievement of UNAIDS 90-90-90. Younger men living with HIV (MLHIV) are less likely to have achieved UNAIDS 90-90-90 compared to MLHIV 50-64 years old: aOR for MLHIV aged 15-34 years was 0.21 (0.08, 0.53) and aOR for MLHIV aged 35-49 years was0.77 (0.36, 1.66). To close the UNAIDS 90-90-90 gap in Rwanda, innovative service delivery strategies are needed to support young MLHIV to reach 90-90-90. This article is protected by copyright. All rights reserved.
Collapse
Affiliation(s)
| | | | - Eric Remera
- Rwanda Biomedical Center, Ministry of Health, Kigali, Rwanda
| | - Samuel S Malamba
- Division of Global HIV and TB, Center for Global Health, CDC, Kigali, Rwanda
| | | | | | | | - Haotian Cai
- Division of Global HIV and TB, Center for Global Health, CDC, Kigali, Rwanda
| | - Eugenie Kayirangwa
- Division of Global HIV and TB, Center for Global Health, CDC, Kigali, Rwanda
| | | |
Collapse
|
13
|
Mutesa L, Misbah G, Remera E, Ebbers H, Schalke E, Tuyisenge P, Sindayiheba R, Igiraneza C, Uwimana J, Mbabazi D, Kayonga E, Twagiramungu M, Mugwaneza D, Ishema L, Butera Y, Musanabaganwa C, Rwagasore E, Twele F, Meller S, Tuyishime A, Rutayisire R, Murindahabi MM, Wilson LA, Bigirimana N, Volk HA, Ndahindwa V, Kayijuka B, Mills EJ, Muvunyi CM, Nsanzimana S. Use of trained scent dogs for detection of COVID-19 and evidence of cost-saving. Front Med (Lausanne) 2022; 9:1006315. [PMID: 36530913 PMCID: PMC9751420 DOI: 10.3389/fmed.2022.1006315] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2022] [Accepted: 11/17/2022] [Indexed: 12/04/2022] Open
Abstract
Background One of the lessons learned from the coronavirus disease 2019 (COVID-19) pandemic is the importance of early, flexible, and rapidly deployable disease detection methods. Currently, diagnosis of COVID-19 requires the collection of oro/nasopharyngal swabs, nasal turbinate, anterior nares and saliva but as the pandemic continues, disease detection methods that can identify infected individuals earlier and more quickly will be crucial for slowing the spread of the virus. Previous studies have indicated that dogs can be trained to identify volatile organic compounds (VOCs) produced during respiratory infections. We sought to determine whether this approach could be applied for detection of COVID-19 in Rwanda and measured its cost-saving. Methods Over a period of 5 months, four dogs were trained to detect VOCs in sweat samples collected from human subjects confirmed positive or negative for COVID-19 by reverse transcription polymerase chain reaction (RT-PCR) testing. Dogs were trained using a detection dog training system (DDTS) and in vivo diagnosis. Samples were collected from 5,253 participants using a cotton pad swiped in the underarm to collect sweat samples. Statistical analysis was conducted using R statistical software. Findings From August to September 2021 during the Delta wave, the sensitivity of the dogs' COVID-19 detection ranged from 75.0 to 89.9% for the lowest- and highest-performing dogs, respectively. Specificity ranged from 96.1 to 98.4%, respectively. In the second phase coinciding with the Omicron wave (January-March 2022), the sensitivity decreased substantially from 36.6 to 41.5%, while specificity remained above 95% for all four dogs. The sensitivity and specificity by any positive sample detected by at least one dog was 83.9, 95% CI: 75.8-90.2 and 94.9%; 95% CI: 93.9-95.8, respectively. The use of scent detection dogs was also found to be cost-saving compared to antigen rapid diagnostic tests, based on a marginal cost of approximately $14,000 USD for testing of the 5,253 samples which makes 2.67 USD per sample. Testing turnaround time was also faster with the scent detection dogs, at 3 h compared to 11 h with routine diagnostic testing. Conclusion The findings from this study indicate that trained dogs can accurately identify respiratory secretion samples from asymptomatic and symptomatic COVID-19 patients timely and cost-effectively. Our findings recommend further uptake of this approach for COVID-19 detection.
Collapse
Affiliation(s)
- Leon Mutesa
- Center for Human Genetics, Inc., College of Medicine and Health Sciences, University of Rwanda, Kigali, Rwanda,Rwanda National Joint Task Force COVID-19, Kigali, Rwanda,*Correspondence: Leon Mutesa,
| | - Gashegu Misbah
- Rwanda National Joint Task Force COVID-19, Kigali, Rwanda
| | - Eric Remera
- Rwanda National Joint Task Force COVID-19, Kigali, Rwanda
| | - Hans Ebbers
- Kynoscience UG, Praxis und Wissenschaft, Hörstel, Germany
| | - Esther Schalke
- Kynoscience UG, Praxis und Wissenschaft, Hörstel, Germany
| | | | | | | | | | - Diane Mbabazi
- Rwanda National Joint Task Force COVID-19, Kigali, Rwanda
| | | | | | | | - Leandre Ishema
- Rwanda National Joint Task Force COVID-19, Kigali, Rwanda
| | - Yvan Butera
- Center for Human Genetics, Inc., College of Medicine and Health Sciences, University of Rwanda, Kigali, Rwanda,Rwanda National Joint Task Force COVID-19, Kigali, Rwanda
| | - Clarisse Musanabaganwa
- Center for Human Genetics, Inc., College of Medicine and Health Sciences, University of Rwanda, Kigali, Rwanda,Rwanda National Joint Task Force COVID-19, Kigali, Rwanda
| | | | - Friederike Twele
- Department of Small Animal Medicine and Surgery, University of Veterinary Medicine Hannover, Hannover, Germany
| | - Sebastian Meller
- Department of Small Animal Medicine and Surgery, University of Veterinary Medicine Hannover, Hannover, Germany
| | | | | | | | - Lindsay A. Wilson
- School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada
| | | | - Holger A. Volk
- Department of Small Animal Medicine and Surgery, University of Veterinary Medicine Hannover, Hannover, Germany
| | | | | | - Edward J. Mills
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
| | | | | |
Collapse
|
14
|
Peck ME, Ong KS, Lucas T, Prainito A, Thomas AG, Brun A, Kiggundu V, Yansaneh A, Busang L, Kgongwana K, Kelaphile D, Seipone K, Letebele MH, Makadzange PF, Marwiro A, Sesinyi M, Lapidos T, Lukhele N, Maziya V, Mkhontfo M, Gultie T, Mulatu D, Shimelis M, Zegeye T, Teka T, Bulterys M, Njenga JN, Odoyo-June E, Juma AW, Soo L, Talam N, Brown M, Chakare T, Nonyana N, Khoabane MA, Auld AF, Maida A, Msungama W, Kapito M, Nyirenda R, Matchere F, Odek J, Canda M, Malimane I, Come J, Gaspar N, Langa A, Aupokolo MA, Vejorerako KC, Kahindi L, Mali D, Zegeye A, Mangoya D, Zemburuka BL, Bamwesigye J, Kankindi I, Kayirangwa E, Malamba SS, Roels T, Kayonde L, Zimulinda E, Ndengo E, Nsanzimana S, Remera E, Rwibasira GN, Sangwayire B, Semakula M, Rugira E, Rugwizangoga E, Tubane E, Yoboka E, Lawrence J, Loykissoonlal D, Maphothi N, Achut V, Bunga S, Moi M, Amuri M, Kazaura K, Simbeye D, Fida N, Kayange AA, Seleman M, Akao J, Alamo ST, Kabuye G, Kyobutungi S, Makumbi FE, Mudiope P, Nantez B, Chituwo O, Godfrey L, Muyunda B, Kamboyi R, Masiye J, Lifuka E, Mandisarisa J, Mhangara M, Xaba S, Toledo C. Effects of COVID-19 Pandemic on Voluntary Medical Male Circumcision Services for HIV Prevention, Sub-Saharan Africa, 2020. Emerg Infect Dis 2022; 28:S262-S269. [PMID: 36502454 DOI: 10.3201/eid2813.212455] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Beginning in March 2020, to reduce COVID-19 transmission, the US President's Emergency Plan for AIDS Relief supporting voluntary medical male circumcision (VMMC) services was delayed in 15 sub-Saharan African countries. We reviewed performance indicators to compare the number of VMMCs performed in 2020 with those performed in previous years. In all countries, the annual number of VMMCs performed decreased 32.5% (from 3,898,960 in 2019 to 2,631,951 in 2020). That reduction is largely attributed to national and local COVID-19 mitigation measures instituted by ministries of health. Overall, 66.7% of the VMMC global annual target was met in 2020, compared with 102.0% in 2019. Countries were not uniformly affected; South Africa achieved only 30.7% of its annual target in 2020, but Rwanda achieved 123.0%. Continued disruption to the VMMC program may lead to reduced circumcision coverage and potentially increased HIV-susceptible populations. Strategies for modifying VMMC services provide lessons for adapting healthcare systems during a global pandemic.
Collapse
|
15
|
Musengimana G, Umugisha JP, Habinshuti P, Anderson T, Mukesharurema G, Remera E, Ndahimana JD, Barnhart DA. Characteristics and clinical outcomes of patients presenting with advanced HIV disease in the "treat all" era: a retrospective cohort study from rural Rwanda. BMC Infect Dis 2022; 22:706. [PMID: 36008786 PMCID: PMC9404671 DOI: 10.1186/s12879-022-07692-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Accepted: 08/16/2022] [Indexed: 11/21/2022] Open
Abstract
Background In 2016 Rwanda adopted “treat all” where all patients with HIV are immediately eligible for ART regardless of disease progression. Despite widespread availability of treatment, it is unknown whether presentation with advanced HIV persists. Methods We conducted a retrospective cohort among patients aged ≥ 15 who enrolled in care between July 2016 and July 2018 in three rural Rwandan districts. We estimated the prevalence of advanced HIV, defined as presenting with CD4 count < 200 cells/mm3 or WHO stage 3 or 4, and compared baseline characteristics of patients with and without advanced HIV. We compared cumulative incidences and time to events using Chi squared tests and Cox proportional hazards models, respectively, for (a) viral load tests; (b) viral suppression; (c) death; and (d) treatment failure (a composite of death, lost to follow up, or virologic failure). Results Among 957 patients, 105 (11.0%) presented with advanced HIV. These patients were significantly more likely to have low body mass index, come from Burera district, be older, and be identified through inpatient settings rather than through voluntary or prenatal testing. Patients with advanced HIV had significantly higher risks of death at 12-months (9.5% vs 1.5%, p < 0.001) and 18-months (10.5% vs 1.9%, p < 0.001) and significantly higher risk of treatment failure at 12-months (21.9% vs. 14.2%, p = 0.037). After adjusting for confounders, patients with advanced HIV had still higher rates of death (adjusted Hazard ratio [aHR] = 4.4, 95% CI: 1.9, 10.2, p < 0.001) and treatment failure (aHR = 1.7, 95% CI: 1.1, 2.5, p = 0.017), but no difference in viral load testing (aHR = 1.1, 95% CI: 0.8, 1.5, p = 0.442) or viral suppression (aHR = 1.0, 95% CI: 0.8, 1.4, p = 0.949). When allowing for the hazard ratio to vary over time, patients with advanced HIV experienced elevated rates of treatment failure in the first six of enrollment, but not after nine months. Conclusion Presenting with advanced HIV remains common and is still associated with poor patient outcomes. Sensitization of the community to the benefits of early ART initiation, identification of patients with advanced HIV, and holistic support programs for the first 6 months of treatment may be needed to improve outcomes.
Collapse
Affiliation(s)
- Gentille Musengimana
- Division of HIV/AIDs, Rwanda Biomedical Center, STIs and Viral Hepatitis, City of Kigali, Rwanda.
| | - Jean Paul Umugisha
- Partners in Heath, Inshuti Mu Buzima, Infectious Disease Program, City of Kigali, Rwanda
| | - Placide Habinshuti
- Partners in Heath, Inshuti Mu Buzima, Infectious Disease Program, City of Kigali, Rwanda
| | - Todd Anderson
- Partners in Heath, Inshuti Mu Buzima, Infectious Disease Program, City of Kigali, Rwanda
| | | | - Eric Remera
- Division of HIV/AIDs, Rwanda Biomedical Center, STIs and Viral Hepatitis, City of Kigali, Rwanda
| | - Jean D'Amour Ndahimana
- Partners in Heath, Inshuti Mu Buzima, Infectious Disease Program, City of Kigali, Rwanda
| | - Dale A Barnhart
- Partners in Heath, Inshuti Mu Buzima, Infectious Disease Program, City of Kigali, Rwanda.,Department of Global Health and Social Medicine Boston, Harvard Medical School, Boston, MA, USA
| |
Collapse
|
16
|
Makuza JD, Soe P, Jeong D, Nisingizwe MP, Dushimiyimana D, Umutesi J, Nshimiyimana L, Maliza C, Serumondo J, Remera E, Rwibasira GN, Tuyishime A, Riedel DJ. Epidemiology of sexually transmitted infections: trends among patients screened for sexually transmitted infections in rwandan health facilities 2014–2020. BMC Infect Dis 2022; 22:701. [PMID: 35987614 PMCID: PMC9392439 DOI: 10.1186/s12879-022-07685-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Accepted: 08/12/2022] [Indexed: 11/25/2022] Open
Abstract
Background Sexually Transmitted Infections (STIs) are of great global health concern. Currently, there are limited epidemiological data characterizing STIs in the general population in Rwanda. We assessed the national and regional epidemiology of STIs in Rwanda from 2014–2020 among patients syndromically screened for STIs in all health facilities in Rwanda. Methods This is a retrospective analysis of the trend of STIs epidemiology among screened patients at all health facilities in Rwanda using data from the Health Management Information System (HMIS) reporting. Adult patients (15 years and over) screened for STIs between July 2014 and June 2020 were included in the analysis. Outcomes of interest were the number of individuals screened for STIs and individuals diagnosed with at least one STI with a syndromic approach only or plus a test together. Results Overall, the number of individuals screened for STIs over the study period was 5.3 million (M) in 2014–2015, 6.6 M in 2015–2016, 6.3 M in 2016–2017, 6.7 M in 2017–2018, 6.2 M in 2018–2019, and 4.9 M in 2019–2020. There was a modest increase in the number of individuals diagnosed and treated for STIs from 139,357 in 2014–15 to 202,294 (45% increase) in 2019–2020. At the national level, the prevalence of STI syndromes amongst individuals screened at health facilities in Rwanda varied between 2.37% to 4.16% during the study period. Among the provinces, Kigali city had the highest prevalence for the whole 6 years ranging from 3.46% (95%CI: 3.41, 3.51) in 2014–2015 to 8.23% (95%CI: 8.15, 8.31) in 2019–2020. Conclusion From 2014 to 2020, the number of patients screened for STI syndromes in Rwanda varied between 4.9 M and 6.7 M. However, the prevalence of STIs among screened patients increased considerably over time, which could be associated with public awareness and improved data recording. The highest prevalence of all STIs was observed in urban areas and near borders, and private clinics reported more cases, suggesting the need to improve awareness in these settings and increase confidentiality and trust in public health clinics.
Collapse
|
17
|
Musengimana G, Tuyishime E, Kiromera A, Malamba SS, Mulindabigwi A, Habimana MR, Baribwira C, Ribakare M, Habimana SD, DeVos J, Mwesigwa RCN, Kayirangwa E, Semuhore JM, Rwibasira GN, Suthar AB, Remera E. Acquired HIV drug resistance among adults living with HIV receiving first-line antiretroviral therapy in Rwanda: A cross-sectional nationally representative survey. Antivir Ther 2022; 27:13596535221102690. [PMID: 35593031 PMCID: PMC9263597 DOI: 10.1177/13596535221102690] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
BACKGROUND We assessed the prevalence of acquired HIV drug resistance (HIVDR) and associated factors among patients receiving first-line antiretroviral therapy (ART) in Rwanda. METHODS This cross-sectional study included 702 patients receiving first-line ART for at least 6 months with last viral load (VL) results ≥1000 copies/mL. Blood plasma samples were subjected to VL testing; specimens with unsuppressed VL were genotyped to identify HIVDR-associated mutations. Data were analysed using STATA/SE. RESULTS Median time on ART was 86.4 months (interquartile range [IQR], 44.8-130.2 months), and median CD4 count at ART initiation was 311 cells/mm3 (IQR, 197-484 cells/mm3). Of 414 (68.2%) samples with unsuppressed VL, 378 (88.3%) were genotyped. HIVDR included 347 (90.4%) non-nucleoside reverse transcriptase inhibitor- (NNRTI), 291 (75.5%) nucleoside reverse transcriptase inhibitor- (NRTI) and 13 (3.5%) protease inhibitor (PI) resistance-associated mutations. The most common HIVDR mutations were K65R (22.7%), M184V (15.4%) and D67N (9.8%) for NRTIs and K103N (34.4%) and Y181C/I/V/YC (7%) for NNRTIs. Independent predictors of acquired HIVDR included current ART regimen of zidovudine + lamivudine + nevirapine (adjusted odds ratio [aOR], 3.333 [95% confidence interval (CI): 1.022-10.870]; p = 0.046) for NRTI resistance and current ART regimen of tenofovir + emtricitabine + nevirapine (aOR, 0.148 [95% CI: 0.028-0.779]; p = 0.025), zidovudine + lamivudine + efavirenz (aOR, 0.105 [95% CI: 0.016-0.693]; p = 0.020) and zidovudine + lamivudine + nevirapine (aOR, 0.259 [95% CI: 0.084-0.793]; p = 0.019) for NNRTI resistance. History of ever switching ART regimen was associated with NRTI resistance (aOR, 2.53 [95% CI: 1.198-5.356]; p = 0.016) and NNRTI resistance (aOR, 3.23 [95% CI: 1.435-7.278], p = 0.005). CONCLUSION The prevalence of acquired HIV drug resistance (HIVDR) was high among patient failing to re-suppress VL and was associated with current ART regimen and ever switching ART regimen. The findings of this study support the current WHO guidelines recommending that patients on an NNRTI-based regimen should be switched based on a single viral load test and suggests that national HIV VL monitoring of patients receiving ART has prevented long-term treatment failure that would result in the accumulation of TAMs and potential loss of efficacy of all NRTI used in second-line ART as the backbone in combination with either dolutegravir or boosted PIs.
Collapse
Affiliation(s)
- Gentille Musengimana
- Ministry of Health, Rwanda Biomedical Center, HIV/AIDs, STIs and OBBI Division, Kigali City, Rwanda,U.S. Centers for Disease Control and Prevention, Center for Global Health, Division of Global HIV & TB, Rwanda
| | - Elysee Tuyishime
- U.S. Centers for Disease Control and Prevention, Center for Global Health, Division of Global HIV & TB, Rwanda
| | - Athanase Kiromera
- University of Maryland, Center for International Health, Education and Biosecurity, (CIHEB), Baltimore, MD USA
| | - Samuel S. Malamba
- U.S. Centers for Disease Control and Prevention, Center for Global Health, Division of Global HIV & TB, Rwanda
| | - Augustin Mulindabigwi
- Ministry of Health, Rwanda Biomedical Center, HIV/AIDs, STIs and OBBI Division, Kigali City, Rwanda
| | - Madjid R. Habimana
- Ministry of Health, Rwanda Biomedical Center, HIV/AIDs, STIs and OBBI Division, Kigali City, Rwanda
| | - Cyprien Baribwira
- University of Maryland, Center for International Health, Education and Biosecurity, (CIHEB), Baltimore, MD USA
| | - Muhayimpundu Ribakare
- Ministry of Health, Rwanda Biomedical Center, HIV/AIDs, STIs and OBBI Division, Kigali City, Rwanda
| | - Savio D. Habimana
- Ministry of Health, Rwanda Biomedical Center, HIV/AIDs, STIs and OBBI Division, Kigali City, Rwanda
| | - Josh DeVos
- U.S. Centers for Disease Control and Prevention, Center for Global Health, Division of Global HIV & TB, Atlanta, GA USA
| | - Richard C. N. Mwesigwa
- U.S. Centers for Disease Control and Prevention, Center for Global Health, Division of Global HIV & TB, Rwanda
| | - Eugenie Kayirangwa
- U.S. Centers for Disease Control and Prevention, Center for Global Health, Division of Global HIV & TB, Rwanda
| | | | - Gallican N. Rwibasira
- Ministry of Health, Rwanda Biomedical Center, HIV/AIDs, STIs and OBBI Division, Kigali City, Rwanda
| | - Amitabh B. Suthar
- U.S. Centers for Disease Control and Prevention, Center for Global Health, Division of Global HIV & TB, Atlanta, GA USA
| | - Eric Remera
- Ministry of Health, Rwanda Biomedical Center, HIV/AIDs, STIs and OBBI Division, Kigali City, Rwanda,University of Basel, Basel, Switzerland,Swiss Tropical and Public Health Institute, Basel, Switzerland
| |
Collapse
|
18
|
Donenberg GR, Fitts J, Ingabire C, Nsanzimana S, Fabri M, Emerson E, Remera E, Manzi O, Bray B, Cohen MH. Results of the Kigali Imbereheza Project: A 2-Arm Individually Randomized Trial of TI-CBT Enhanced to Address ART Adherence and Mental Health for Rwandan Youth Living With HIV. J Acquir Immune Defic Syndr 2022; 90:69-78. [PMID: 35013089 PMCID: PMC8986574 DOI: 10.1097/qai.0000000000002911] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Accepted: 12/20/2021] [Indexed: 10/19/2022]
Abstract
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.
Collapse
Affiliation(s)
- Geri R. Donenberg
- Center for Dissemination and Implementation Science, Department of Medicine, University of Illinois at Chicago, Chicago, IL USA
- Department of Medicine, University of Illinois at Chicago
| | - Jessica Fitts
- Center for Dissemination and Implementation Science, Department of Medicine, University of Illinois at Chicago, Chicago, IL USA
| | | | | | - Mary Fabri
- Women’s Equity in Access to Care and Treatment (WE-ACTx), San Francisco, California, US
| | - Erin Emerson
- Center for Dissemination and Implementation Science, Department of Medicine, University of Illinois at Chicago, Chicago, IL USA
| | | | - Olivier Manzi
- University Teaching Hospital of Kigali (CHUK), Department of Medicine, Kigali, Rwanda
| | - Bethany Bray
- Center for Dissemination and Implementation Science, Department of Medicine, University of Illinois at Chicago, Chicago, IL USA
| | - Mardge H. Cohen
- Women’s Equity in Access to Care and Treatment (WE-ACTx), San Francisco, California, US
- Department of Medicine, Stroger Hospital of Cook County, Chicago IL USA
| |
Collapse
|
19
|
Remera E, Nsanzimana S, Chammartin F, Semakula M, Rwibasira GN, Malamba SS, Riedel DJ, Tuyishime E, Condo JU, Ndimubanzi P, Sangwayire B, Forrest JI, Cantoreggi SL, Mills EJ, Bucher HC. Brief Report: Active HIV Case Finding in the City of Kigali, Rwanda: Assessment of Voluntary Assisted Partner Notification Modalities to Detect Undiagnosed HIV Infections. J Acquir Immune Defic Syndr 2022; 89:423-427. [PMID: 35202049 PMCID: PMC8860213 DOI: 10.1097/qai.0000000000002878] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Accepted: 11/15/2021] [Indexed: 11/30/2022]
Abstract
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.
Collapse
Affiliation(s)
- Eric Remera
- Institute of HIV Disease Prevention and Control, Rwanda Biomedical Centre, Kigali, Rwanda
- Basel Institute for Clinical Epidemiology and Biostatistics, Department of Clinical Research, University Hospital Basel, Basel, Switzerland
- University of Basel, Faculty of Science, Basel- Switzerland
- Department of Epidemiology and Public Health, Swiss Tropical and Public Health Institute, Basel, Switzerland
| | - Sabin Nsanzimana
- Institute of HIV Disease Prevention and Control, Rwanda Biomedical Centre, Kigali, Rwanda
| | - Frédérique Chammartin
- Basel Institute for Clinical Epidemiology and Biostatistics, Department of Clinical Research, University Hospital Basel, Basel, Switzerland
- University of Basel, Faculty of Science, Basel- Switzerland
| | - Muhammed Semakula
- Institute of HIV Disease Prevention and Control, Rwanda Biomedical Centre, Kigali, Rwanda
- I-BioStat, Hasselt University, Hasselt, Belgium
| | - Gallican N. Rwibasira
- Institute of HIV Disease Prevention and Control, Rwanda Biomedical Centre, Kigali, Rwanda
| | | | - David J. Riedel
- Division of Infectious Diseases, University of Maryland School of Medicine, Baltimore, MD
| | - Elysee Tuyishime
- African Center of Excellence in Data Science, University of Rwanda, Kigali, Rwanda
| | - Jeanine U. Condo
- School of Public Health, College of Medicine & Health Sciences, University of Rwanda, Kigali, Rwanda
- Tulane University, New Orleans, LA
| | | | - Beata Sangwayire
- Institute of HIV Disease Prevention and Control, Rwanda Biomedical Centre, Kigali, Rwanda
| | - Jamie I. Forrest
- School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada; and
| | - Sara L. Cantoreggi
- Institute of HIV Disease Prevention and Control, Rwanda Biomedical Centre, Kigali, Rwanda
- University of Basel, Faculty of Science, Basel- Switzerland
| | - Edward J. Mills
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Heiner C. Bucher
- Basel Institute for Clinical Epidemiology and Biostatistics, Department of Clinical Research, University Hospital Basel, Basel, Switzerland
- University of Basel, Faculty of Science, Basel- Switzerland
| |
Collapse
|
20
|
Nsanzimana S, Rwibasira GN, Malamba SS, Musengimana G, Kayirangwa E, Jonnalagadda S, Fazito Rezende E, Eaton JW, Mugisha V, Remera E, Muhamed S, Mulindabigwi A, Omolo J, Weisner L, Moore C, Patel H, Justman JE. HIV incidence and prevalence among adults aged 15-64 years in Rwanda: Results from the Rwanda Population-based HIV Impact Assessment (RPHIA) and District-level Modeling, 2019. Int J Infect Dis 2022; 116:245-254. [PMID: 35066161 PMCID: PMC9069967 DOI: 10.1016/j.ijid.2022.01.032] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2021] [Revised: 01/10/2022] [Accepted: 01/13/2022] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVES The 2018-2019 Rwanda Population-based HIV Impact Assessment (RPHIA) was conducted to measure national HIV incidence and prevalence. District-level estimates were modeled to inform resources allocation. METHODS RPHIA was a nationally representative cross-sectional household survey. Consenting adults were interviewed and tested for HIV using the national diagnostic algorithm followed by laboratory-based confirmation of HIV status and testing for viral load (VL), limiting antigen (LAg) avidity, and presence of antiretrovirals. Incidence was calculated using normalized optical density ≤ 1·5, VL ≥ 1,000 copies/mL, and undetectable antiretrovirals. Survey and programmatic data were used to model district-level HIV incidence and prevalence. RESULTS Of 31,028 eligible adults, 98·7% participated in RPHIA and 934 tested HIV positive. HIV prevalence among adults in Rwanda was 3·0% (95% CI:2·7-3·3). National HIV incidence was 0·08% (95% CI:0·02-0·14) and 0·11% (95% CI:0·00-0·26) in the City of Kigali (CoK). Based on district-level modeling, HIV incidence was greatest in the 3 CoK districts (0·11% to 0·15%) and varied across other districts (0·03% to 0·10%). CONCLUSIONS HIV prevalence among adults in Rwanda is 3.0%; HIV incidence is low at 0.08%. District-level modeling has identified disproportionately affected urban hotspots: areas to focus resources.
Collapse
Affiliation(s)
| | | | | | | | | | | | | | - Jeffrey W Eaton
- MRC Centre for Global Infectious Disease Analysis, School of Public Health, Imperial College London, London, UK
| | | | - Eric Remera
- Ministry of Health, Rwanda Biomedical Centre
| | | | | | - Jared Omolo
- US Centers for Disease Control and Prevention
| | - Lubbe Weisner
- UCT Pharmacology Research Laboratory, City of Cape Town, Western Cape, South Africa, Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | | | - Hetal Patel
- US Centers for Disease Control and Prevention
| | | |
Collapse
|
21
|
Remera E, Rwibasira G, Mulindabigwi A, Omolo J, Malamba S, Nsanzimana S. Use of index testing to close the gap in HIV diagnosis among older people in Rwanda: analysis of data from a public health programme. Lancet HIV 2022; 9 Suppl 1:S6. [PMID: 35304848 DOI: 10.1016/s2352-3018(22)00071-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
BACKGROUND As Rwanda inches closer to the UNAIDS HIV first 95 of knowing one's HIV status by 2030, finding the remaining HIV-positive individuals could be difficult by use of passive methods. Index testing is an approach whereby the exposed contacts of an HIV-positive person are notified and offered an HIV test. We aimed to assess the factors related to the HIV-positive outcome among older people (aged 50 years and above) in Rwanda. METHODS In Rwanda, adults (aged ≥18 years) on antiretroviral therapy (ART) who reported having had sexual partners with unknown HIV status, and individuals with newly diagnosed HIV, described as index cases, were asked to provide details of their sexual partners and invite them to the health facility for HIV testing through client referral, provider referral, or dual referral. We used logistic regression to model the odds of identifying partners who were HIV-positive or aged 50 years or older through partner notification services and to assess predictive factors related to index case and partner, after adjusting for partner related variables (age group, gender, relationship between index and sexual partner, province of residence, notification used) and index case related variables (type of index case, multiple partnership, had unprotected sex in past 12 months, viral load suppression, age difference between notified sexual partner and index case). Written informed consent was obtained from each participant before inclusion in the study. The Rwanda National Ethics Committee approved the protocol for implementation. FINDINGS Between October, 2018, and September, 2021, 18 453 index cases were recruited and 31 227 partners were notified and tested, of whom 3156 (10·0%) were aged 50 years and older. Of the partners aged 50 years and older, 877 (27·8%) were female and 2279 (88·1%) were male, and 1638 (51·9%) were notified by index cases who were younger than them. Among partners aged 50 years and older, 6·0% (3156) were HIV-positive, with a higher prevalence in partners notified by newly diagnosed index cases 14·7% (46 of 313). In the multivariable analysis, among partners aged 50 years and older, the adjusted odds ratio was 2·66 (95% CI 1·78-3·98) for female partners compared with male partners, 3·14 (2·08-4·77) for partners of newly HIV-diagnosed index cases compared with those of index cases who were already taking ART, and 1·89 (1·07-3·37) for partners who were 15 years older than the index case compared with partners who were 5 years older or younger. INTERPRETATION Partners of people with newly diagnosed HIV, older individuals who engaged in sexual relationship with younger individuals, and female partners had an increased risk of being diagnosed with HIV. Index testing successfully identified older people with undiagnosed HIV. FUNDING None.
Collapse
Affiliation(s)
- Eric Remera
- Rwanda Biomedical Centre, Kigali, Rwanda; University of Basel, Basel, Switzerland; Swiss Tropical and Public Health Institute, Basel, Switzerland.
| | | | | | | | - Samuel Malamba
- Uganda Virus Research Institute, HIV Reference Laboratory Program, Uganda
| | | |
Collapse
|
22
|
Serumondo J, Shilton S, Nshimiyimana L, Karame P, Dushimiyimana D, Fajardo E, Remera E, Rwibasira GN, Martínez-Pérez GZ. Values and preferences for hepatitis C self-testing among the general population and healthcare workers in Rwanda. BMC Infect Dis 2021; 21:1064. [PMID: 34649503 PMCID: PMC8514804 DOI: 10.1186/s12879-021-06773-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Accepted: 10/01/2021] [Indexed: 12/19/2022] Open
Abstract
Background In 2018, Rwanda launched a 5-year hepatitis C virus (HCV) elimination plan as per the World Health Organization global targets to eliminate HCV by 2030. To improve awareness of HCV status, strategies are needed to ensure easy access to HCV testing by as-yet unreached populations. HCV-self-testing, an innovative strategy, could further increase HCV testing uptake. This assessment explores perceptions around HCV self-testing among members of the public and healthcare workers in Rwanda. Methods A qualitative study was undertaken in Masaka District Hospital, comprising individual interviews, group interviews and participatory action research (PAR) activities. Purposive and snowball sampling methods guided the selection of informants. Informed consent was obtained from all participants. A thematic analysis approach was used to analyse the findings. Results The participants comprised 36 members of the public and 36 healthcare workers. Informants appreciated HCV self-testing as an innovative means of increasing access to HCV testing, as well as an opportunity to test privately and subsequently autonomously decide whether to seek further HCV care. Informants further highlighted the need to make HCV self-testing services free of charge at the nearest health facility. Disadvantages identified included the lack of pre/post-test counselling, as well as the potential psychosocial harm which may result from the use of HCV self-testing. Conclusion HCV self-testing is perceived to be an acceptable method to increase HCV testing in Rwanda. Further research is needed to assess the impact of HCV self-testing on HCV cascade of care outcomes. Supplementary Information The online version contains supplementary material available at 10.1186/s12879-021-06773-6.
Collapse
Affiliation(s)
| | - Sonjelle Shilton
- Foundation for Innovative New Diagnostics (FIND), Geneva, Switzerland.
| | | | | | | | - Emmanuel Fajardo
- Foundation for Innovative New Diagnostics (FIND), Geneva, Switzerland
| | - Eric Remera
- Rwanda Biomedical Centre (RBC), Kigali, Rwanda
| | | | - Guillermo Z Martínez-Pérez
- Foundation for Innovative New Diagnostics (FIND), Geneva, Switzerland.,Department of Physiatrics and Nursing, University of Saragossa, Zaragoza, Spain
| |
Collapse
|
23
|
West CA, Chang GC, W Currie D, Bray R, Kinchen S, Behel S, McCullough-Sanden R, Low A, Bissek A, Shang JD, Ndongmo CB, Dokubo EK, Balachandra S, Lobognon LR, Dube L, Nuwagaba-Biribonwoha H, Li M, Pasipamire M, Getaneh Y, Lulseged S, Eshetu F, Kingwara L, Zielinski-Gutierrez E, Tlhomola M, Ramphalla P, Kalua T, F Auld A, B Williams D, Remera E, Rwibasira GN, Mugisha V, Malamba SS, Mushi J, Jalloh MF, Mgomella GS, Kirungi WL, Biraro S, C Awor A, Barradas DT, Mugurungi O, H Rogers J, Bronson M, M Bodika S, Ajiboye A, Gaffga N, Moore C, Patel HK, C Voetsch A. Unawareness of HIV Infection Among Men Aged 15-59 Years in 13 Sub-Saharan African Countries: Findings From the Population-Based HIV Impact Assessments, 2015-2019. J Acquir Immune Defic Syndr 2021; 87:S97-S106. [PMID: 34166316 PMCID: PMC8711576 DOI: 10.1097/qai.0000000000002708] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Accepted: 04/07/2021] [Indexed: 01/21/2023]
Abstract
BACKGROUND Identifying men living with HIV in sub-Saharan Africa (SSA) is critical to end the epidemic. We describe the underlying factors of unawareness among men aged 15-59 years who ever tested for HIV in 13 SSA countries. METHODS Using pooled data from the nationally representative Population-based HIV Impact Assessments, we fit a log-binomial regression model to identify characteristics related to HIV positivity among HIV-positive unaware and HIV-negative men ever tested for HIV. RESULTS A total of 114,776 men were interviewed and tested for HIV; 4.4% were HIV-positive. Of those, 33.7% were unaware of their HIV-positive status, (range: 20.2%-58.7%, in Rwanda and Cote d'Ivoire). Most unaware men reported they had ever received an HIV test (63.0%). Age, region, marital status, and education were significantly associated with HIV positivity. Men who had HIV-positive sexual partners (adjusted prevalence ratio [aPR]: 5.73; confidence interval [95% CI]: 4.13 to 7.95) or sexual partners with unknown HIV status (aPR: 2.32; 95% CI: 1.89 to 2.84) were more likely to be HIV-positive unaware, as were men who tested more than 12 months compared with HIV-negative men who tested within 12 months before the interview (aPR: 1.58; 95% CI: 1.31 to 1.91). Tuberculosis diagnosis and not being circumcised were also associated with HIV positivity. CONCLUSION Targeting subgroups of men at risk for infection who once tested negative could improve yield of testing programs. Interventions include improving partner testing, frequency of testing, outreach and educational strategies, and availability of HIV testing where men are accessing routine health services.
Collapse
Affiliation(s)
| | - Gregory C Chang
- Division of Global HIV and TB, Center for Global Health, CDC
- ASPPH/PHI/CDC HIV Surveillance Fellowship
| | - Dustin W Currie
- Division of Global HIV and TB, Center for Global Health, CDC
| | | | - Steve Kinchen
- Division of Global HIV and TB, Center for Global Health, CDC
| | - Stephanie Behel
- Division of Global HIV and TB, Center for Global Health, CDC
| | - Rachel McCullough-Sanden
- ASPPH/PHI/CDC HIV Surveillance Fellowship
- Division of Global HIV and TB, Center for Global Health, CDC Cameroon
| | - Andrea Low
- ICAP at Columbia University, New York, NY
- Department of Epidemiology, Columbia University Mailman School of Public Health, New York, NY
| | | | - Judith D Shang
- Division of Global HIV and TB, Center for Global Health, CDC Cameroon
| | - Clement B Ndongmo
- Division of Global HIV and TB, Center for Global Health, CDC Cameroon
- Division of Global HIV and TB, Center for Global Health, CDC Zambia
| | - Emily K Dokubo
- Division of Global HIV and TB, Center for Global Health, CDC Cameroon
| | | | - Legre R Lobognon
- Division of Global HIV and TB, Center for Global Health, CDC Cote d'Ivoire
| | - Lenhle Dube
- National AIDS Program/Ministry of Health, Eswatini
| | | | - Michelle Li
- Division of Global HIV and TB, Center for Global Health, CDC Eswatini
| | | | | | | | - Frehywot Eshetu
- Division of Global HIV and TB, Center for Global Health, CDC Ethiopia
| | - Leonard Kingwara
- National AIDS and STI Control Programme, Ministry of Health, Kenya
| | | | | | - Puleng Ramphalla
- Division of Global HIV and TB, Center for Global Health, CDC Lesotho
| | | | - Andrew F Auld
- Division of Global HIV and TB, Center for Global Health, CDC Malawi
| | - Daniel B Williams
- Division of Global HIV and TB, Center for Global Health, CDC Namibia
| | | | | | - Veronicah Mugisha
- ICAP at Columbia University, Rwanda
- ICAP at Columbia University, Tanzania
| | - Samuel S Malamba
- Division of Global HIV and TB, Center for Global Health, CDC Rwanda
| | - Jeremiah Mushi
- National AIDS Control Programme, Ministry of Health, Community Development, Gender, Elderly and Children, Tanzania
| | - Mohamed F Jalloh
- Division of Global HIV and TB, Center for Global Health, CDC Tanzania
| | - George S Mgomella
- Division of Global HIV and TB, Center for Global Health, CDC Tanzania
| | | | | | - Anna C Awor
- Division of Global HIV and TB, Center for Global Health, CDC Uganda
| | | | | | - John H Rogers
- Division of Global HIV and TB, Center for Global Health, CDC Zimbabwe
| | - Megan Bronson
- Division of Global HIV and TB, Center for Global Health, CDC
| | | | | | - Nicholas Gaffga
- Division of Global HIV and TB, Center for Global Health, CDC
| | - Carole Moore
- Division of Global HIV and TB, Center for Global Health, CDC
| | - Hetal K Patel
- Division of Global HIV and TB, Center for Global Health, CDC
| | | |
Collapse
|
24
|
Fraser HSF, Mugisha M, Remera E, Ngenzi JL, Richards J, Santas X, Naidoo W, Seebregts C, Condo J, Umubyeyi A. User Perceptions and Use of an Enhanced EHR with and without Clinical Alerts, in 54 Health Centers In Rwanda: Cross sectional survey (Preprint). JMIR Med Inform 2021; 10:e32305. [PMID: 35503526 PMCID: PMC9115652 DOI: 10.2196/32305] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2021] [Revised: 01/08/2022] [Accepted: 01/31/2022] [Indexed: 11/13/2022] Open
Abstract
Background Objective Methods Results Conclusions
Collapse
Affiliation(s)
- Hamish S F Fraser
- Brown Center for Biomedical Informatics, Brown University, Providence, RI, United States
| | - Michael Mugisha
- School of Public Health, University of Rwanda, Kigali, Rwanda
| | | | | | | | | | | | | | - Jeanine Condo
- School of Public Health, University of Rwanda, Kigali, Rwanda
| | - Aline Umubyeyi
- School of Public Health, University of Rwanda, Kigali, Rwanda
| |
Collapse
|
25
|
Semakula M, Niragire F, Umutoni A, Nsanzimana S, Ndahindwa V, Rwagasore E, Nyatanyi T, Remera E, Faes C. The secondary transmission pattern of COVID-19 based on contact tracing in Rwanda. BMJ Glob Health 2021; 6:bmjgh-2020-004885. [PMID: 34103325 PMCID: PMC8189754 DOI: 10.1136/bmjgh-2020-004885] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Revised: 04/01/2021] [Accepted: 04/05/2021] [Indexed: 12/18/2022] Open
Abstract
Introduction COVID-19 has shown an exceptionally high spread rate across and within countries worldwide. Understanding the dynamics of such an infectious disease transmission is critical for devising strategies to control its spread. In particular, Rwanda was one of the African countries that started COVID-19 preparedness early in January 2020, and a total lockdown was imposed when the country had only 18 COVID-19 confirmed cases known. Using intensive contact tracing, several infections were identified, with the majority of them being returning travellers and their close contacts. We used the contact tracing data in Rwanda for understanding the geographic patterns of COVID-19 to inform targeted interventions. Methods We estimated the attack rates and identified risk factors associated to COVID-19 spread. We used Bayesian disease mapping models to assess the spatial pattern of COVID-19 and to identify areas characterised by unusually high or low relative risk. In addition, we used multiple variable conditional logistic regression to assess the impact of the risk factors. Results The results showed that COVID-19 cases in Rwanda are localised mainly in the central regions and in the southwest of Rwanda and that some clusters occurred in the northeast of Rwanda. Relationship to the index case, being male and coworkers are the important risk factors for COVID-19 transmission in Rwanda. Conclusion The analysis of contact tracing data using spatial modelling allowed us to identify high-risk areas at subnational level in Rwanda. Estimating risk factors for infection with SARS-CoV-2 is vital in identifying the clusters in low spread of SARS-CoV-2 subnational level. It is imperative to understand the interactions between the index case and contacts to identify superspreaders, risk factors and high-risk places. The findings recommend that self-isolation at home in Rwanda should be reviewed to limit secondary cases from the same households and spatiotemporal analysis should be introduced in routine monitoring of COVID-19 in Rwanda for policy making decision on real time.
Collapse
Affiliation(s)
- Muhammed Semakula
- Center for Excellence in Data Science, University of Rwanda - Kigali Campus, Kigali, Rwanda .,Centre for Statistics, Hasselt Biostatistics and statistical Bioinformatics Center, Diepenbeek, Limburg, Belgium
| | - FranÇois Niragire
- Applied Statistics, University of Rwanda College of Business and Economics - Gikondo Campus, Kigali, Rwanda
| | - Angela Umutoni
- Institute for HIV, Diseases Prevention and Control, Rwanda Biomedical Center, Kigali, Rwanda
| | - Sabin Nsanzimana
- Institute for HIV, Diseases Prevention and Control, Rwanda Biomedical Center, Kigali, Rwanda
| | - Vedaste Ndahindwa
- College of Medicine and Health Sciences, University of Rwanda, Kigali, Rwanda
| | - Edison Rwagasore
- Rwanda Biomedical Center, Rwanda Ministry of Health, Kigali, Rwanda
| | - Thierry Nyatanyi
- Institute for HIV, Diseases Prevention and Control, Rwanda Biomedical Center, Kigali, Rwanda
| | - Eric Remera
- Institute for HIV, Diseases Prevention and Control, Rwanda Biomedical Center, Kigali, Rwanda
| | - Christel Faes
- BioStat, Hasselt Biostatistics and statistical Bioinformatics Center, Diepenbeek, Limburg, Belgium
| |
Collapse
|
26
|
Habimana DS, Ngabonziza JCS, Migambi P, Mucyo-Habimana Y, Mutembayire G, Byukusenge F, Habiyambere I, Remera E, Mugwaneza P, Mwikarago IE, Mazarati JB, Turate I, Nsanzimana S, Decroo T, de Jong CB. Predictors of Rifampicin-Resistant Tuberculosis Mortality among HIV-Coinfected Patients in Rwanda. Am J Trop Med Hyg 2021; 105:47-53. [PMID: 33999845 PMCID: PMC8274780 DOI: 10.4269/ajtmh.20-1361] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2020] [Accepted: 02/26/2021] [Indexed: 11/22/2022] Open
Abstract
Tuberculosis (TB), including multidrug-resistant (MDR; i.e., resistant to at least rifampicin and isoniazid)/rifampicin-resistant (MDR/RR) TB, is the most important opportunistic infection among people living with HIV (PLHIV). In 2005, Rwanda launched the programmatic management of MDR/RR-TB. The shorter MDR/RR-TB treatment regimen (STR) has been implemented since 2014. We analyzed predictors of MDR/RR-TB mortality, including the effect of using the STR overall and among PLHIV. This retrospective study included data from patients diagnosed with RR-TB in Rwanda between July 2005 and December 2018. Multivariable logistic regression was used to assess predictors of mortality. Of 898 registered MDR/RR-TB patients, 861 (95.9%) were included in this analysis, of whom 360 (41.8%) were HIV coinfected. Overall, 86 (10%) patients died during MDR/RR-TB treatment. Mortality was higher among HIV-coinfected compared with HIV-negative TB patients (13.3% versus 7.6%). Among HIV-coinfected patients, patients aged ≥ 55 years (adjusted odds ratio = 5.89) and those with CD4 count ≤ 100 cells/mm3 (adjusted odds ratio = 3.77) had a higher likelihood of dying. Using either the standardized longer MDR/RR-TB treatment regimen or the STR was not correlated with mortality overall or among PLHIV. The STR was as effective as the long MDR/RR-TB regimen. In conclusion, older age and advanced HIV disease were strong predictors of MDR/RR-TB mortality. Therefore, special care for elderly and HIV-coinfected patients with ≤ 100 CD4 cells/mL might further reduce MDR/RR-TB mortality.
Collapse
Affiliation(s)
- Dominique Savio Habimana
- HIV, AIDS, STIs and Other Blood Borne Infections Division, Institute of HIV/AIDS Disease Prevention and Control, Rwanda Biomedical Centre, Kigali, Rwanda
| | - Jean Claude Semuto Ngabonziza
- National Reference Laboratory Division, Department of Biomedical Services, Rwanda Biomedical Center, Kigali, Rwanda
- Mycobacteriology Unit, Department of Biomedical Sciences, Institute of Tropical Medicine, Antwerp, Belgium
- Department of Biomedical Sciences, University of Antwerp, Antwerp, Belgium
| | - Patrick Migambi
- Tuberculosis and Other Respiratory Diseases Division, Institute of HIV/AIDS Disease Prevention and Control, Rwanda Biomedical Center, Kigali, Rwanda
| | - Yves Mucyo-Habimana
- Tuberculosis and Other Respiratory Diseases Division, Institute of HIV/AIDS Disease Prevention and Control, Rwanda Biomedical Center, Kigali, Rwanda
| | - Grace Mutembayire
- Tuberculosis and Other Respiratory Diseases Division, Institute of HIV/AIDS Disease Prevention and Control, Rwanda Biomedical Center, Kigali, Rwanda
| | - Francine Byukusenge
- Tuberculosis and Other Respiratory Diseases Division, Institute of HIV/AIDS Disease Prevention and Control, Rwanda Biomedical Center, Kigali, Rwanda
| | - Innocent Habiyambere
- Tuberculosis and Other Respiratory Diseases Division, Institute of HIV/AIDS Disease Prevention and Control, Rwanda Biomedical Center, Kigali, Rwanda
| | - Eric Remera
- HIV, AIDS, STIs and Other Blood Borne Infections Division, Institute of HIV/AIDS Disease Prevention and Control, Rwanda Biomedical Centre, Kigali, Rwanda
| | - Placidie Mugwaneza
- HIV, AIDS, STIs and Other Blood Borne Infections Division, Institute of HIV/AIDS Disease Prevention and Control, Rwanda Biomedical Centre, Kigali, Rwanda
| | - Ivan Emil Mwikarago
- National Reference Laboratory Division, Department of Biomedical Services, Rwanda Biomedical Center, Kigali, Rwanda
| | | | - Innocent Turate
- Department of Institute of HIV/AIDS Disease Prevention and Control, Rwanda Biomedical Centre, Kigali, Rwanda
| | | | - Tom Decroo
- Department of Clinical Sciences, Institute of Tropical Medicine, Antwerp, Belgium
- Research Foundation Flanders, Brussels, Belgium
| | - Catherine Bouke de Jong
- Mycobacteriology Unit, Department of Biomedical Sciences, Institute of Tropical Medicine, Antwerp, Belgium
| |
Collapse
|
27
|
Remera E, Chammartin F, Nsanzimana S, Forrest JI, Smith GE, Mugwaneza P, Malamba SS, Semakula M, Condo JU, Ford N, Riedel DJ, Nisingizwe MP, Binagwaho A, Mills EJ, Bucher H. Child mortality associated with maternal HIV status: a retrospective analysis in Rwanda, 2005-2015. BMJ Glob Health 2021; 6:e004398. [PMID: 33975886 PMCID: PMC8118007 DOI: 10.1136/bmjgh-2020-004398] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Revised: 01/22/2021] [Accepted: 01/26/2021] [Indexed: 11/14/2022] Open
Abstract
INTRODUCTION Child mortality remains highest in regions of the world most affected by HIV/AIDS. The aim of this study was to assess child mortality rates in relation to maternal HIV status from 2005 to 2015, the period of rapid HIV treatment scale-up in Rwanda. METHODS We used data from the 2005, 2010 and 2015 Rwanda Demographic Health Surveys to derive under-2 mortality rates by survey year and mother's HIV status and to build a multivariable logistic regression model to establish the association of independent predictors of under-2 mortality stratified by mother's HIV status. RESULTS In total, 12 010 live births were reported by mothers in the study period. Our findings show a higher mortality among children born to mothers with HIV compared with HIV negative mothers in 2005 (216.9 vs 100.7 per 1000 live births) and a significant reduction in mortality for both groups in 2015 (72.0 and 42.4 per 1000 live births, respectively). In the pooled reduced multivariable model, the odds of child mortality was higher among children born to mothers with HIV, (adjusted OR, AOR 2.09; 95% CI 1.57 to 2.78). The odds of child mortality were reduced in 2010 (AOR 0.69; 95% CI 0.59 to 0.81) and 2015 (AOR 0.35; 95% CI 0.28 to 0.44) compared with 2005. Other independent predictors of under-2 mortality included living in smaller families of 1-2 members (AOR 5.25; 95% CI 3.59 to 7.68), being twin (AOR 4.93; 95% CI 3.51 to 6.92) and being offspring from mothers not using contraceptives at the time of the survey (AOR 1.6; 95% CI 1.38 to 1.99). Higher education of mothers (completed primary school: (AOR 0.74; 95% CI 0.64 to 0.87) and secondary or higher education: (AOR 0.53; 95% CI 0.38 to 0.74)) was also associated with reduced child mortality. CONCLUSIONS This study shows an important decline in under-2 child mortality among children born to both mothers with and without HIV in Rwanda over a 10-year span.
Collapse
Affiliation(s)
- Eric Remera
- Institute of HIV, Disease Prevention and Control, Rwanda Biomedical Center, Gasabo, City of Kigali, Rwanda
- Swiss Tropical and Public Health Institute, Basel, Switzerland
- University of Basel, Basel, Switzerland
- Basel Institute for Clinical Epidemiology and Biostatistics Department of Clinical Research, University Hospital Basel, Basel, Switzerland
- University of Global Health Equity, Kigali, Rwanda
| | - Frédérique Chammartin
- University of Basel, Basel, Switzerland
- Basel Institute for Clinical Epidemiology and Biostatistics Department of Clinical Research, University Hospital Basel, Basel, Switzerland
| | - Sabin Nsanzimana
- Institute of HIV, Disease Prevention and Control, Rwanda Biomedical Center, Gasabo, City of Kigali, Rwanda
- University of Global Health Equity, Kigali, Rwanda
| | - Jamie Ian Forrest
- The University of British Columbia School of Population and Public Health, Vancouver, British Columbia, Canada
| | | | - Placidie Mugwaneza
- Institute of HIV, Disease Prevention and Control, Rwanda Biomedical Center, Gasabo, City of Kigali, Rwanda
| | | | - Muhammed Semakula
- Institute of HIV, Disease Prevention and Control, Rwanda Biomedical Center, Gasabo, City of Kigali, Rwanda
- Center for Excellence in Data Science, University of Rwanda - Kigali Campus, Kigali, Rwanda
- Centre for Statistics, Hasselt University Faculty of Business Economics, Hasselt, Limburg, Belgium
| | - Jeanine U Condo
- National University of Rwanda School of Public Health, Kigali, Rwanda
- Tulane University, New Orleans, Louisiana, USA
| | - Nathan Ford
- Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - David J Riedel
- University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Marie Paul Nisingizwe
- The University of British Columbia School of Population and Public Health, Vancouver, British Columbia, Canada
| | | | - Edward J Mills
- Cytel, Vancouver, British Columbia, Canada
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Heiner Bucher
- University of Basel, Basel, Switzerland
- Basel Institute for Clinical Epidemiology and Biostatistics Department of Clinical Research, University Hospital Basel, Basel, Switzerland
| |
Collapse
|
28
|
Remera E, Mugwaneza P, Chammartin F, Mulindabigwi A, Musengimana G, Forrest JI, Mwanyumba F, Kondwani N, Condo JU, Riedel DJ, Mills EJ, Nsanzimana S, Bucher HC. Towards elimination of mother-to-child transmission of HIV in Rwanda: a nested case-control study of risk factors for transmission. BMC Pregnancy Childbirth 2021; 21:339. [PMID: 33910502 PMCID: PMC8082927 DOI: 10.1186/s12884-021-03806-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2020] [Accepted: 04/13/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Mother-to-child HIV transmission (MTCT) has substantially declined since the scale-up of prevention programs around the world, including Rwanda. To achieve full elimination of MTCT, it is important to understand the risk factors associated with residual HIV transmission, defined as MTCT at the population-level that still occurs despite universal access to PMTCT. METHODS We performed a case control study of children born from mothers with HIV with known vital status at 18 months from birth, who were followed in three national cohorts between October and December 2013, 2014, and 2015 in Rwanda. Children with HIV were matched in a ratio of 1:2 with HIV-uninfected children and a conditional logistic regression model was used to investigate risk factors for MTCT. RESULTS In total, 84 children with HIV were identified and matched with 164 non-infected children. The median age of mothers from both groups was 29 years (interquartile range (IQR): 24-33). Of these mothers, 126 (51.4 %) initiated antiretroviral therapy (ART) before their pregnancy on record. In a multivariable regression analysis, initiation of ART in the third trimester (Adjusted Odds Ratio [aOR]: 9.25; 95 % Confidence Interval [95 % CI]: 2.12-40.38) and during labour or post-partum (aOR: 8.87; 95 % CI: 1.92-40.88), compared to initiation of ART before pregnancy, increased the risk of MTCT. Similarly, offspring of single mothers (aOR: 7.15; 95 % CI: 1.15-44.21), and absence of postpartum neonatal ART prophylaxis (aOR: 7.26; 95 % CI: 1.66-31.59) were factors significantly associated with MTCT. CONCLUSIONS Late ART initiation for PMTCT and lack of postpartum infant prophylaxis are still the most important risk factors to explain MTCT in the era of universal access. Improved early attendance at antenatal care, early ART initiation, and enhancing the continuum of care especially for single mothers is crucial for MTCT elimination in Rwanda.
Collapse
Affiliation(s)
- Eric Remera
- Institute of HIV Disease Prevention and Control, Rwanda Biomedical Centre, Kigali, Rwanda. .,Basel Institute for Clinical Epidemiology and Biostatistics, Department of Clinical Research, University Hospital Basel, Basel, Switzerland. .,University of Basel, Basel, Switzerland. .,Swiss Tropical and Public Health Institute, Basel, Switzerland.
| | - Placidie Mugwaneza
- Institute of HIV Disease Prevention and Control, Rwanda Biomedical Centre, Kigali, Rwanda
| | - Frédérique Chammartin
- Basel Institute for Clinical Epidemiology and Biostatistics, Department of Clinical Research, University Hospital Basel, Basel, Switzerland.,University of Basel, Basel, Switzerland
| | - Augustin Mulindabigwi
- Institute of HIV Disease Prevention and Control, Rwanda Biomedical Centre, Kigali, Rwanda
| | - Gentille Musengimana
- Institute of HIV Disease Prevention and Control, Rwanda Biomedical Centre, Kigali, Rwanda
| | - Jamie I Forrest
- School of Population and Public Health, University of British Columbia, Vancouver, Canada
| | - Fabian Mwanyumba
- United Nations International Children's Emergency Fund, Kampala, Uganda
| | - Ng'oma Kondwani
- United Nations International Children's Emergency Fund, Kigali, Rwanda
| | - Jeanine U Condo
- School of Public Health, College of Medicine & Health Sciences, University of Rwanda, Kigali, Rwanda.,Tulane University, New Orleans, USA
| | - David J Riedel
- Institute of Human Virology, University of Maryland School of Medicine, Baltimore, USA
| | - Edward J Mills
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Canada
| | - Sabin Nsanzimana
- Institute of HIV Disease Prevention and Control, Rwanda Biomedical Centre, Kigali, Rwanda
| | - Heiner C Bucher
- Basel Institute for Clinical Epidemiology and Biostatistics, Department of Clinical Research, University Hospital Basel, Basel, Switzerland.,University of Basel, Basel, Switzerland
| |
Collapse
|
29
|
Ross J, Murenzi G, Hill S, Remera E, Ingabire C, Umwiza F, Munyaneza A, Muhoza B, Habimana DS, Mugwaneza P, Zhang C, Yotebieng M, Anastos K. Reducing time to differentiated service delivery for newly diagnosed people living with HIV in Kigali, Rwanda: study protocol for a pilot, unblinded, randomised controlled study. BMJ Open 2021; 11:e047443. [PMID: 33895720 PMCID: PMC8074553 DOI: 10.1136/bmjopen-2020-047443] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
INTRODUCTION Current HIV guidelines recommend differentiated service delivery (DSD) models that allow for fewer health centre visits for clinically stable people living with HIV (PLHIV). Newly diagnosed PLHIV may require more intensive care early in their treatment course, yet frequent appointments can be burdensome to patients and health systems. Determining the optimal parameters for defining clinical stability and transitioning to less frequent appointments could decrease patient burden and health system costs. The objectives of this pilot study are to explore the feasibility and acceptability of (1) reducing the time to DSD from 12 to 6 months after antiretroviral therapy (ART) initiation,and (2) reducing the number of suppressed viral loads required to enter DSD from two to one. METHODS AND ANALYSES The present study is a pilot, unblinded trial taking place in three health facilities in Kigali, Rwanda. Current Rwandan guidelines require PLHIV to be on ART for ≥12 months with two consecutive suppressed viral loads in order to transition to less frequent appointments. We will randomise 90 participants to one of three arms: entry into DSD at 6 months after one suppressed viral load (n=30), entry into DSD at 6 months after two suppressed viral loads (n=30) or current standard of care (n=30). We will measure feasibility and acceptability of this intervention; clinical outcomes include viral suppression at 12 months (primary outcome) and appointment attendance (secondary outcome). ETHICS AND DISSEMINATION This clinical trial was approved by the institutional review board of Albert Einstein College of Medicine and by the Rwanda National Ethics Committee. Findings will be disseminated through conferences and peer-reviewed publications, as well as meetings with stakeholders. TRIAL REGISTRATION NUMBER NCT04567693.
Collapse
Affiliation(s)
- Jonathan Ross
- Division of General Internal Medicine, Montefiore Health System, Bronx, New York, USA
- Division of General Internal Medicine, Yeshiva University Albert Einstein College of Medicine, Bronx, New York, USA
| | - Gad Murenzi
- Clinical Education and Research Division, Rwanda Military Hospital, Kigali, Kigali City, Rwanda
| | - Sarah Hill
- Division of General Internal Medicine, Yeshiva University Albert Einstein College of Medicine, Bronx, New York, USA
| | - Eric Remera
- Institute of HIV Disease Prevention and Control, Rwanda Biomedical Center, Kigali, Rwanda
| | - Charles Ingabire
- Clinical Education and Research Division, Rwanda Military Hospital, Kigali, Kigali City, Rwanda
| | - Francine Umwiza
- Clinical Education and Research Division, Rwanda Military Hospital, Kigali, Kigali City, Rwanda
| | - Athanase Munyaneza
- Clinical Education and Research Division, Rwanda Military Hospital, Kigali, Kigali City, Rwanda
| | - Benjamin Muhoza
- Clinical Education and Research Division, Rwanda Military Hospital, Kigali, Kigali City, Rwanda
| | | | - Placidie Mugwaneza
- Institute of HIV Disease Prevention and Control, Rwanda Biomedical Center, Kigali, Rwanda
| | - Chenshu Zhang
- Division of General Internal Medicine, Montefiore Health System, Bronx, New York, USA
- Division of General Internal Medicine, Yeshiva University Albert Einstein College of Medicine, Bronx, New York, USA
| | - Marcel Yotebieng
- Division of General Internal Medicine, Montefiore Health System, Bronx, New York, USA
- Division of General Internal Medicine, Yeshiva University Albert Einstein College of Medicine, Bronx, New York, USA
| | - Kathryn Anastos
- Division of General Internal Medicine, Montefiore Health System, Bronx, New York, USA
- Division of General Internal Medicine, Yeshiva University Albert Einstein College of Medicine, Bronx, New York, USA
| |
Collapse
|
30
|
Binagwaho A, Remera E, Bayingana AU, Gishoma D, Scott KW, Goosman M, Campbell E, Agbonyitor M, Kayiteshonga Y, Nsanzimana S. Addressing the mental health needs of children affected by HIV in Rwanda: validation of a rapid depression screening tool for children 7-14 years old. BMC Pediatr 2021; 21:59. [PMID: 33514343 PMCID: PMC7844907 DOI: 10.1186/s12887-020-02475-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Accepted: 12/16/2020] [Indexed: 12/01/2022] Open
Abstract
BACKGROUND Depression in children presents a significant health burden to society and often co-exists with chronic illnesses, such as human immunodeficiency virus (HIV). Research has demonstrated that 10-37% of children and adolescents living with HIV also suffer from depression. Low-and-middle income countries (LMICs) shoulder a disproportionate burden of HIV among other health challenges, but reliable estimates of co-morbid depression are lacking in these settings. Prior studies in Rwanda, a LMIC of 12 million people in East Africa, found that 25% of children living with HIV met criteria for depression. Though depression may negatively affect adherence to HIV treatment among children and adolescents, most LMICs fail to routinely screen children for mental health problems due to a shortage of trained health care providers. While some screening tools exist, they can be costly to implement in resource-constrained settings and are often lacking a contextual appropriateness. METHODS Relying on international guidelines for diagnosing depression, Rwandan health experts developed a freely available, open-access Child Depression Screening Tool (CDST). To validate this tool in Rwanda, a sample of 296 children with a known diagnosis of HIV between ages 7-14 years were recruited as study participants. In addition to completing the CDST, all participants were evaluated by a mental health professional using a structured clinical interview. The validity of the CDST was assessed in terms of sensitivity, specificity, and a receiver operating characteristic (ROC) curve. RESULTS This analysis found that depression continues to be a co-morbid condition among children living with HIV in Rwanda. For identifying these at-risk children, the CDST had a sensitivity of 88.1% and specificity of 96.5% in identifying risk for depression among children living with HIV at a cutoff score of 6 points. This corresponded with an area under the ROC curve of 92.3%. CONCLUSIONS This study provides evidence that the CDST is a valid tool for screening depression among children affected by HIV in a resource-constrained setting. As an open-access and freely available tool in LMICs, the CDST can allow any health practitioner to identify children at risk of depression and refer them in a timely manner to more specialized mental health services. Future work can show if and how this tool has the potential to be useful in screening depression in children suffering from other chronic illnesses.
Collapse
Affiliation(s)
- Agnes Binagwaho
- University of Global Health Equity, Kigali, Rwanda
- Harvard Medical School, Boston, MA, USA
- Dartmouth College Geisel School of Medicine, Hanover, NH, USA
| | - Eric Remera
- University of Global Health Equity, Kigali, Rwanda
- Rwanda Biomedical Center, Kigali, Rwanda
| | | | - Darius Gishoma
- University of Rwanda College of Medicine and Health Sciences, Kigali, Rwanda
| | | | | | | | | | | | - Sabin Nsanzimana
- University of Global Health Equity, Kigali, Rwanda
- Rwanda Biomedical Center, Kigali, Rwanda
| |
Collapse
|
31
|
Nsanzimana S, Penkunas MJ, Liu CY, Sebuhoro D, Ngwije A, Remera E, Umutesi J, Ntirenganya C, Mugeni SD, Serumondo J. Effectiveness of Direct-Acting Antivirals for the treatment of chronic hepatitis C in Rwanda: A retrospective study. Clin Infect Dis 2020; 73:e3300-e3307. [PMID: 32505127 DOI: 10.1093/cid/ciaa701] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2019] [Accepted: 06/01/2020] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Direct-acting antivirals (DAAs) are becoming accessible in sub-Saharan Africa. This study examined the effectiveness of DAAs in patients treated through the Rwandan national health system and identified factors associated with treatment outcomes. METHODS This retrospective study utilized data from the national HCV program for patients who initiated DAAs between November 2015 and March 2017. Sustained virological response at 12 weeks post-treatment (SVR12) was the primary outcome. Logistic regression models were fit to estimate the relationship between patients' clinical and demographic characteristics and treatment outcome. RESULTS 894 patients initiated treatment during the study period; 590 completed treatment and had SVR12 results. Among the 304 patients without SVR12 results, 48 were lost to follow-up and 256 had no SVR12 results but clinical data indicated they likely completed treatment - these patients were classified as non-virological failure since viral clearance could not be determined. In a per-protocol analysis for 590 patients with SVR12 results, 540 (92%) achieved SVR12 and 50 (8%) experienced virological failure. Pre-treatment HCV RNA above the median split was associated with virological failure. Intention-to-treat analyses including all patients indicated 540 (60%) achieved SVR12, 304 (34%) experienced non-virological failure, and 50 (6%) experienced virological failure. Patients in Western Province were more likely to experience non-virological failure than patients in Kigali, likely due to the five- to seven-hour travel required to access testing and treatment. CONCLUSIONS DAAs were effective when implemented through the Rwandan national health system. Decentralization and enhanced financing are underway in Rwanda, which could improve access to treatment and follow-up as the country prepares for HCV elimination.
Collapse
Affiliation(s)
| | | | - Carol Y Liu
- Clinton Health Access Initiative, Kigali, Rwanda
| | | | - Alida Ngwije
- Clinton Health Access Initiative, Kigali, Rwanda
| | | | | | | | | | | |
Collapse
|
32
|
Ross J, Ribakare M, Remera E, Murenzi G, Munyaneza A, Hoover DR, Shi Q, Nsanzimana S, Yotebieng M, Nash D, Anastos K. High levels of viral load monitoring and viral suppression under Treat All in Rwanda - a cross-sectional study. J Int AIDS Soc 2020; 23:e25543. [PMID: 32536033 PMCID: PMC7293767 DOI: 10.1002/jia2.25543] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Revised: 04/14/2020] [Accepted: 05/13/2020] [Indexed: 12/15/2022] Open
Abstract
INTRODUCTION Aiming to reach UNAIDS 90-90-90 targets, nearly all sub-Saharan African countries have expanded antiretroviral therapy (ART) to all people living with HIV (PLWH) (Treat All). Few published data exist on viral load testing and viral suppression under Treat All in this region. We assessed proportions of patients with available viral load test results and who were virally suppressed, as well as factors associated with viral suppression, among PLWH in 10 Rwandan health centres after Treat All implementation. METHODS Cross-sectional study during 2018 of adults (≥15 years) engaged in HIV care at 10 Rwandan health centres. Outcomes were being on ART (available ART initiation date in the study database, with no ART discontinuation prior to 1 January 2018), retained on ART (≥2 post-ART health centre visits ≥90 days apart during 2018), available viral load test results (viral load measured in 2018 and available in study database) and virally suppressed (most recent 2018 viral load <200 copies/mL). We used modified Poisson regression models accounting for clustering by health centre to determine factors associated with being virally suppressed. RESULTS Of 12,238 patients, 7050 (58%) were female and 1028 (8%) were aged 15 to 24 years. Nearly all patients (11,933; 97%) were on ART, of whom 11,198 (94%) were retained on ART. Among patients retained on ART, 10,200 (91%) had available viral load results; of these 9331 (91%) were virally suppressed. Viral suppression was less likely among patients aged 15 to 24 compared to >49 years (adjusted prevalence ratio (aPR): 0.83, 95% CI 0.76 to 0.90 and those with pre-ART CD4 counts of <200 compared to ≥500 cells/mm3 (aPR: 0.92, 95% CI 0.90 to 0.93). There was no statistically significant difference in viral suppression among patients who entered after Treat All implementation compared to those who enrolled before 2010 (aPR 0.98, 95% CI 0.94 to 1.03). CONCLUSIONS In this large cohort of Rwandan PLWH receiving HIV care after Treat All implementation, patients in study health centres have surpassed the third UNAIDS 90-90-90 target. To ensure all PLWH fully benefit from ART, additional efforts should focus on improving ART adherence among younger persons.
Collapse
Affiliation(s)
- Jonathan Ross
- Division of General Internal MedicineMontefiore Medical Center/Albert Einstein College of MedicineBronxNYUSA
| | - Muhayimpundu Ribakare
- Institute of HIV/AIDS Disease Prevention and ControlRwanda Biomedical CenterKigaliRwanda
| | - Eric Remera
- Institute of HIV/AIDS Disease Prevention and ControlRwanda Biomedical CenterKigaliRwanda
| | - Gad Murenzi
- Research DivisionRwanda Military HospitalKigaliRwanda
| | | | - Donald R Hoover
- Department of Statistics and Biostatistics and Institute for HealthHealth Care Policy and Aging ResearchRutgers the State University of New JerseyNJUSA
| | - Qiuhu Shi
- Department of Epidemiology and Community HealthNew York Medical CollegeValhallaNYUSA
| | - Sabin Nsanzimana
- Institute of HIV/AIDS Disease Prevention and ControlRwanda Biomedical CenterKigaliRwanda
| | - Marcel Yotebieng
- Division of General Internal MedicineMontefiore Medical Center/Albert Einstein College of MedicineBronxNYUSA
| | - Denis Nash
- Institute for Implementation Science in Population HealthCity University of New YorkNew YorkNYUSA
| | - Kathryn Anastos
- Division of General Internal MedicineMontefiore Medical Center/Albert Einstein College of MedicineBronxNYUSA
| | | |
Collapse
|
33
|
Muhoza B, Remera E, Shi Q, Kabahizi J, Brazier E, Sinayobye JD, Duda SN. Secondary Data Use in Rwanda: Leveraging OpenMRS for Global HIV Research. Stud Health Technol Inform 2019; 264:1732. [PMID: 31438316 DOI: 10.3233/shti190620] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The Rwandan Ministry of Health supports a countrywide installation of the Open Medical Record System (OpenMRS) to improve clinical recordkeeping and patient care. However, electronic medical records also can be a valuable source of data for observational and experimental studies. We describe the challenges and lessons learned when reusing OpenMRS data in Rwanda for global HIV epidemiology research.
Collapse
Affiliation(s)
| | | | - Qiuhu Shi
- Department of Epidemiology and Community Health, New York Medical College, Valhalla, USA
| | | | - Ellen Brazier
- Institute for Implementation Science in Population Health, City University of New York, New York, USA
| | | | - Stephany N Duda
- Department of Biomedical Informatics, Vanderbilt University School of Medicine, Nashville, USA
| |
Collapse
|
34
|
Nsanzimana S, Semakula M, Ndahindwa V, Remera E, Sebuhoro D, Uwizihiwe JP, Ford N, Tanner M, Kanters S, Mills EJ, Bucher HC. Retention in care and virological failure among adult HIV+ patients on second-line ART in Rwanda: a national representative study. BMC Infect Dis 2019; 19:312. [PMID: 30953449 PMCID: PMC6451213 DOI: 10.1186/s12879-019-3934-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2018] [Accepted: 03/24/2019] [Indexed: 11/27/2022] Open
Abstract
Background Currently, there is limited evidence on the effectiveness of second-line antiretroviral therapy (ART) in sub-Saharan Africa. To address this challenge, outcomes of second-line protease inhibitor (PI) based ART in Rwanda were assessed. Methods A two-stage cluster sampling design was undertaken. 49 of 340 health facilities linked to the open-source electronic medical record (EMR) system of Rwanda were randomly sampled. Data sampling criteria included adult HIV positive patients with documented change from first to second-line ART regimen. Retention in care and treatment failure (viral load above 1000 copies/mL) were evaluated using multivariable Cox proportional hazards and logistic regression models. Results A total of 1688 patients (60% females) initiated second-line ART PI-based regimen by 31st December 2016 with a median follow-up time of 26 months (IQR 24–36). Overall, 92.5% of patients were retained in care; 83% achieved VL ≤ 1000 copies/ml, 2.8% were lost to care and 2.2% died. Defaulting from care was associated with more recent initiation of ART- PI based regimen, CD4 cell count ≤500 cells/mm3 at initiation of second line ART and viral load > 1000 copies/ml at last measurement. Viral failure was associated with younger age, WHO stage III&IV at ART initiation, CD4 cell count ≤500 cells/mm3 at switch, atazanavir based second-line ART and receiving care at a health center compared to hospital settings. Conclusions A high proportion of patients on second-line ART are doing relatively well in Rwanda and retained in care with low viral failure rates. However, enhanced understandings of adherence and adherence interventions for less healthy individuals are required. Routine viral load measurement and tracing of loss to follow-up is fundamental in resource limited settings, especially among less healthy patients.
Collapse
Affiliation(s)
- Sabin Nsanzimana
- Institute of HIV Disease Prevention and Control, Rwanda Biomedical Centre, KG 203 St, Kigali, Rwanda. .,Basel Institute for Clinical Epidemiology and Biostatistics, University Hospital Basel, University of Basel, Spitalstrasse 12, 1st floor, CH-4031, Basel, Switzerland. .,Swiss Tropical and Public Health Institute, University of Basel, Socinstrasse 57, 4051, Basel, Switzerland.
| | - Muhammed Semakula
- Institute of HIV Disease Prevention and Control, Rwanda Biomedical Centre, KG 203 St, Kigali, Rwanda
| | - Vedaste Ndahindwa
- University of Rwanda, School of Medicine and Allied Sciences, KK 737 Street-Gikondo, Kigali, Rwanda
| | - Eric Remera
- Institute of HIV Disease Prevention and Control, Rwanda Biomedical Centre, KG 203 St, Kigali, Rwanda
| | - Dieudonne Sebuhoro
- Institute of HIV Disease Prevention and Control, Rwanda Biomedical Centre, KG 203 St, Kigali, Rwanda
| | - Jean Paul Uwizihiwe
- Institute of HIV Disease Prevention and Control, Rwanda Biomedical Centre, KG 203 St, Kigali, Rwanda
| | - Nathan Ford
- Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, Faculty of Health Sciences, University of Cape Town, Observatory, 7925, South Africa
| | - Marcel Tanner
- Swiss Tropical and Public Health Institute, University of Basel, Socinstrasse 57, 4051, Basel, Switzerland
| | - Steve Kanters
- School of Population and Public Health, University of British Columbia, 2206 East Mall, Vancouver, BC, V6T 1Z3, Canada
| | - Edward J Mills
- Department of Health Research Methods, Evidence, and Impact, McMaster University, 1280 Main Street, West Hamilton, ON, L8S 4K1, Canada
| | - Heiner C Bucher
- Basel Institute for Clinical Epidemiology and Biostatistics, University Hospital Basel, University of Basel, Spitalstrasse 12, 1st floor, CH-4031, Basel, Switzerland
| |
Collapse
|
35
|
Ross J, Sinayobye JD, Yotebieng M, Hoover DR, Shi Q, Ribakare M, Remera E, Bachhuber MA, Murenzi G, Sugira V, Nash D, Anastos K. Early outcomes after implementation of treat all in Rwanda: an interrupted time series study. J Int AIDS Soc 2019; 22:e25279. [PMID: 30993854 PMCID: PMC6468264 DOI: 10.1002/jia2.25279] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2018] [Accepted: 03/29/2019] [Indexed: 12/17/2022] Open
Abstract
INTRODUCTION Nearly all countries in sub-Saharan Africa have adopted policies to provide antiretroviral therapy (ART) to all persons living with HIV (Treat All), though HIV care outcomes of these programmes are not well-described. We estimated changes in ART initiation and retention in care following Treat All implementation in Rwanda in July 2016. METHODS We conducted an interrupted time series analysis of adults enrolling in HIV care at ten Rwandan health centres from July 2014 to September 2017. Using segmented linear regression, we assessed changes in levels and trends of 30-day ART initiation and six-month retention in care before and after Treat All implementation. We compared modelled outcomes with counterfactual estimates calculated by extrapolating baseline trends. Modified Poisson regression models identified predictors of outcomes among patients enrolling after Treat All implementation. RESULTS Among 2885 patients, 1803 (62.5%) enrolled in care before and 1082 (37.5%) after Treat All implementation. Immediately after Treat All implementation, there was a 31.3 percentage point increase in the predicted probability of 30-day ART initiation (95% CI 15.5, 47.2), with a subsequent increase of 1.1 percentage points per month (95% CI 0.1, 2.1). At the end of the study period, 30-day ART initiation was 47.8 percentage points (95% CI 8.1, 87.8) above what would have been expected under the pre-Treat All trend. For six-month retention, neither the immediate change nor monthly trend after Treat All were statistically significant. While 30-day ART initiation and six-month retention were less likely among patients 15 to 24 versus >24 years, the predicted probability of both outcomes increased significantly for younger patients in each month after Treat All implementation. CONCLUSIONS Implementation of Treat All in Rwanda was associated with a substantial increase in timely ART initiation without negatively impacting care retention. These early findings support Treat All as a strategy to help achieve global HIV targets.
Collapse
Affiliation(s)
- Jonathan Ross
- Department of MedicineMontefiore Medical Center/Albert Einstein College of MedicineBronxNYUSA
| | | | - Marcel Yotebieng
- Division of EpidemiologyCollege of Public HealthOhio State UniversityColumbusOHUSA
| | - Donald R Hoover
- Department of Statistics and Biostatistics and Institute for HealthHealth Care Policy and Aging ResearchRutgers the State University of New JerseyPiscatawayNJUSA
| | - Qiuhu Shi
- Department of Epidemiology and Community HealthNew York Medical CollegeValhallaNYUSA
| | | | | | - Marcus A Bachhuber
- Department of MedicineMontefiore Medical Center/Albert Einstein College of MedicineBronxNYUSA
| | - Gad Murenzi
- Research DivisionRwanda Military HospitalKigaliRwanda
| | | | - Denis Nash
- Institute for Implementation Science in Population HealthCity University of New YorkNew YorkNYUSA
| | - Kathryn Anastos
- Department of MedicineMontefiore Medical Center/Albert Einstein College of MedicineBronxNYUSA
| | | |
Collapse
|
36
|
Mutagoma M, Sebuhoro D, Nyemazi JP, Mills EJ, Forrest JI, Remera E, Murindabigwi A, Semakula M, Nsanzimana S. The role of community health workers and local leaders in reducing attrition among participant in the AIDS indicator survey and HIV incidence in a national cohort study in Rwanda. BMC Public Health 2018. [PMID: 29523102 PMCID: PMC5845190 DOI: 10.1186/s12889-018-5243-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Background Retention of participants in longitudinal prospective surveys can challenging for population health researchers. Community health workers (CHWs) may help reduce attrition. Methods We used data came from a longitudinal prospective household-based survey targeting women and men in Rwanda, collected between June 2013 and December 2014. The sample was drawn from a population that included all residents of all 30 districts, 416 sectors, and 14,837 villages in Rwanda. The outcome measure was time to loss-to-follow-up. Follow up visits occurred at three, six and nine, and 12 months. A Cox proportional hazards model was constructed to identify factors independently associated with time to loss-to-follow-up. Results Overall, 14,222 respondents consented to be interviewed at baseline. At the end of 12 months of follow up, 13,728 were revisited and consented to participate at 12 months of follow up. The overall attrition rate was 8.0%. A majority of those lost (54.3%) were less than 25 years of age, male (55.1%), not living in union (67.3%), had no education level or had primary education level (71.4%), or were in the highest wealth index (54.2%). Compared to illiterate, secondary education was negatively associated with attrition. Conclusion The Rwanda AIDS indicator and HIV incidence survey recorded a very high retention of participants after 12 months. CHWs and local leaders played a major role to reduce attrition rate and identifying factors associated with loss-to-follow-up can help CHWs strengthen the quality of longitudinal survey data.
Collapse
Affiliation(s)
- Mwumvaneza Mutagoma
- Rwanda Biomedical Center, Ministry of Health, P. O. Box 7162, Kigali, Rwanda. .,School of Public Health, University of Rwanda, Kigali, Rwanda.
| | - Dieudonné Sebuhoro
- Rwanda Biomedical Center, Ministry of Health, P. O. Box 7162, Kigali, Rwanda
| | | | | | | | - Eric Remera
- Rwanda Biomedical Center, Ministry of Health, P. O. Box 7162, Kigali, Rwanda
| | | | - Mouhamed Semakula
- Rwanda Biomedical Center, Ministry of Health, P. O. Box 7162, Kigali, Rwanda
| | - Sabin Nsanzimana
- Rwanda Biomedical Center, Ministry of Health, P. O. Box 7162, Kigali, Rwanda.,Basel Clinical epidemiology and biostatistics institute, University Hospital, Basel, Switzerland.,Swiss Tropical and Public Health institute, University of Basel, Basel, Switzerland
| |
Collapse
|
37
|
Buckee CO, Cardenas MIE, Corpuz J, Ghosh A, Haque F, Karim J, Mahmud AS, Maude RJ, Mensah K, Motaze NV, Nabaggala M, Metcalf CJE, Mioramalala SA, Mubiru F, Peak CM, Pramanik S, Rakotondramanga JM, Remera E, Sinha I, Sovannaroth S, Tatem AJ, Zaw W. Productive disruption: opportunities and challenges for innovation in infectious disease surveillance. BMJ Glob Health 2018. [PMID: 29527343 PMCID: PMC5841510 DOI: 10.1136/bmjgh-2017-000538] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Affiliation(s)
- Caroline O Buckee
- Department of Epidemiology, Center for Communicable Disease Dynamics, Harvard School of Public Health, Boston, Massachusetts, USA
| | - Maria I E Cardenas
- Centro de Atención y Diagnóstico de Enfermedades Infecciosas, Universidad Industrial de Santander, Bucaramanga, Colombia
| | - June Corpuz
- Epidemiology Bureau, Department of Health of the Philippines, Manila, Philippines
| | - Arpita Ghosh
- Public Health Foundation of India, Vasant Kunj, New Delhi, India
| | - Farhana Haque
- Programme for Emerging Infections (PEI), Infectious Diseases Division (IDD), ICDDR, B, Dhaka, Bangladesh
| | - Jahirul Karim
- Disease Control Department, Directorate General of Health Services, Dhaka, Bangladesh.,Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Ayesha S Mahmud
- Department of Epidemiology, Center for Communicable Disease Dynamics, Harvard School of Public Health, Boston, Massachusetts, USA
| | - Richard J Maude
- Department of Epidemiology, Center for Communicable Disease Dynamics, Harvard School of Public Health, Boston, Massachusetts, USA.,Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand.,Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Keitly Mensah
- Dept of Ecology and Evolutionary Biology, Princeton University, Princeton, NJ, USA
| | | | - Maria Nabaggala
- Infectious Disease Institute, College of Health Sciences, Makarere University, Uganda
| | | | | | - Frank Mubiru
- Infectious Disease Institute, College of Health Sciences, Makarere University, Uganda
| | - Corey M Peak
- Department of Epidemiology, Center for Communicable Disease Dynamics, Harvard School of Public Health, Boston, Massachusetts, USA
| | - Santanu Pramanik
- Public Health Foundation of India, Vasant Kunj, New Delhi, India
| | | | | | - Ipsita Sinha
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand.,Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Siv Sovannaroth
- Technical Bureau, National Malaria Control Program, Pnom Penh, Cambodia
| | - Andrew J Tatem
- WorldPop, Department of Geography and Environment, University of Southampton, Southampton, UK
| | - Win Zaw
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| |
Collapse
|
38
|
Buckee CO, Cardenas MIE, Corpuz J, Ghosh A, Haque F, Karim J, Mahmud AS, Maude RJ, Mensah K, Motaze NV, Nabaggala M, Metcalf CJE, Mioramalala SA, Mubiru F, Peak CM, Pramanik S, Rakotondramanga JM, Remera E, Sinha I, Sovannaroth S, Tatem AJ, Zaw W. Productive disruption: opportunities and challenges for innovation in infectious disease surveillance. BMJ Glob Health 2018; 3:e000538. [PMID: 29527343 DOI: 10.1136/bmjgh-2017-00053] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2017] [Revised: 11/16/2017] [Accepted: 11/17/2017] [Indexed: 05/27/2023] Open
Affiliation(s)
- Caroline O Buckee
- Department of Epidemiology, Center for Communicable Disease Dynamics, Harvard School of Public Health, Boston, Massachusetts, USA
| | - Maria I E Cardenas
- Centro de Atención y Diagnóstico de Enfermedades Infecciosas, Universidad Industrial de Santander, Bucaramanga, Colombia
| | - June Corpuz
- Epidemiology Bureau, Department of Health of the Philippines, Manila, Philippines
| | - Arpita Ghosh
- Public Health Foundation of India, Vasant Kunj, New Delhi, India
| | - Farhana Haque
- Programme for Emerging Infections (PEI), Infectious Diseases Division (IDD), ICDDR, B, Dhaka, Bangladesh
| | - Jahirul Karim
- Disease Control Department, Directorate General of Health Services, Dhaka, Bangladesh
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Ayesha S Mahmud
- Department of Epidemiology, Center for Communicable Disease Dynamics, Harvard School of Public Health, Boston, Massachusetts, USA
| | - Richard J Maude
- Department of Epidemiology, Center for Communicable Disease Dynamics, Harvard School of Public Health, Boston, Massachusetts, USA
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Keitly Mensah
- Dept of Ecology and Evolutionary Biology, Princeton University, Princeton, NJ, USA
| | | | - Maria Nabaggala
- Infectious Disease Institute, College of Health Sciences, Makarere University, Uganda
| | | | | | - Frank Mubiru
- Infectious Disease Institute, College of Health Sciences, Makarere University, Uganda
| | - Corey M Peak
- Department of Epidemiology, Center for Communicable Disease Dynamics, Harvard School of Public Health, Boston, Massachusetts, USA
| | - Santanu Pramanik
- Public Health Foundation of India, Vasant Kunj, New Delhi, India
| | | | | | - Ipsita Sinha
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Siv Sovannaroth
- Technical Bureau, National Malaria Control Program, Pnom Penh, Cambodia
| | - Andrew J Tatem
- WorldPop, Department of Geography and Environment, University of Southampton, Southampton, UK
| | - Win Zaw
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| |
Collapse
|
39
|
Abimpaye M, Kirk CM, Iyer HS, Gupta N, Remera E, Mugwaneza P, Law MR. The impact of "Option B" on HIV transmission from mother to child in Rwanda: An interrupted time series analysis. PLoS One 2018; 13:e0192910. [PMID: 29451925 PMCID: PMC5815596 DOI: 10.1371/journal.pone.0192910] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2017] [Accepted: 01/22/2018] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Nearly a quarter of a million children have acquired HIV, prompting the implementation of new protocols-Option B and B+-for treating HIV+ pregnant women. While efficacy has been demonstrated in randomized trials, there is limited real-world evidence on the impact of these changes. Using longitudinal, routinely collected data we assessed the impact of the adoption of WHO Option B in Rwanda on mother to infant transmission. METHODS We used interrupted time series analysis to evaluate the impact of Option B on mother-to-child HIV transmission in Rwanda. Our primary outcome was the proportion of HIV tests in infants with positive results at six weeks of age. We included data for 20 months before and 22 months after the 2010 policy change. RESULTS Of the 15,830 HIV tests conducted during our study period, 392 tested positive. We found a significant decrease in both the level (-2.08 positive tests per 100 tests conducted, 95% CI: -2.71 to -1.45, p < 0.001) and trend (-0.11 positive tests per 100 tests conducted per month, 95% CI: -0.16 to -0.07, p < 0.001) of test positivity. This represents an estimated 297 fewer children born without HIV in the post-policy period or a 46% reduction in HIV transmission from mother to child. CONCLUSIONS The adoption of Option B in Rwanda contributed to an immediate decrease in the rate of HIV transmission from mother to child. This suggests other countries may benefit from adopting these WHO guidelines.
Collapse
Affiliation(s)
| | | | - Hari S. Iyer
- Partners In Health/Inshuti Mu Buzima, Rwinkwavu, Rwanda
- Brigham and Women’s Hospital, Boston, MA, United States of America
| | - Neil Gupta
- Partners In Health/Inshuti Mu Buzima, Rwinkwavu, Rwanda
- Brigham and Women’s Hospital, Boston, MA, United States of America
| | | | | | - Michael R. Law
- The University of British Columbia, Vancouver, British Columbia, Canada
- University of Rwanda, Kigali, Rwanda
- Harvard Medical School, Boston, MA, United States of America
| |
Collapse
|
40
|
Nsanzimana S, Remera E, Kanters S, Mulindabigwi A, Suthar AB, Uwizihiwe JP, Mwumvaneza M, Mills EJ, Bucher HC. Household survey of HIV incidence in Rwanda: a national observational cohort study. Lancet HIV 2017; 4:e457-e464. [PMID: 28801191 DOI: 10.1016/s2352-3018(17)30124-8] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2016] [Revised: 06/09/2017] [Accepted: 06/14/2017] [Indexed: 11/25/2022]
Abstract
BACKGROUND In Rwanda, HIV prevalence among adults aged 15-49 years has been stable at 3% since 2005. The aim of this study was to characterise HIV incidence across Rwanda. METHODS We did a nationally representative, prospective HIV incidence survey for the period of 2013-14, which used two-stage sampling. We randomly selected 492 villages in the first sampling stage and 14 households per village in the second stage. Participants completed a questionnaire and 14 140 people were tested for HIV. 13 728 participants were HIV negative, and were enrolled in the incidence cohort. Participants were retested and surveyed again after 12 months. Weights were calculated as the inverse of the probability to select the villages and the households. FINDINGS The study period was from Nov 5, 2013, to Nov 15, 2014. Among 14 222 respondents from 6792 households, 14 140 were tested for HIV and 13 728 were HIV negative. Of 12 593 people who participated in the endpoint data collection activities, 5965 (47·4%) were men and the mean age was 30 years (SD 10·8). 11 237 (89·2%) participants lived in rural areas, 4826 (38·3%) were single, and 7140 (56·7%) were married or cohabitating. During the year, 35 participants had seroconversion, including 13 men and 22 women, resulting in an overall incidence of 0·27 per 100 person-years (95% CI 0·18-0·35). Incidence was 0·21 per 100 person-years (0·10-0·32) in men and 0·32 per 100 person-years (0·19-0·45) in women. Our findings suggested multiple breakouts, with multiple seroconversions occurring in three villages and two households. Incidence was higher in adults aged 36-45 years (0·37 per 100 person-years, 0·12-0·62; adjusted hazard ratio [aHR] 4·49, 95% CI 1·30-14·70) relative to those aged 16-25, higher in western province (0·57 per 100 person-years, 0·31-0·87; aHR 5·90, 1·33-25·28) relative to the northern province, and higher in urban areas (0·65 per 100 person-years, 0·23-1·07; aHR 3·10, 1·28-6·99) than in rural areas. INTERPRETATION The incidence of HIV in Rwanda was higher than that previously estimated from models, with outbreaks seeming to contribute to the ongoing epidemic. Characterisation of incident infections can help the national HIV programmes to plan for preventive interventions tailored to the most at risk populations. FUNDING Global Fund to Fight HIV, Tuberculosis and Malaria, WHO Rwanda, UNAIDS Rwanda, and the Government of Rwanda.
Collapse
Affiliation(s)
- Sabin Nsanzimana
- Institute of HIV Disease Prevention and Control, Rwanda Biomedical Center, Kigali, Rwanda; Basel Institute for Clinical Epidemiology and Biostatistics, University Hospital, University of Basel, Basel, Switzerland; Swiss Tropical and Public Health Institute, University of Basel, Switzerland.
| | - Eric Remera
- Institute of HIV Disease Prevention and Control, Rwanda Biomedical Center, Kigali, Rwanda
| | - Steve Kanters
- School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada
| | - Augustin Mulindabigwi
- Institute of HIV Disease Prevention and Control, Rwanda Biomedical Center, Kigali, Rwanda
| | - Amitabh B Suthar
- South African Centre for Epidemiological Modelling and Analysis, University of Stellenbosch, Epidemiology Department, Stellenbosch, South Africa
| | - Jean Paul Uwizihiwe
- Institute of HIV Disease Prevention and Control, Rwanda Biomedical Center, Kigali, Rwanda
| | - Mutagoma Mwumvaneza
- Institute of HIV Disease Prevention and Control, Rwanda Biomedical Center, Kigali, Rwanda
| | - Edward J Mills
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Heiner C Bucher
- Basel Institute for Clinical Epidemiology and Biostatistics, University Hospital, University of Basel, Basel, Switzerland
| |
Collapse
|
41
|
Remera E, Boer K, Umuhoza SM, Hedt-Gauthier BL, Thomson DR, Ndimubanzi P, Kayirangwa E, Mutsinzi S, Bayingana A, Mugwaneza P, Koama JBT. Fertility and HIV following universal access to ART in Rwanda: a cross-sectional analysis of Demographic and Health Survey data. Reprod Health 2017; 14:40. [PMID: 28292306 PMCID: PMC5351174 DOI: 10.1186/s12978-017-0301-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2015] [Accepted: 03/06/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND HIV infection is linked to decreased fertility and fertility desires in sub-Saharan Africa due to biological and social factors. We investigate the relationship between HIV infection and fertility or fertility desires in the context of universal access to antiretroviral therapy introduced in 2004 in Rwanda. METHODS We used data from 3532 and 4527 women aged 20-49 from the 2005 and 2010 Rwandan Demographic and Health Surveys (RDHS), respectively. The RDHSs included blood-tests for HIV, as well as detailed interviews about fertility, demographic and behavioral outcomes. In both years, multiple logistic regression was used to assess the association between HIV and fertility outcomes within three age categories (20-29, 30-39 and 40-49 years), controlling for confounders and compensating for the complex survey design. RESULTS In 2010, we did not find a difference in the odds of pregnancy in the last 5 years between HIV-seropositive and HIV-seronegative women after controlling for potential biological and social confounders. Controlling for the same confounders, we found that HIV-seropositive women under age 40 were less likely to desire more children compared to HIV-seronegative women (20-29 years adjusted odds ratio (AOR) = 0.31, 95% CI: 0.17, 0.58; 30-39 years AOR = 0.24, 95% CI: 0.14, 0.43), but no difference was found among women aged 40 or older. No associations between HIV and fertility or fertility desire were found in 2005. CONCLUSIONS These findings suggest no difference in births or current pregnancy among HIV-seropositive and HIV-seronegative women. That in 2010 HIV-seropositive women in their earlier childbearing years desired fewer children than HIV-seronegative women could suggest more women with HIV survived; and stigma, fear of transmitting HIV, or realism about living with HIV and prematurely dying from HIV may affect their desire to have children. These findings emphasize the importance of delivering appropriate information about pregnancy and childbearing to HIV-infected women, enabling women living with HIV to make informed decisions about their reproductive life.
Collapse
Affiliation(s)
- Eric Remera
- Institute of HIV/AIDS Disease Prevention and Control, Rwanda Biomedical Center, Kigali, Rwanda.
| | - Kimberly Boer
- Centers for Disease Control and Prevention, Kigali, Rwanda
| | - Stella M Umuhoza
- College of Medicine and Health Sciences, School of Public Health, University of Rwanda, Kigali, Rwanda
| | - Bethany L Hedt-Gauthier
- College of Medicine and Health Sciences, School of Public Health, University of Rwanda, Kigali, Rwanda.,Department of Global Health and Social Medicine, Harvard Medical School, Boston, USA.,Inshuti Mu Buzima/Partners in Health, Rwinkwavu, Rwanda
| | - Dana R Thomson
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, USA
| | | | | | | | - Alice Bayingana
- Institute of HIV/AIDS Disease Prevention and Control, Rwanda Biomedical Center, Kigali, Rwanda
| | - Placidie Mugwaneza
- Institute of HIV/AIDS Disease Prevention and Control, Rwanda Biomedical Center, Kigali, Rwanda
| | | |
Collapse
|
42
|
Mutagoma M, Balisanga H, Sebuhoro D, Mbituyumuremyi A, Remera E, Malamba SS, Riedel DJ, Nsanzimana S. Hepatitis C virus and HIV co-infection among pregnant women in Rwanda. BMC Infect Dis 2017; 17:167. [PMID: 28228126 PMCID: PMC5322679 DOI: 10.1186/s12879-017-2269-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2016] [Accepted: 02/17/2017] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Hepatitis C virus (HCV) infection is a pandemic causing disease; more than 185 million people are infected worldwide. An HCV antibody (Ab) prevalence of 6.0% was estimated in Central African countries. The study aimed at providing HCV prevalence estimates among pregnant women in Rwanda. METHODS HCV surveillance through antibody screening test among pregnant women attending antenatal clinics was performed in 30 HIV sentinel surveillance sites in Rwanda. RESULTS Among 12,903 pregnant women tested at antenatal clinics, 335 (2.6% [95% Confidence Interval 2.32-2.87]) tested positive for HCV Ab. The prevalence of HCV Ab in women aged 25-49 years was 2.8% compared to 2.4% in women aged 15-24 years (aOR = 1.3; [1.05-1.59]); This proportion was 2.7% [2.37-2.94] in pregnant women in engaged in non-salaried employment compared to 1.2% [0.24-2.14] in those engaged in salaried employment (aOR = 3.2; [1.60-6.58]). The proportion of HCV Ab-positive co-infected with HIV was estimated at 3.9% (13 cases). Women in urban residence were more likely to be associated with HCV-infection (OR = 1.3; 95%CI [1.0-1.6]) compared to those living in rural setting. CONCLUSION HCV is a public health problem in pregnant women in Rwanda. Few pregnant women were co-infected with HCV and HIV. Living in urban setting was more likely to associate pregnant women with HCV infection.
Collapse
Affiliation(s)
- Mwumvaneza Mutagoma
- Rwanda Biomedical Center, Ministry of Health, P.O. Box: 7162, Kigali, Rwanda
| | - Helene Balisanga
- Rwanda Biomedical Center, Ministry of Health, P.O. Box: 7162, Kigali, Rwanda
| | - Dieudonné Sebuhoro
- Rwanda Biomedical Center, Ministry of Health, P.O. Box: 7162, Kigali, Rwanda
| | | | - Eric Remera
- Rwanda Biomedical Center, Ministry of Health, P.O. Box: 7162, Kigali, Rwanda
| | - Samuel S. Malamba
- US Centers for Disease Control and Prevention (CDC), Center for Global Health (CGH), Division of Global HIV/AIDS (DGHA), Kigali, Rwanda
| | - David J. Riedel
- Institute of Human Virology and Division of Infectious Diseases, University of Maryland School of Medicine, Baltimore, MD USA
| | - Sabin Nsanzimana
- Rwanda Biomedical Center, Ministry of Health, P.O. Box: 7162, Kigali, Rwanda
| |
Collapse
|
43
|
Karita E, Nsanzimana S, Ndagije F, Wall KM, Mukamuyango J, Mugwaneza P, Remera E, Raghunathan PL, Bayingana R, Kayitenkore K, Bekan-Homawoo B, Tichacek A, Allen S. Implementation and Operational Research: Evolution of Couples' Voluntary Counseling and Testing for HIV in Rwanda: From Research to Public Health Practice. J Acquir Immune Defic Syndr 2016; 73:e51-e58. [PMID: 27741033 PMCID: PMC5367509 DOI: 10.1097/qai.0000000000001138] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2016] [Accepted: 07/14/2016] [Indexed: 01/18/2023]
Abstract
BACKGROUND Couples' voluntary HIV counseling and testing (CVCT) is a WHO-recommended intervention for prevention of heterosexual HIV transmission which very few African couples have received. We report the successful nationwide implementation of CVCT in Rwanda. METHODS From 1988 to 1994 in Rwanda, pregnant and postpartum women were tested for HIV and requested testing for their husbands. Partner testing was associated with more condom use and lower HIV and sexually transmitted infection rates, particularly among HIV-discordant couples. After the 1994 genocide, the research team continued to refine CVCT procedures in Zambia. These were reintroduced to Rwanda in 2001 and continually tested and improved. In 2003, the Government of Rwanda (GoR) established targets for partner testing among pregnant women, with the proportion rising from 16% in 2003 to 84% in 2008 as the prevention of mother-to-child transmission program expanded to >400 clinics. In 2009, the GoR adopted joint posttest counseling procedures, and in 2010 a quarterly follow-up program for discordant couples was established in government clinics with training and technical assistance. An estimated 80%-90% of Rwandan couples have now been jointly counseled and tested resulting in prevention of >70% of new HIV infections. CONCLUSIONS Rwanda is the first African country to have established CVCT as standard of care in antenatal care. More than 20 countries have sent providers to Rwanda for CVCT training. To duplicate Rwanda's success, training and technical assistance must be part of a coordinated effort to set national targets, timelines, indicators, and budgets. Governments, bilateral, and multilateral funding agencies must jointly prioritize CVCT for prevention of new HIV infections.
Collapse
Affiliation(s)
- Etienne Karita
- Project San Francisco (PSF), Kigali, Rwanda
- Department of Pathology & Laboratory Medicine, Emory University School of Medicine, Atlanta, GA
| | | | - Felix Ndagije
- US Centers for Disease Control and Prevention (CDC), Kigali, Rwanda
| | - Kristin M. Wall
- Department of Epidemiology, School of Public Health, Emory University, Atlanta, GA
| | - Jeannine Mukamuyango
- Project San Francisco (PSF), Kigali, Rwanda
- Department of Pathology & Laboratory Medicine, Emory University School of Medicine, Atlanta, GA
| | | | - Eric Remera
- Rwanda Biomedical Center (RBC), Kigali, Rwanda
| | - Pratima L. Raghunathan
- US Centers for Disease Control and Prevention, Center for Global Health, Atlanta, GA; and
| | - Roger Bayingana
- Project San Francisco (PSF), Kigali, Rwanda
- Department of Pathology & Laboratory Medicine, Emory University School of Medicine, Atlanta, GA
| | - Kayitesi Kayitenkore
- Project San Francisco (PSF), Kigali, Rwanda
- Department of Pathology & Laboratory Medicine, Emory University School of Medicine, Atlanta, GA
| | - Brigitte Bekan-Homawoo
- Project San Francisco (PSF), Kigali, Rwanda
- Department of Pathology & Laboratory Medicine, Emory University School of Medicine, Atlanta, GA
| | - Amanda Tichacek
- Department of Pathology & Laboratory Medicine, Emory University School of Medicine, Atlanta, GA
| | - Susan Allen
- Department of Pathology & Laboratory Medicine, Emory University School of Medicine, Atlanta, GA
| |
Collapse
|
44
|
Balisanga H, Mutagoma M, Remera E, Kayitesi C, Kayirangwa E, Dee J, Malamba S, Boer KR, Hedt-Gauthier B, Umugwaneza P, Nsanzimana S. HIV surveillance in Rwanda: readiness assessment to transition from antenatal care-based to prevention of mother-to-child transmission program-based HIV surveillance. Int J Infect Dis 2016; 52:62-67. [PMID: 27616035 DOI: 10.1016/j.ijid.2016.08.029] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2016] [Revised: 08/29/2016] [Accepted: 08/31/2016] [Indexed: 10/21/2022] Open
Abstract
BACKGROUND In 2013, the World Health Organization (WHO) recommended that for efficiency and ethical considerations, transitioning from antenatal clinic-based surveillance to prevention of mother-to-child transmission (PMTCT)-based routine data should be investigated. An assessment of the readiness for this transition was carried out in Rwanda in 2011 and 2013. METHODS This assessment applied the WHO recommended method. Individual HIV rapid testing at site was compared to antenatal surveillance results at all existing 30 sites, involving 13 292 women. In addition, PMTCT HIV testing quality assurance and PMTCT routine data quality were assessed at 27 out of the 30 sites. RESULTS All sentinel sites provided PMTCT services and had a high uptake of HIV testing (more than 90%). At all sites, PMTCT data were recorded in longitudinal and standardized antenatal clinic registers. Twenty-six out of 27 sites had HIV result completeness above 90%. A positive percentage agreement of 97.5% and negative percentage agreement of 99.9% were observed between routine PMTCT and sero-surveillance HIV test results. Of 27 sites, 25 scored more than 80% in all phases of HIV testing quality assurance. CONCLUSIONS According to WHO standards, Rwanda antenatal care HIV sero-surveillance is ready to transition to PMTCT-based sero-surveillance.
Collapse
Affiliation(s)
- Helene Balisanga
- Rwanda Biomedical Center, Ministry of Health, PO Box 7162, Kigali, Rwanda.
| | | | - Eric Remera
- Rwanda Biomedical Center, Ministry of Health, PO Box 7162, Kigali, Rwanda
| | - Catherine Kayitesi
- Rwanda Biomedical Center, Ministry of Health, PO Box 7162, Kigali, Rwanda
| | - Eugenie Kayirangwa
- US Centers for Disease Control and Prevention (CDC), Center for Global Health (CGH), Division of Global HIV/AIDS (DGHA), Atlanta, Georgia, USA
| | - Jacob Dee
- US Centers for Disease Control and Prevention (CDC), Center for Global Health (CGH), Division of Global HIV/AIDS (DGHA), Atlanta, Georgia, USA
| | - Samuel Malamba
- US Centers for Disease Control and Prevention (CDC), Center for Global Health (CGH), Division of Global HIV/AIDS (DGHA), Atlanta, Georgia, USA
| | - Kimberly R Boer
- US Centers for Disease Control and Prevention (CDC), Center for Global Health (CGH), Division of Global HIV/AIDS (DGHA), Atlanta, Georgia, USA
| | - Bethany Hedt-Gauthier
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | | | - Sabin Nsanzimana
- Rwanda Biomedical Center, Ministry of Health, PO Box 7162, Kigali, Rwanda
| |
Collapse
|
45
|
Mutagoma M, Balisanga H, Remera E, Gupta N, Malamba SS, Riedel DJ, Nsanzimana S. Ten-year trends of syphilis in sero-surveillance of pregnant women in Rwanda and correlates of syphilis-HIV co-infection. Int J STD AIDS 2016; 28:45-53. [PMID: 26692548 DOI: 10.1177/0956462415624058] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
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.
Collapse
Affiliation(s)
| | | | - Eric Remera
- 1 Rwanda Biomedical Center, Ministry of Health, Kigali, Rwanda
| | - Neil Gupta
- 2 Global Health Equity, Brigham & Women's Hospital, Boston, MA, USA.,3 Partners in Health / Inshuti Mu Buzima, Rwinkwavu, Rwanda
| | - Samuel S Malamba
- 4 U.S. Centers for Disease Control and Prevention (CDC), Center for Global Health (CGH), Division of Global HIV/AIDS (DGHA), Rwanda
| | - David J Riedel
- 5 Institute of Human Virology and Division of Infectious Diseases, University of Maryland School of Medicine, Baltimore, Maryland, MD, USA
| | - Sabin Nsanzimana
- 1 Rwanda Biomedical Center, Ministry of Health, Kigali, Rwanda.,6 Swiss Tropical and Public Health Institute, University of Basel, Basel, Switzerland
| |
Collapse
|
46
|
Collins SE, Grant PM, Uwinkindi F, Talbot A, Seruyange E, Slamowitz D, Mugeni A, Remera E, Niyonsenga SP, Nyirimigabo J, Uwizihiwe JP, Dongier P, Muhayimpundu R, Mazarati JB, Zolopa A, Nsanzimana S. A Randomized Switch From Nevirapine-Based Antiretroviral Therapy to Single Tablet Rilpivirine/Emtricitabine/Tenofovir Disoproxil Fumarate in Virologically Suppressed Human Immunodeficiency Virus-1-Infected Rwandans. Open Forum Infect Dis 2016; 3:ofw141. [PMID: 27704000 PMCID: PMC5047400 DOI: 10.1093/ofid/ofw141] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2016] [Accepted: 06/23/2016] [Indexed: 12/12/2022] Open
Abstract
There is a need to improve antiretroviral options in Africa. This study shows switching from a neviripine-based treatment to co-formulated rilpivirine/emtricitabine/tenofovir disoproxil fumarate in virologically suppressed Rwandans is safe and non-inferior to continued nevirapine-based therapy at 24 weeks. Background. Many human immunodeficiency virus (HIV)-infected patients remain on nevirapine-based antiretroviral therapy (ART) despite safety and efficacy concerns. Switching to a rilpivirine-based regimen is an alternative, but there is little experience with rilpivirine in sub-Saharan Africa where induction of rilpivirine metabolism by nevirapine, HIV subtype, and dietary differences could potentially impact efficacy. Methods. We conducted an open-label noninferiority study of virologically suppressed (HIV-1 ribonucleic acid [RNA] < 50 copies/mL) HIV-1-infected Rwandan adults taking nevirapine plus 2 nucleos(t)ide reverse-transcriptase inhibitors. One hundred fifty participants were randomized 2:1 to switch to coformulated rilpivirine-emtricitabine-tenofovir disoproxil fumarate (referenced as the Switch Arm) or continue current therapy. The primary efficacy endpoint was HIV-1 RNA < 200 copies/mL at week 24 assessed by the US Food and Drug Administration Snapshot algorithm with a noninferiority margin of 12%. Results. Between April and September 2014, 184 patients were screened, and 150 patients were enrolled; 99 patients switched to rilpivirine-emtricitabine-tenofovir, and 51 patients continued their nevirapine-based ART. The mean age was 42 years and 43% of participants were women. At week 24, virologic suppression (HIV-1 RNA level <200 copies/mL) was maintained in 93% and 92% in the Switch Arm versus the continuation arm, respectively. The Switch Arm was noninferior to continued nevirapine-based ART (efficacy difference 0.8%; 95% confidence interval, −7.5% to +12.0%). Both regimens were generally safe and well tolerated, although 2 deaths, neither attributed to study medications, occurred in participants in the Switch Arm. Conclusions. A switch from nevirapine-based ART to rilpivirine-emtricitabine-tenofovir disoproxil fumarate had similar virologic efficacy to continued nevirapine-based ART after 24 weeks with few adverse events.
Collapse
Affiliation(s)
- Sean E Collins
- Department of Medicine , Stanford University , California
| | - Philip M Grant
- Department of Medicine , Stanford University , California
| | - Francois Uwinkindi
- Institute of HIV Disease Prevention and Control , Rwanda Biomedical Center , Kigali
| | - Annie Talbot
- Department of Family Medicine , University of Montreal , Ontario , Canada
| | | | | | | | - Eric Remera
- Institute of HIV Disease Prevention and Control , Rwanda Biomedical Center , Kigali
| | | | - Josbert Nyirimigabo
- Institute of HIV Disease Prevention and Control , Rwanda Biomedical Center , Kigali
| | - Jean Paul Uwizihiwe
- Institute of HIV Disease Prevention and Control , Rwanda Biomedical Center , Kigali
| | - Pierre Dongier
- Institute of HIV Disease Prevention and Control , Rwanda Biomedical Center , Kigali
| | | | | | - Andrew Zolopa
- Department of Medicine, Stanford University, California; Viiv Healthcare, Research Triangle Park, North Carolina
| | - Sabin Nsanzimana
- Institute of HIV Disease Prevention and Control , Rwanda Biomedical Center , Kigali
| |
Collapse
|
47
|
Binagwaho A, Fawzi MCS, Agbonyitor M, Nsanzimana S, Karema C, Remera E, Mutabazi V, Shyirambere C, Cyamatare P, Nutt C, Wagner C, Condo J, Misago N, Kayiteshonga Y. Validating the Children's Depression Inventory in the context of Rwanda. BMC Pediatr 2016; 16:29. [PMID: 26898199 PMCID: PMC4762156 DOI: 10.1186/s12887-016-0565-2] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2014] [Accepted: 02/16/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Depression is often co-morbid with chronic conditions, and when combined with HIV it can increase progression and reduce survival. A brief and accurate screening tool for depression among children living with HIV is necessary to increase access to mental health care and improve HIV-related outcomes in the long-term. METHODS A validation study was conducted, comparing the Children's Depression Inventory (CDI) with a structured clinical assessment as the gold standard among children living with HIV ages 7-14 years in Rwanda. The response rate was 87 % and the analysis was performed among 100 study participants. RESULTS Twenty-five percent of children had a diagnosis of depression based on the clinical interview. Sensitivity of the CDI ranged from 44 to 76 % and specificity was 92 to 100 % for cut-off scores from 5 to 9. The area under the curve (AUC) for receiver operating characteristic analysis, an estimate of overall accuracy, was 0.87 (95 % confidence interval: 0.77 - 0.97). CONCLUSIONS The significant prevalence of depression among children living with HIV in Rwanda reflects a critical need to advance mental health care in this population. Although overall accuracy of the CDI is reasonable in this context, further research needs to be done to develop a more sensitive measure of depression in this vulnerable population. Development of a highly sensitive screening measure will be a fundamental step towards improving access to mental health care among children living with HIV, potentially improving health outcomes and quality of life in the long-term as this vulnerable population transitions into adulthood.
Collapse
Affiliation(s)
- Agnes Binagwaho
- Ministry of Health of Rwanda, P.O. Box 84, Kigali, Rwanda. .,Department of Global Health and Social Medicine, Harvard Medical School, 641 Huntington Avenue, Boston, MA, 02115, USA. .,University of Global Health Equity, 260 Blvd de l'Umuganda, P.O. Box 6955, Kigali, Rwanda. .,Geisel School of Medicine at Dartmouth, 1 Rope Ferry Road, Hanover, NH, 03755, USA.
| | - Mary C Smith Fawzi
- Department of Global Health and Social Medicine, Harvard Medical School, 641 Huntington Avenue, Boston, MA, 02115, USA
| | - Mawuena Agbonyitor
- University of Maryland School of Medicine, 685 W Baltimore St., Baltimore, MD, 21201, USA
| | | | - Corine Karema
- Rwanda Biomedical Center, P.O. Box 83, Kigali, Rwanda
| | - Eric Remera
- Rwanda Biomedical Center, P.O. Box 83, Kigali, Rwanda
| | | | | | | | - Cameron Nutt
- Partners In Health, 641 Huntington Avenue, Boston, MA, 02115, USA
| | - Claire Wagner
- Dana-Farber Cancer Institute Center for Global Cancer Medicine, 450 Brookline Avenue, Boston, MA, 02115, USA
| | - Jeanine Condo
- School of Public Health, University of Rwanda, P.O. Box 5229, Kigali, Rwanda
| | - Nancy Misago
- Rwanda Biomedical Center, P.O. Box 83, Kigali, Rwanda
| | | |
Collapse
|
48
|
Nsanzimana S, Remera E, Kanters S, Chan K, Forrest JI, Ford N, Condo J, Binagwaho A, Mills EJ. Life expectancy among HIV-positive patients in Rwanda: a retrospective observational cohort study. Lancet Glob Health 2015; 3:e169-77. [PMID: 25701995 DOI: 10.1016/s2214-109x(14)70364-x] [Citation(s) in RCA: 85] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND Rwanda has achieved substantial progress in scaling up of antiretroviral therapy. We aimed to assess the effect of increased access to antiretroviral therapy on life expectancy among HIV-positive patients in two distinct periods of lower and higher antiretroviral therapy coverage (1997-2007 and 2008-11). METHODS In a retrospective observational cohort study, we collected clinical and demographic data for all HIV-positive patients enrolled in care at 110 health facilities across all five provinces of Rwanda. We included patients aged 15 years or older with a known enrolment date between 1997 and 2014. We constructed abridged life tables from age-specific mortality rates and life expectancy stratified by sex, CD4 cell count, and WHO disease stage at enrolment in care and initiation of antiretroviral therapy. FINDINGS We included 72,061 patients in this study, contributing 213,983 person-years of follow-up. The crude mortality rate was 33·4 deaths per 1000 person-years (95% CI 32·7-34·2). Life expectancy for the overall cohort was 25·6 additional years (95% CI 25·1-26·1) at 20 years of age and 23·3 additional years (95% CI 22·9-23·7) at 35 years of age. Life expectancy at 20 years of age in the period of 1997-2007 was 20·4 additional years (95% CI 19·5-21·3); for the period of 2008-11, life expectancy had increased to 25·6 additional years (95% CI 24·8-26·4). Individuals enrolling in care with CD4 cell counts of 500 cells per μL or more, and with WHO disease stage I, had the highest life expectancies. INTERPRETATION This study adds to the growing body of evidence showing the benefit to HIV-positive patients of early enrolment in care and initiation of antiretroviral therapy. FUNDING Bill & Melinda Gates Foundation.
Collapse
Affiliation(s)
- Sabin Nsanzimana
- Institute of HIV Disease Prevention and Control, Rwanda Biomedical Centre, Kigali, Rwanda
| | - Eric Remera
- Institute of HIV Disease Prevention and Control, Rwanda Biomedical Centre, Kigali, Rwanda
| | - Steve Kanters
- Global Evaluative Sciences, Vancouver, BC, Canada; School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada
| | - Keith Chan
- Global Evaluative Sciences, Vancouver, BC, Canada
| | - Jamie I Forrest
- Global Evaluative Sciences, Vancouver, BC, Canada; School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada
| | - Nathan Ford
- Centre for Infectious Disease Epidemiology and Research, University of Cape Town, South Africa
| | - Jeanine Condo
- School of Public Health, College of Medicine & Health Sciences, University of Rwanda, Kigali, Rwanda
| | - Agnes Binagwaho
- Ministry of Health, Government of Rwanda, Kigali, Rwanda; Harvard Medical School, Boston, MA, USA
| | - Edward J Mills
- Global Evaluative Sciences, Vancouver, BC, Canada; School of Public Health, College of Medicine & Health Sciences, University of Rwanda, Kigali, Rwanda.
| |
Collapse
|
49
|
Nsanzimana S, Remera E, Kanters S, Forrest JI, Ford N, Condo J, Binagwaho A, Bucher H, Thorlund K, Vitoria M, Mills EJ. Effect of baseline CD4 cell count at linkage to HIV care and at initiation of antiretroviral therapy on mortality in HIV-positive adult patients in Rwanda: a nationwide cohort study. Lancet HIV 2015; 2:e376-84. [PMID: 26423551 DOI: 10.1016/s2352-3018(15)00112-5] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2015] [Revised: 05/06/2015] [Accepted: 06/02/2015] [Indexed: 11/19/2022]
Abstract
BACKGROUND Continued debate exists about whether initiation of antiretroviral therapy (ART) in symptom-free patients at higher baseline CD4 cell counts results in important clinical benefits. We aimed to examine to what extent baseline CD4 cell count at linkage to HIV care and at ART initiation predicts mortality in adults with HIV in Rwanda. METHODS We included data for patients with HIV in Rwanda who were aged 15 years or older and linked to care or initiated ART between Jan 1, 1997, and April 30, 2014, from nationally representative databases. We analysed the effect on mortality of baseline CD4 cell count at ART initiation and at linkage to care. Follow-up time was measured from time of ART initiation and from linkage to HIV care to study exit. To account for effect modification by time, we stratified by era of linkage (before 2008 vs 2008 or after) and for other indications for initiation of ART. We also stratified CD4 cell count by indication to initiate ART other than CD4 cell count status. We used Cox proportional hazard regressions to examine the effect of CD4 cell count at linkage and at ART initiation on mortality. FINDINGS Our analysis was based on data from 50,147 patients who initiated ART and 72,061 patients linked to care. In the late era (2008 and after), linkage to care at a CD4 cell count of 100-199 cells per μL without any further indication was associated with higher mortality than linkage at 200-349 cells per μL (hazard ratio [HR] 1·37, 95% CI 0·95-1·97); the effect was much the same for initiation of ART in this CD4 stratum (1·37, 0·92-2·04). For higher CD4 strata, linkage to care at 500 cells per μL or more was protective (0·53, 0·39-0·72), whereas the reported effect of initiation of ART on mortality was not distinguishable from chance alone (0·82, 0·21-3·20). INTERPRETATION Efforts are needed to link and retain patients early in pre-ART HIV care. In settings where ART is not yet available for immediate treatment, retention in a strong pre-ART programme is effective at improving survival. FUNDING The Bill & Melinda Gates Foundation.
Collapse
Affiliation(s)
- Sabin Nsanzimana
- University of Basel, Swiss Tropical and Public health institute and Institute for Clinical Epidemiology and Biostatistics, Basel Switzerland
| | - Eric Remera
- Institute of HIV Disease Prevention and Control, Rwanda Biomedical Centre, Kigali, Rwanda
| | - Steve Kanters
- Global Evaluative Sciences, Vancouver, BC, Canada; School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada
| | - Jamie I Forrest
- Global Evaluative Sciences, Vancouver, BC, Canada; School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada
| | - Nathan Ford
- Department of HIV/AIDS, World Health Organization, Geneva, Switzerland
| | - Jeanine Condo
- School of Public Health, College of Medicine & Health Sciences, University of Rwanda, Kigali, Rwanda
| | | | - Heiner Bucher
- Basel Institute for Clinical Epidemiology and Biostatistics, University Hospital of Basel, Basel, Switzerland
| | | | - Marco Vitoria
- Department of HIV/AIDS, World Health Organization, Geneva, Switzerland
| | | |
Collapse
|
50
|
Nsanzimana S, Kanters S, Remera E, Forrest JI, Binagwaho A, Condo J, Mills EJ. HIV care continuum in Rwanda: a cross-sectional analysis of the national programme. Lancet HIV 2015; 2:e208-15. [PMID: 26423003 DOI: 10.1016/s2352-3018(15)00024-7] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Rwanda has made remarkable progress towards HIV care programme with strong national monitoring and surveillance. Knowledge about the HIV care continuum model can help to improve outcomes in patients. We aimed to quantify engagement, mortality, and loss to follow-up of patients along the HIV care continuum in Rwanda in 2013. METHODS We collated data for individuals with HIV who participated in the national HIV care programme in Rwanda and calculated the numbers of individuals or proportions of the population at each stage and the transition probabilities between stages of the continuum. We calculated factors associated with mortality and loss to follow-up by fitting Cox proportional hazards regression models, one for the stage of care before antiretroviral therapy (ART) initiation and another for stage of care during ART. FINDINGS An estimated 204,899 individuals were HIV-positive in Rwanda in 2013. Among these individuals, 176,174 (86%) were in pre-ART or in ART stages and 129,405 (63%) had initiated ART by the end of 2013. 82·1% (95% CI 80·7-83·4) of patients with viral load measurements (n=3066) were virally suppressed (translating to 106,371 individuals or 52% of HIV-positive individuals). Mortality was 0·6% (304 patients) in the pre-ART stage and 1·0% (1255 patients) in the ART stage; 2247 (3·9%) patients were lost to follow-up in pre-ART stage and 2847 (2·2%) lost in ART stage. Risk factors for mortality among patients in both pre-ART and ART stages included older age, CD4 cell count at initiation, and male sex. Risk factors for loss to follow-up among patients at both pre-ART and ART stages included younger age (age 10-29 year) and male sex. INTERPRETATION The HIV care continuum is a multitrajectory pathway in which patients have many opportunities to leave and re-engage in care. Knowledge about the points at which individuals are most likely to leave care could improve large-scale delivery of HIV programmes. FUNDING The Bill & Melinda Gates Foundation.
Collapse
Affiliation(s)
- Sabin Nsanzimana
- Institute of HIV Disease Prevention and Control, Rwanda Biomedical Centre, Kigali, Rwanda; Swiss Tropical and Public Health Institute, University of Basel, Basel, Switzerland.
| | - Steve Kanters
- Global Evaluative Sciences, Vancouver, BC, Canada; School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada
| | - Eric Remera
- Institute of HIV Disease Prevention and Control, Rwanda Biomedical Centre, Kigali, Rwanda
| | - Jamie I Forrest
- Global Evaluative Sciences, Vancouver, BC, Canada; School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada
| | - Agnes Binagwaho
- Ministry of Health, Government of Rwanda, Kigali, Rwanda; Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA; Geisel School of Medicine, Dartmouth College, Hanover, NH, USA
| | - Jeanine Condo
- School of Public Health, College of Medicine and Health Sciences, University of Rwanda, Kigali, Rwanda
| | - Edward J Mills
- Global Evaluative Sciences, Vancouver, BC, Canada; School of Public Health, College of Medicine and Health Sciences, University of Rwanda, Kigali, Rwanda
| |
Collapse
|