Current trends in Rwanda's HIV/AIDS epidemic

Evaluation of a health education program for improving uptake of HIV self-testing by men in Rwanda: a pilot pragmatic randomized control trial

Background

Health education interventions tailored to suit men have the potential to improve health outcomes for this underserved population. HIV self-testing (HIVST) is a promising approach to overcoming challenges associated with low HIV testing rates among men. The primary objective of this study is to assess the feasibility of conducting a definitive trial to determine the effectiveness of a locally adapted and optimized health education program (HEP) on the uptake of HIVST among men in Kigali, Rwanda.

Methods

This study employs a pilot pragmatic randomized controlled trial to evaluate an HIVST HEP for men. Participants were randomized to the intervention (HEP) arm or to the control arm. In the intervention group, the adapted HEP was administered in addition to routine health education. In the non-intervention group, only routine health education was offered. Participant data was collected first upon recruitment and then after 3 months’ follow-up using interviewer-administered questionnaires.

Results

There was a 100% response rate at enrollment and no loss to follow-up at exit. There was significant association between the study arm and knowledge of HIVST. Participants in the control arm had a mean knowledge score of 67% compared to 92% among participants in the intervention arm. There was an association between the study arm and HIVST uptake: 67% of the study participants in the intervention arm self-reported HIVST uptake compared to 23% of the participants in the control arm.

Discussion

This pilot study demonstrates the feasibility of a larger trial to assess the effectiveness of an HEP intervention on uptake of HIVST among men. We found preliminary evidence of increased uptake of HIVST in the intervention group.

Trial registration

Pan African Clinical Trial Registry PACTR201908758321490. Registered on 8 August 2019.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40814-021-00940-x.

Perceived quality of primary healthcare post-National Health Insurance pilot implementation

Background

Contracting private medical practitioners for the National Health Insurance pilot project in 2012 by the National Department of Health in South Africa was envisaged to reduce workload at referral district hospitals by reducing self-referral by clients as the perceived quality of care at the primary healthcare level improves.

Aim

To describe the effect of contracting private medical practitioners at primary healthcare facilities on the self-referral rate of clients at district hospitals as a proxy for perceived quality of care in a National Health Insurance pilot district.

Setting

The study was set in Tshwane National Health Insurance pilot district compared to Ekurhuleni district.

Methods

We compared findings before and after implementing the National Health Insurance private medical practitioners contracting between a pilot and a non-pilot district. A quasi-experimental ecological study design was used to compare district hospital outpatient department indicators of clients follow-up, self-referral, self-referral rate and referred in the two districts from June 2012 to May 2014 using single and controlled interrupted time-series analyses.

Results

Controlled interrupted time series analysis found decreases in self-referral rate (-1.8 [-2.2, -1.1] [p < 0.0001]) and the initial trend of headcounts of self-referral (-516 [-969, -66] [p = 0.0260]), but an increase in headcounts of referred clients (1293 [77, 2508] [p = 0.0376]) in the pilot compared with the non-pilot district.

Conclusion

We concluded that the implementation of contracting private medical practitioners in primary healthcare facilities might have resulted in an improved perceived quality of care at primary health care facilities. However, the higher number of outpatient department headcounts for follow-up and the increase in referred cases in the pilot district would need to be investigated.

Adaptation of a Health Education Program for Improving the Uptake of HIV Self-Testing by Men in Rwanda: A Study Protocol

Background and objectives: Available evidence shows a low uptake of HIV services among men in Rwanda. HIV self-testing (HIVST), a new intervention, may have the potential to improve the uptake of HIV testing services among men. The current study aims to adapt a health education program (HEP) for improving the uptake of HIVST among men in Rwanda. Materials and Methods: We propose a mixed method study, which will be conducted in four phases. In Phase 1, we will conduct a scoping review to map the available evidence on health education programs for men in low- and middle-income countries (LMICs). In Phase 2, we will conduct interviews with stakeholders in the Rwanda HIV response and healthcare providers to determine their perspectives on implementation of HIVST in Rwanda. In Phase 3, a cross-sectional survey will be used to assess HIVST awareness and acceptability among men in Rwanda. Guided by findings from Phases 1, 2, and 3, we will employ the nominal group technique to develop and optimize the HEP for improving the uptake of HIVST among men in Rwanda. In Phase 4, we will use a pragmatic pilot randomized controlled trial to assess the preliminary impact of the HEP for men in Rwanda and assess the feasibility of a later, larger study. We will employ the Stata version 16 statistical package and NVivo version 12 for the analysis of quantitative and qualitative data, respectively. We anticipate that the findings of this study will inform implementers and policy makers to guide strategies on the implementation of HIVST in Rwanda and ultimately accomplish goals set forth in the Rwanda 2019–2024 Fourth Health Sector Strategic Plan on scaling up the number of men who know their HIV status. Conclusion: It is anticipated that this study will proffer solutions and strategies that are applicable not only in Rwanda but also in similar settings of LMICs.

Female sex workers in Kigali, Rwanda: a key population at risk of HIV, sexually transmitted infections, and unplanned pregnancy

Female sex workers (FSWs) were recruited from known hotspots in Kigali, Rwanda, and offered free, anonymous human immunodeficiency virus (HIV) counseling and testing, diagnosis and treatment of sexually transmitted infections (STIs) and long-acting reversible contraception (LARC). From September 2012 to March 2015, 1168 FSWs sought services, including 587 (50%) who were HIV-positive. More than 90% had previously tested for HIV, and 26% who reported previously testing negative had seroconverted. Of the 349 who already knew their HIV-positive status, 74% were on antiretroviral treatment. The prevalence of serologic syphilis was 43% in HIV-positive and 19% in HIV-negative FSWs (p < 0.0001), and Trichomonas vaginalis was found in vaginal wet mounts in 21% of HIV-positive and 13% of HIV-negative FSWs (p < 0.0001). Signs and symptoms of STIs were found in 35% of HIV-positive compared with 21% of HIV-negative FSWs (p < 0.0001). Only one-third reported consistent condom use in the last month. Modern contraceptive use was reported by 43% of HIV-positive and 56% of HIV-negative FSWs (p < 0.0001). Current pregnancy was reported by 4% of HIV-positive and 6% of HIV-negative FSWs (p = 0.0409). Despite Rwanda's successes with preventing 70% of new infections in the general population through nationwide couples' testing in antenatal clinics, prevention and timely treatment in key populations including FSWs are lacking. The prevalence of HIV - including many new cases - and STIs among FSWs in Kigali is high and condom and contraceptive use are low. Tailored and integrated HIV/STIs and family planning programs are urgently needed for FSWs.

Assessing the impact of HIV status on injury outcomes: A multicenter study of trauma patients in Rwanda

BACKGROUND

There is conflicting evidence regarding the impact of human immunodeficiency virus serostatus on trauma outcomes in low-resource settings. This study sought to evaluate the impact of human immunodeficiency virus serostatus on mortality outcomes for Rwandan patients presenting after trauma.

METHODS

This retrospective review of the University of Rwanda trauma registry captured all adult trauma patients with known human immunodeficiency virus status presenting between March 2011 and July 2015. Confirmed human immunodeficiency virus-positive cases were matched 1:2 with known human immunodeficiency virus-negative controls using a modified Kampala Trauma Score, sex, and district of residence or primary hospital. All-cause mortality was compared using multivariable logistic regression.

RESULTS

In total, 11,280 patients were recorded prospectively in the registry (169 human immunodeficiency virus positive; 334 human immunodeficiency virus negative matches). There was no difference in delay of hospital presentation or time until operation (P = .50 and P = .57, respectively). Less than 30% of all patients underwent operation during admission (n = 133), and the rate of operative intervention was independent of human immunodeficiency virus serostatus (P = .946). There was no association between development of any complication and human immunodeficiency virus status (P = .837). The overall mortality rate was 8.9% and 3.3% for human immunodeficiency virus-positive and human immunodeficiency virus-negative patients, respectively (P = .010). Human immunodeficiency virus positivity was associated with increased 30-day mortality when controlling for potential confounders (P = .016; odds ratio 3.60, 95% confidence interval: 1.27-10.2, C statistic 0.88).

CONCLUSION

Both human immunodeficiency virus and trauma pose substantial public health threats in sub-Saharan Africa. Known human immunodeficiency virus seropositivity in Rwandan trauma patients is associated with early mortality. Further investigation regarding testing, treatment, and outcomes in human immunodeficiency virus-positive trauma patients is warranted and provides an opportunity for leveraging human immunodeficiency virus global health efforts in trauma outcomes assessment.

Understanding HIV Transmission and Illness Stigma: A Relationship Revisited in Rural Rwanda

Integrating an understanding of HIV transmission with structural-behavioral prevention approaches remains a priority in low prevalence rural regions in Africa. Many national indicators use categorical survey responses which do not capture the cultural nuances of HIV transmission knowledge that potentially reify stigmatizing treatment of persons living with HIV (PL-HIV). We examined the relationship between quantitative and qualitative measures of HIV knowledge and four forms of stigma (individual attitudes, felt normative, social distance, and stigma perceived by PLHIV) among 200 rural residents in Rwanda. Forty-two percent qualitatively reported concurrent accurate and partial knowledge of HIV transmission. Being more knowledgeable about HIV transmission was associated with less desire for social distancing from PLHIV. Our findings highlight the continued importance of reinforcing an accurate understanding of HIV transmission and correcting misinformation by drawing on quantitative and qualitative assessments of HIV knowledge as critical arms of HIV stigma reduction programs in low prevalence rural regions.

Circumcision Status and Time to Sexual Debut Among Youth in Sub-Saharan Africa: Evidence from Six Demographic and Health Surveys

This paper examines the relationship between circumcision status and timing of sexual debut among unmarried youth in Sub-Saharan Africa using Demographic and Health Surveys. Results from survival analysis indicate that the association between circumcision and timing of first sex is place and context specific. Compared to uncircumcised, circumcised men in Rwanda, Uganda and Namibia hasten sexual initiation, whilst circumcised youth in Ethiopia and Mali delayed sex initiation. In Togo however, we found parity in timing to sexual debut. Our multivariate results reveal that, knowledge of HIV/AIDS risk and educational level also feed into the association between circumcision and timing of sex initiation- implying that efforts to prevent new HIV infection through circumcision could benefit from a proper understanding of how diverse set of factors interact in specific contexts to shape youth's decisions to initiate early sex.

Young People's Views and Experiences of a Mobile Phone Texting Intervention to Promote Safer Sex Behavior

BACKGROUND

The risk of poor sexual health, including unplanned pregnancy and sexually transmitted infections (STIs), is greatest amongst young people. Innovative and acceptable interventions to improve sexual health are required. Mobile phone text messaging (short message service, SMS) interventions have the potential to reach large numbers of people at relatively low cost, but greater understanding is needed on how these interventions should be developed and how they work.

OBJECTIVES

The aim of this paper is to explore young people's views of and experiences with a mobile phone text messaging intervention to promote safer sex behavior.

METHODS

We undertook qualitative interviews with young people aged 16 to 24 years as part of a pilot trial of a sexual health intervention delivered by text message in the United Kingdom. Study participants received sexual health promotion text messages based on behavior-change techniques. The message content, tailored by gender and STI status, included support for correct STI treatment and promotion of safer sex behaviors. Young people were eligible if they had received a positive chlamydia test or had more than one partner and at least one episode of unprotected sex in the last year. Telephone interviews were conducted 2 to 3 weeks after initiation of the intervention. A semi-structured topic guide was followed to explore participant experiences and a thematic analysis was conducted.

RESULTS

We conducted 16 telephone interviews with participants who had received the text intervention and an additional four interviews with those in the control group (13 women and 7 men). Intervention participants found text messages easy to understand and appearing to come from a friendly and trustworthy source. They considered the frequency and timing of messages to be appropriate, and delivery via mobile phones convenient. Receipt of support by text message allowed recipients to assimilate information at their own pace, and prompted reflection on and sharing of messages with friends, family members, and partners, thus providing opportunities for education and discussion. For some recipients, the messages had increased their knowledge of how to correctly use condoms. Some described how the messages had increased their confidence and reduced stigma, enabling them to disclose infection to a partner and/or to do so sooner and more calmly. Discussing the messages with a partner reportedly enabled some women to negotiate condom use.

CONCLUSION

From the perspective of the recipients, the tone, frequency, and content of the text messaging-based sexual health intervention was acceptable and appropriate. Their accounts indicated that the intervention increased knowledge, confidence, and safer sex behaviors. A large-scale randomized controlled trial (RCT) is needed to assess effectiveness.

Factors associated with HIV infection among sexually experienced adolescents in Africa: a pooled data analysis

The article examines the factors associated with HIV status among adolescents aged 15-19 years in 13 African countries: Côte d'Ivoire, Democratic Republic of Congo, Guinea, Kenya, Liberia, Mali, Malawi, Rwanda, Sierra Leone, Swaziland, Tanzania, Zambia and Zimbabwe. The data were derived from demographic and health surveys or AIDS indicator surveys conducted between 2004 and 2009. The levels of HIV prevalence among adolescents varied considerably across the countries. There was significantly higher HIV prevalence among female adolescents as compared with their male counterparts. For male adolescents, circumcision was the only variable significantly associated with HIV status. Nonetheless, the data suggest that the association between male circumcision and HIV status may be exaggerated. Indeed, regional-level random effects became insignificant once male circumcision was introduced into the estimated models, indicating a strong correlation between unmeasured regional-level factors and male circumcision. For female adolescents, multiple sexual partnerships, time elapsed since sexual debut, marital status, household wealth, and the regional prevalence of male circumcision were strongly and positively associated with HIV status. Moreover, for female adolescents there appear to be significant unmeasured variables operating at the regional level which influence the levels of HIV infection. The implications of the findings for HIV-prevention programming, policy and research are discussed.

High HIV Prevalence among Asylum Seekers Who Gave Birth in the Netherlands: A Nationwide Study Based on Antenatal HIV Tests

OBJECTIVES

Asylum seekers are considered to be a particularly vulnerable group with respect to HIV. Data on the HIV prevalence among asylum seekers, however, are scarce. The aim of this study is to map the HIV prevalence among asylum seekers who gave birth in The Netherlands.

METHODS

We used a nationwide electronic medical records database from the community health services for asylum seekers (MOA). The study population consisted of 4,854 women and girls who delivered in asylum reception between 2000 and 2008. A unique electronic health data base was used and case allocation was based on ICPC-codes.

RESULTS

The number of women and girls that was HIV positive during their last pregnancy was 80, of which 79 originated from sub-Saharan Africa. The prevalence for women from this region of origin (3.4%) was high compared to women from all other regions of origin (0.04%; OR = 90.2; 95%CI 12.5-648.8). The highest HIV prevalence rates were found for women from Rwanda (17.0%) and Cameroon (13.2%). HIV prevalence rates were higher among women who arrived in reception without partner (OR = 1.82; 95%CI 0.75-4.44) and unaccompanied minors (OR = 2.59; 95%CI 0.79-8.49), compared to women who arrived in reception with partner.

CONCLUSIONS

We conclude that, among asylum-seeking women from sub-Saharan Africa giving birth in The Netherlands, the HIV prevalence is high compared to the host population. For women from other regions of origin, the prevalence is at the same level as in the host population. The high HIV prevalence underlines the importance of preventive interventions and voluntary HIV testing for sub-Saharan African asylum seekers as from shortly after arrival.

The Historiography of HIV and AIDS in Uganda

Uganda has been in the world headlines since the mid-1980s, first as a nation severely hit by HIV and AIDS, and later, from the late 1990s onwards, as the first country in sub-Saharan Africa that has managed to reverse a generalised HIV epidemic. Countless newspaper articles, television and radio documentaries and broadcasts, papers, books, and films have been produced about AIDS in Uganda, making the epidemic one of the most thoroughly researched and documented in the world. Medical doctors, virologists, epidemiologists and social and behavioral scientists, both Ugandan and expatriate, have produced massive amounts of scientific information about it since the early 1980s, in addition to which there have been policy papers, evaluation reports, and action plans produced by various government ministries, international donor agencies, and national and international NGOs and relief organizations which document the epidemic from administrative, developmental, and humanitarian perspectives.

Uganda's AIDS epidemic has been publicized worldwide through the news media and various international agencies. It is being constantly monitored not only by national authorities and international health experts, but by myriads of Ugandan and international organizations, media, academics, and concerned members of the public using modern means of communication. Some of these national and international bodies not only monitor, report and educate, but demand their say in how the epidemic should be managed. Uganda has become a testing ground for medical and behavioral interventions, as exemplified by AIDS vaccination trials, the social marketing of condoms, antiretroviral treatment, and, recently, by the male circumcision trial. Positive results have then been marketed to other countries in sub-Saharan Africa as successful AIDS prevention strategies.

HIV seroprevalence, associated risk behavior, and alcohol use among male Rwanda Defense Forces military personnel

A cross-sectional study was conducted among active-duty male soldiers, aged ≥21 years, in the Rwanda Defense Forces (RDF) and included an anonymous behavioral survey and HIV rapid testing to determine risk factors associated with HIV seroprevalence. Overall prevalence was 2.6 % (95 % CI: 1.84-3.66); personnel who were divorced, separated or widowed, served ≥6 years, never deployed, uncircumcised, reported STI symptoms, had ≥6 lifetime sex partners, or screened positive for harmful alcohol use (via Alcohol Use Disorders Identification Test) had higher HIV prevalence. Ever being divorced, separated or widowed (OR = 29.8; 95 % CI: 5.5-159.9), and STI symptoms (OR = 3.4; 95 % CI: 1.5-7.6) were significantly associated with infection, after multivariable adjustment, while circumcision was protective (OR = 0.4; 95 % CI: 0.2-0.9). Despite mobility and other factors that uniquely influence HIV transmission in militaries, RDF prevalence was similar to the general population. A reason for this finding may be conservative sexual behavior combined with effective leadership-supported prevention programs. Data suggest a concentrated rather than generalized epidemic, with targets identified for intervention.

Molecular and phylogeographic analysis of human immuno-deficiency virus type 1 strains infecting treatment-naive patients from Kigali, Rwanda

This study aimed at describing the genetic subtype distribution of HIV-1 strains circulating in Kigali and their epidemiological link with the HIV-1 strains from the five countries surrounding Rwanda. One hundred and thirty eight pol (RT and PR) sequences from 116 chronically- and 22 recently-infected antiretroviral therapy (ART)-naïve patients from Kigali were generated and subjected to HIV drug resistance (HIV-DR), phylogenetic and recombinant analyses in connection with 366 reference pol sequences from Rwanda, Burundi, Kenya, Democratic Republic of Congo, Tanzania and Uganda (Los Alamos database). Among the Rwandan samples, subtype A1 predominated (71.7%), followed by A1/C recombinants (18.1%), subtype C (5.8%), subtype D (2.9%), one A1/D recombinant (0.7%) and one unknown subtype (0.7%). Thirteen unique and three multiple A1/C recombinant forms were identified. No evidence for direct transmission events was found within the Rwandan strains. Molecular characteristics of HIV-1 were similar between chronically and recently-infected individuals and were not significantly associated with demographic or social factors. Our report suggests that the HIV-1 epidemic in Kigali is characterized by the emergence of A1/C recombinants and is not phylogenetically connected with the HIV-1 epidemic in the five neighboring countries. The relatively low level of transmitted HIV-DR mutations (2.9%) reported here indicates the good performance of the ART programme in Rwanda. However, the importance of promoting couples' counseling, testing and disclosure during HIV prevention strategies is highlighted.

Prevalence and concordance of HPV, HIV, and HSV-2 in heterosexual couples in Kigali, Rwanda

BACKGROUND

In the absence of prospectively collected transmission data, the transmission potential of a sexually transmissible infection (STI) can be estimated by its proxy of concordance in sexual partners. Here we report concordance data of 3 viral STIs: human papillomavirus (HPV), HIV, and herpes simplex virus type 2 (HSV-2) among heterosexual couples in Kigali, Rwanda.

METHODS

Cervical and penile HPV typing was performed among 166 community-sampled fertile couples in Kigali, Rwanda (median sampling interval 10 days (interquartile range: 5-36). HIV and HSV-2 serostatus, curable STIs, and sociobehavioral and clinical characteristics were also assessed.

RESULTS

Concordance rates for all 3 viral STIs were higher than expected by chance alone. Positive concordance among couples was 25% for HSV-2, 15.7% for any HPV, 8.4% for high-risk (HR)-HPV, and 6% for HIV. HR-HPV prevalence among women and men was 19.9% and 26.5%, respectively. Partner's HIV status was more strongly associated with HR-HPV detection in men (OR: 8.5; confidence interval: 2.9-24.6) than in women (OR: 1.9; confidence interval 0.5-6.7).

CONCLUSION

More than half of the couples were discordant for HIV, HPV, and/or HSV-2, indicating that prevention strategies directed to infected cases are important to protect their uninfected sexual partners.

Conceptual and methodological challenges to measuring political commitment to respond to HIV

Background

Researchers have long recognized the importance of a central government’s political “commitment” in order to mount an effective response to HIV. The concept of political commitment remains ill-defined, however, and little guidance has been given on how to measure this construct and its relationship with HIV-related outcomes. Several countries have experienced declines in HIV infection rates, but conceptual difficulties arise in linking these declines to political commitment as opposed to underlying social and behavioural factors.

Methods

This paper first presents a critical review of the literature on existing efforts to conceptualize and measure political commitment to respond to HIV and the linkages between political commitment and HIV-related outcomes. Based on the elements identified in this review, the paper then develops and presents a framework to assist researchers in making choices about how to assess a government's level of political commitment to respond to HIV and how to link political commitment to HIV-related outcomes.

Results

The review of existing studies identifies three components of commitment (expressed, institutional and budgetary commitment) as different dimensions along which commitment can be measured. The review also identifies normative and ideological aspects of commitment and a set of variables that mediate and moderate political commitment that need to be accounted for in order to draw valid inferences about the relationship between political commitment and HIV-related outcomes. The framework summarizes a set of steps that researchers can follow in order to assess a government's level of commitment to respond to HIV and suggests ways to apply the framework to country cases.

Conclusions

Whereas existing studies have adopted a limited and often ambiguous conception of political commitment, we argue that conceiving of political commitment along a greater number of dimensions will allow researchers to draw a more complete picture of political commitment to respond to HIV that avoids making invalid inferences about the relationship between political commitment and HIV outcomes.

High burden of prevalent and recently acquired HIV among female sex workers and female HIV voluntary testing center clients in Kigali, Rwanda

Objectives

To estimate HIV prevalence and risk factors in population-based samples of female sex workers (FSW) and female voluntary counseling and testing (VCT) clients in Rwanda.

Methods

We conducted a cross-sectional survey of 800 FSW and 1,250 female VCT clients in Rwanda, which included interviewing and testing for HIV-1/2, HSV-2 and pregnancy, and BED-CEIA and Avidity Index (AI) to identify recent infections among HIV-infected women.

Results

Prevalence of HIV-1, HSV-2, and pregnancy were 24% (95% CI: 21.0–27.0), 59.8% (56.4–63.2), and 7.6% (5.8–9.5) among FSW, and 12.8% (10.9–14.6), 43.2% (40.4–46.0), and 11.4% (9.7–13.3) among VCT clients, respectively. Thirty-five percent of FSW and 25% of VCT clients had never been HIV tested. Per national guidelines, 33% of newly HIV-diagnosed FSW and 36% of VCT clients were already eligible for ART based on CD4<350 cells/µl. Condom use at last sex was higher among FSW (74%) than VCT clients (12%). In age and district of residence-adjusted models, HIV-1 seropositivity was associated with HSV-2 co-infection; recent treatment for sexually transmitted infection (STI); genital symptoms; forced sex; imprisonment; widowhood; and alcohol consumption. Eleven percent of FSW and 12% of VCT clients had recently acquired HIV-1 per BED-CEIA and AI. HSV-2 infection and recent STI treatment were associated with recent HIV infection in both groups, and being married and vaginal cleansing were associated with recent infection before last sex among VCT clients.

Conclusions

This population-based survey reveals a high HIV prevalence and incidence among FSW and female VCT clients in Kigali, the scale of which is masked by the low general-population HIV prevalence in Rwanda. HIV/STI and family planning services should be strengthened.

Understanding locally, culturally, and contextually relevant mental health problems among Rwandan children and adolescents affected by HIV/AIDS

In assessing the mental health of HIV/AIDS-affected children and adolescents in Sub-Saharan Africa, researchers often employ mental health measures developed in other settings. However, measures derived from standard Western psychiatric criteria are frequently based on conceptual models of illness or terminology that may or may not be an appropriate for diverse populations. Understanding local perceptions of mental health problems can aid in the selection or creation of appropriate measures. This study used qualitative methodologies (Free Listing, Key Informant interviews, and Clinician Interviews) to understand local perceptions of mental health problems facing HIV/AIDS-affected youth in Rwinkwavu, Rwanda. Several syndrome terms were identified by participants: agahinda kenshi, kwiheba, guhangayika, ihahamuka, umushiha, and uburara. While these local syndromes share some similarities with Western mood, anxiety, and conduct disorders, they also contain important culture-specific features and gradations of severity. Our findings underscore the importance of understanding local manifestations of mental health syndromes when conducting mental health assessments and when planning interventions for HIV/AIDS-affected children and adolescents in diverse settings.

Spousal intimate partner violence is associated with HIV and Other STIs among married Rwandan women

HIV is a health problem in Rwanda, where the adult HIV prevalence is 3.1% (WHO 2008 in Online database of HIV/AIDS epidemiological data, found at: http://www.who.int/globalatlas ); the majority of those infected are women (UNAIDS 2008 in http://data.unaids.org/pub/Report/2008/rwanda_2008_country_progress_report_en.pdf ). Prior studies indicate that intimate partner violence is frequently associated with increased HIV risk in women, often because men who abuse their wives also exhibit riskier sexual behaviors (Silverman et al. in JAMA 300:703-710 2008. Population-based data from the 2005 Rwanda Demographic and Health Survey indicate that women with few, if any, other sexual risk factors who have experienced sexual, physical, or emotional abuse within their marriages are 1.61-3.46 times as likely to test positive for HIV, and 2.14-4.11 times more likely to report another STI. These findings confirm prior clinical studies that indicate that intimate partner violence is a correlate of HIV/STIs in Rwanda. Further research is needed to determine whether Rwandan men that abuse their wives have higher baseline rates of HIV/STI infection.

Couples' voluntary counselling and testing and nevirapine use in antenatal clinics in two African capitals: a prospective cohort study

Background

With the accessibility of prevention of mother to child transmission (PMTCT) services in sub-Saharan Africa, more women are being tested for HIV in antenatal care settings. Involving partners in the counselling and testing process could help prevent horizontal and vertical transmission of HIV. This study was conducted to assess the feasibility of couples' voluntary counseling and testing (CVCT) in antenatal care and to measure compliance with PMTCT.

Methods

A prospective cohort study was conducted over eight months at two public antenatal clinics in Kigali, Rwanda, and Lusaka, Zambia. A convenience sample of 3625 pregnant women was enrolled. Of these, 1054 women were lost to follow up. The intervention consisted of same-day individual voluntary counselling and testing (VCT) and weekend CVCT; HIV-positive participants received nevirapine tablets. In Kigali, nevirapine syrup was provided in the labour and delivery ward; in Lusaka, nevirapine syrup was supplied in pre-measured single-dose syringes. The main outcome measures were nurse midwife-recorded deliveries and reported nevirapine use.

Results

In eight months, 1940 women enrolled in Kigali (984 VCT, 956 CVCT) and 1685 women enrolled in Lusaka (1022 VCT, 663 CVCT). HIV prevalence was 14% in Kigali, and 27% in Lusaka. Loss to follow up was more common in Kigali than Lusaka (33% vs. 24%, p = 0.000). In Lusaka, HIV-positive and HIV-negative women had significantly different loss-to-follow-up rates (30% vs. 22%, p = 0.002). CVCT was associated with reduced loss to follow up: in Kigali, 31% of couples versus 36% of women testing alone (p = 0.011); and in Lusaka, 22% of couples versus 25% of women testing alone (p = 0.137). Among HIV-positive women with follow up, CVCT had no impact on nevirapine use (86-89% in Kigali; 78-79% in Lusaka).

Conclusions

Weekend CVCT, though new, was feasible in both capital cities. The beneficial impact of CVCT on loss to follow up was significant, while nevirapine compliance was similar in women tested alone or with their partners. Pre-measured nevirapine syrup syringes provided flexibility to HIV-positive mothers in Lusaka, but may have contributed to study loss to follow up. These two prevention interventions remain a challenge, with CVCT still operating without supportive government policy in Zambia.

Impact of an intensive HIV prevention programme for female sex workers on HIV prevalence among antenatal clinic attenders in Karnataka state, south India: an ecological analysis

OBJECTIVES

To examine the impact of an intensive HIV preventive intervention (IPI) among female sex workers (FSW) on community HIV transmission, as represented by HIV prevalence among young antenatal clinic (ANC) attenders in Karnataka state, south India.

METHODS

The IPI was initiated in 18 of the 27 districts in Karnataka in 2003, and was generally at scale by mid-2005, covering over 80% of the urban FSW population. We examined trends over time in HIV prevalence from annual HIV surveillance conducted among ANC attenders in Karnataka under the age of 25 years from 2003 to 2007, comparing the IPI with the other districts.

RESULTS

Overall, HIV prevalence among ANC attenders under 25 years of age declined from 1.40% to 0.77%. In a multivariate model, the decline in HIV prevalence in the IPI districts compared to the other districts was statistically significant (P = 0.01), with an adjusted annual odds ratio of 0.88 (95% CI 0.79-0.97). The decline in standardized HIV prevalence in the IPI districts over the period was 56%, compared to 5% in the non-IPI districts.

CONCLUSIONS

Although this analysis is limited by lack of precise comparative data on intervention coverage and intensity, it supports the notion that scaled-up, intensive, targeted HIV preventive interventions among high-risk groups can have a measurable and relatively rapid impact on HIV transmission in the general population, particularly young sexually active populations as represented by ANC attenders. Such focused intervention programmes should be rapidly taken to scale in all HIV epidemics, and especially in concentrated epidemics such as in India.

The role of in-migrants in the increasing rural HIV-1 epidemic: results from a village population survey in the Kilimanjaro region of Tanzania

OBJECTIVE

To investigate the magnitude of rural in-migration and the role of in-migrants in the observed increase in HIV-1 prevalence in rural Kilimanjaro, Tanzania.

METHODS

A cross-sectional study involving the adult population aged 15-44 years residing in a rural village was conducted from March to May of 2005. Participants were interviewed regarding their risk behaviors and gave blood for HIV-1 and syphilis testing.

RESULTS

Overall, the response rate was 73.0% (1528/2093). A total of 699 (48.1%) participants reported having in-migrated to the village at some point during their life. The prevalences of HIV-1 infection were 1.8%, 2.3%, and 3.7% among non-in-migrant, long-term in-migrant, and recent in-migrant men, respectively (p(trend)<0.001). The corresponding prevalences among women were 9.2%, 11.5%, and 14.5%, respectively (p(trend)=0.048). The odds of HIV-1 infection were higher among recent in-migrants as compared to non-in-migrants (men: adjusted odds ratio (AOR) 2.4, 95% CI 1.8-6.6; women: AOR 2.3, 95% CI 1.1-5.0). Risk behaviors were inversely related to years since in-migration for both sexes.

CONCLUSIONS

The results suggest that rural in-migration is common for both men and women. In-migrants were at higher risk for HIV-1 infection and contributed significantly to increased rural HIV-1 prevalence. More studies to examine the rate and broader causes of rural in-migration in similar communities are called for. These may help in the design of intervention strategies for curbing the rising rural HIV epidemic.

The effects of exercise training on quality of life in HAART-treated HIV-positive Rwandan subjects with body fat redistribution

OBJECTIVE

Our objective was to examine the effects of exercise training (EXS) on quality of life (QoL) in highly active antiretroviral therapy (HAART)-treated HIV-positive (HIV+) subjects with body fat redistribution (BFR) in Rwanda.

METHODS

The effects of a randomised controlled trial of EXS on QoL were measured using World Health Organisation Quality of Life (WHOQOL)-BREF in HIV+ subjects with BFR randomised to EXS (n = 50; BFR + EXS) or no exercise training (n = 50; BFR + noEXS).

RESULTS

At 6 months, scores on the psychological [1.3 (0.3) vs. 0.5 (0.1); P < 0.0001], independence [0.6 (0.1) vs. 0.0 (0.0); P < 0.0001], social relationships [0.6 (0.2) vs. 0.0 (0.0); P < 0.0001] and HIV HAART-specific QoL domains [1.4 (0.2) vs. -0.1 (0.2); P < 0.0001] improved more in BFR + EXS than BFR + noEXS group, respectively. Self-esteem [1.3 (0.8) vs. 0.1 (0.6); P < 0.001], body image [1.5 (0.6) vs. 0.0 (0.5); P < 0.001] and emotional stress [1.6 (0.7) vs. 0.2 (0.5); P < 0.001] improved more in the BFR + EXS group than BFR + noEXS group, respectively. Psychological [1.5 (0.2) vs. 1.1 (0.3); P < 0.0001], social relationship [0.8 (0.2) vs. 0.4 (0.2); P < 0.0001], and HIV HAART-specific well-being [1.8 (0.2) vs. 1.0 (0.0); P < 0.0001] improved more in BFR + EXS female than male subjects.

CONCLUSIONS

Exercise training improved several components of QoL in HAART-treated HIV+ African subjects with BFR. Exercise training is an inexpensive and efficacious strategy for improving QoL in HIV+ African subjects, which may improve HAART adherence and treatment initiatives in resource-limited areas of sub-Saharan Africa.

Lost opportunities in HIV prevention: programmes miss places where exposures are highest

Background

Efforts at HIV prevention that focus on high risk places might be more effective and less stigmatizing than those targeting high risk groups. The objective of the present study was to assess risk behaviour patterns, signs of current preventive interventions and apparent gaps in places where the risk of HIV transmission is high and in communities with high HIV prevalence.

Methods

The PLACE method was used to collect data. Inhabitants of selected communities in Lusaka and Livingstone were interviewed about where people met new sexual partners. Signs of HIV preventive activities in these places were recorded. At selected venues, people were interviewed about their sexual behaviour. Peer educators and staff of NGOs were also interviewed.

Results

The places identified were mostly bars, restaurants or sherbeens, and fewer than 20% reported any HIV preventive activity such as meetings, pamphlets or posters. In 43% of places in Livingstone and 26% in Lusaka, condoms were never available. There were few active peer educators. Among the 432 persons in Lusaka and 676 in Livingstone who were invited for interview about sexual behaviour, consistent condom use was relatively high in Lusaka (77%) but low in Livingstone (44% of men and 34% of women). Having no condom available was the most common reason for not using one. Condom use in Livingstone was higher among individuals socializing in places where condoms always were available.

Conclusion

In the places studied we found a high prevalence of behaviours with a high potential for HIV transmission but few signs of HIV preventive interventions. Covering the gaps in prevention in these high exposure places should be given the highest priority.

Metabolic function and the prevalence of lipodystrophy in a population of HIV-infected African subjects receiving highly active antiretroviral therapy

OBJECTIVE

This study measured the prevalence of lipodystrophy and the metabolic effects of highly active antiretroviral therapy (HAART) in HIV-infected African subjects.

METHODS

Prevalence was measured in 571 Rwandans receiving HAART for > or = 6 months. Metabolic variables were measured in 100 HIV-positive adults with lipodystrophy, 50 HIV-positive nonlipodystrophic adults, and 50 HIV-negative controls.

RESULTS

A HAART regimen of stavudine, lamivudine, and nevirapine was used by 81.6% of subjects; none received protease inhibitors. Lipodystrophy was observed in 34% (48.5% in urban groups and 17.3% in rural groups) of subjects, with a prevalence of 69.6% in those receiving HAART for >72 weeks. Peripheral lipoatrophy combined with abdominal lipohypertrophy was observed in 72% of lipodystrophic subjects. HIV-positive adults with lipodystrophy had a significantly higher waist-to-hip ratio (WHR; 0.99 +/- 0.05 vs. 0.84 +/- 0.03: P < 0.0005) than HIV-positive nonlipodystrophic adults. Total cholesterol concentrations (median [interquartile range], mmol/L) were significantly higher in the HIV-positive adults with lipodystrophy (3.60 [1.38]) than in HIV-positive nonlipodystrophic adults (3.19 [0.65]; P < 0.005) and control (3.13 [0.70]; P < 0.0005) groups. Impaired fasting glucose was observed in 18% of HIV-positive adults with lipodystrophy, 16% of HIV-positive nonlipodystrophic adults, and 2% of controls, but insulin levels did not differ.

CONCLUSIONS

African subjects with lipodystrophy have increased WHR, glucose, and cholesterol levels. Glucose concentrations are also elevated in nonlipodystrophic HIV-positive subjects. Therefore, factors other than body fat redistribution contribute to the glucose intolerance.

Trends in HIV-1 prevalence and risk behaviours over 15 years in a rural population in Kilimanjaro region of Tanzania

Background

Monitoring dynamics in HIV-1 infection and risk behaviours is important in evaluating, adjusting and scaling up prevention programmes. The objective of this study was to estimate trends in the prevalence of HIV-1 infection and risk behaviours over 15 years in a rural village population in Kilimanjaro region of Tanzania using repeated population-based cross-sectional surveys.

Methods

Four rounds of HIV-1 sero-epidemiological and behavioural surveys were completed during 1991 to 2005 in the study village. House-to-house registrations of people aged 15–44 years with an address in the village were conducted before each survey. All consenting individuals were then interviewed for pertinent risk behaviours and tested for HIV-1 seropositivity.

Results

Participation proportions ranged from 73.0% to 79.1%. Overall, age and sex-adjusted HIV-1 prevalence increased from 3.2% in 1991 to 5.6 % in 2005 (relative increase 75.0%; p_trend < 0.001). The increase was significant for both men and women (p_trends < 0.001) and more evident among women aged 35–44 years (2.0% to 13.0%, p_trend < 0.001). Among participants aged 15–24 years a decrease in number of sexual partners was observed with a corresponding stable HIV-1 prevalence. Participants aged 25–44 years continued to report multiple sexual partners, and this was corroborated with increased HIV-1 prevalence trend (4.0% to 9.0%, p_trends < 0.001). Among men aged 25–44 years and women aged 15–24 years significant increases in condom use were observed (p_trend < 0.01).

Conclusion

The HIV-1 prevalence seems to have increased among older participants but remained stable among younger participants. Encouraging trends toward safer sex practices were observed among young participants, while only modest behavioural changes were seen among the older participants. Prevention efforts in rural areas need to be intensified and to address people of all ages.

Global epidemiology of HIV-AIDS

Although intravenous drug use is the major route of transmission in several countries, sexual transmission is the dominant mode of HIV spread globally, with a concomitant epidemic in infants borne to HIV-infected mothers. The HIV epidemic varies substantially from one geographic area to another, and three broad epidemic categories describe the diversity of features observed globally: low epidemic settings, centrzated epidemics, and generalized epidemics. The introduction of highly active antiretroviral therapy in industrialized countries has transformed AIDS from an inevitably fatal condition to a chronic, treatable condition, but this goal has yet to be realized in most resource-constrained settings that bear a disproportionate burden of infection. This article describes the modes of HIV transmission, geographic distribution of the evolving AIDS pandemic, and case studies of each of the three types of HIV epidemics, and presents global trends in AIDS and mortality.

Prevalence of HIV infection in conflict-affected and displaced people in seven sub-Saharan African countries: a systematic review

BACKGROUND

Violence and rape are believed to fuel the HIV epidemic in countries affected by conflict. We compared HIV prevalence in populations directly affected by conflict with that in those not directly affected and in refugees versus the nearest surrounding host communities in sub-Saharan African countries.

METHODS

Seven countries affected by conflict (Democratic Republic of Congo, southern Sudan, Rwanda, Uganda, Sierra Leone, Somalia, and Burundi) were chosen since HIV prevalence surveys within the past 5 years had been done and data, including original antenatal-care sentinel surveillance data, were available. We did a systematic and comprehensive literature search using Medline and Embase. Only articles and reports that contained original data for prevalence of HIV infection were included. All survey reports were independently evaluated by two epidemiologists to assess internationally accepted guidelines for HIV sentinel surveillance and population-based surveys. Whenever possible, data from the nearest antenatal care and host country sentinel site of the neighbouring countries were presented. 95% CIs were provided when available.

FINDINGS

Of the 295 articles that met our search criteria, 88 had original prevalence data and 65 had data from the seven selected countries. Data from these countries did not show an increase in prevalence of HIV infection during periods of conflict, irrespective of prevalence when conflict began. Prevalence in urban areas affected by conflict decreased in Burundi, Rwanda, and Uganda at similar rates to urban areas unaffected by conflict in their respective countries. Prevalence in conflict-affected rural areas remained low and fairly stable in these countries. Of the 12 sets of refugee camps, nine had a lower prevalence of HIV infection, two a similar prevalence, and one a higher prevalence than their respective host communities. Despite wide-scale rape in many countries, there are no data to show that rape increased prevalence of HIV infection at the population level.

INTERPRETATION

We have shown that there is a need for mechanisms to provide time-sensitive information on the effect of conflict on incidence of HIV infection, since we found insufficient data to support the assertions that conflict, forced displacement, and wide-scale rape increase prevalence or that refugees spread HIV infection in host communities.

Declines in HIV prevalence can be associated with changing sexual behaviour in Uganda, urban Kenya, Zimbabwe, and urban Haiti

OBJECTIVE

To determine whether observed changes in HIV prevalence in countries with generalised HIV epidemics are associated with changes in sexual risk behaviour.

METHODS

A mathematical model was developed to explore the relation between prevalence recorded at antenatal clinics (ANCs) and the pattern of incidence of infection throughout the population. To create a null model a range of assumptions about sexual behaviour, natural history of infection, and sampling biases in ANC populations were explored to determine which factors maximised declines in prevalence in the absence of behaviour change. Modelled prevalence, where possible based on locally collected behavioural data, was compared with the observed prevalence data in urban Haiti, urban Kenya, urban Cote d'Ivoire, Malawi, Zimbabwe, Rwanda, Uganda, and urban Ethiopia.

RESULTS

Recent downturns in prevalence observed in urban Kenya, Zimbabwe, and urban Haiti, like Uganda before them, could only be replicated in the model through reductions in risk associated with changes in behaviour. In contrast, prevalence trends in urban Cote d'Ivoire, Malawi, urban Ethiopia, and Rwanda show no signs of changed sexual behaviour.

CONCLUSIONS

Changes in patterns of HIV prevalence in urban Kenya, Zimbabwe, and urban Haiti are quite recent and caution is required because of doubts over the accuracy and representativeness of these estimates. Nonetheless, the observed changes are consistent with behaviour change and not the natural course of the HIV epidemic.