Country Spotlight: Rwanda

Country Overview

The Elizabeth Glaser Pediatric AIDS Foundation (EGPAF) began its support for HIV clinical services in Rwanda in 2001 with technical and financial support to the Treatment and Research AIDS Center (today known as the Rwanda Biomedical Center [RBC]) for scale-up of Rwanda’s prevention of mother-to-child transmission of HIV (PMTCT) program. The HIV Clinical Services Program (HSCP), funded by the U.S. Agency for International Development (USAID) and the President’s Emergency Plan for AIDS Relief (PEPFAR) began in June 2007. Under the HCSP, EGPAF was the lead PEPFAR technical partner in the Eastern Province of Rwanda, working closely with Rwandan governmental institutions at the district level, the Ministry of Health (MOH), other partners, and local organizations.

James Pursey/EGPAF

Our Work in Rwanda

EGPAF/Rwanda’s HIV program was developed to respond to Rwanda’s development vision for its health programs, which is comprised of a strategic plan (Rwanda Vision 2020), the Economic Development and Poverty Reduction Strategy (EDPRS), and other health sector strategies. The program also is aligned with donor mandates and bilateral accords such as the partnership framework between the U.S. and Rwandan Governments that focuses on HIV/AIDS prevention; care and treatment; quality of care; health systems strengthening (HSS); and transitioning of financial and technical management capacity to local institutions.

EGPAF/Rwanda assists in implementing comprehensive, integrated HIV clinical services at the site and central levels, providing technical expertise to health institutions to build their capacity to maintain high-quality HIV services in their districts. These include:

EGPAF also ensures that districts and sites can efficiently manage and disburse funds they receive through sub-agreements.

Finally, EGPAF/Rwanda is committed to sustainable, locally-owned programs, and works closely with the MOH, districts, and health facilities to address priorities and build local staff capacity. To this end, EGPAF/Rwanda offers grants, mentorship, and training to districts, health facilities, and community members.

As of September 30, 2012, EGPAF-supported programs in Rwanda have:

Key Projects in Rwanda

Food and Nutrition Interventions for People Living with HIV/AIDS -The USAID Ibyiringiro Project (USAID/CRS: 2008-2013)

The Ibyiringiro project’s goal is to provide food, livelihood and nutrition interventions for people living with HIV/AIDS. The project will address impediments to improving the livelihood security and resiliency of households impacted by HIV and AIDS. These include:

  • Lack of available resources to expand the quantity and quality of services to people living with HIV and orphans and vulnerable children (OVC) households already receiving food rations;
  • Lack of strong community-based organizations to consistently support people living with HIV and OVC;
  • Insufficient economic opportunities for people living with HIV and OVC households;
  • Insufficient weaning food and targeted nutrition education to HIV-positive mothers to prevent the transmission of HIV to their infants after six months of exclusive breastfeeding.

Funded by USAID and PEPFAR and led by Catholic Relief Services (CRS), EGPAF’s role is to improve the nutritional status of infants and mothers enrolled in prevention of mother-to-child transmission of HIV (PMTCT) programs through improved access to fortified weaning foods. As the lead PMTCT partner, EGPAF has:

  • Developed/adapted behavior change communication and technical support tools on maternal nutrition and infant and young child feeding (IYCF) in the context of HIV;
  • Conducted trainings for and supportive supervision of health care providers and community health workers;
  • Extended IYCF counseling and support to community-based health services and people living with HIV/AIDS groups.

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A Secondary Analysis of Retention Across the PMTCT Cascade in Selected Countries Implementing the Various Guidelines. Kenya: Option A; Swaziland: Option A; Rwanda: Option B; Malawi: Option B+ (USAID/Population Council: 2011-2014)

This PEPFAR-funded HIVCORE study is a retrospective cohort analysis of mother-infant pair retention in prevention of mother-to-child transmission of HIV (PMTCT) services from antenatal clinic through 18 months postpartum in four selected EGPAF-supported country programs that are implementing Option A, Option B, or Option B+ for PMTCT. The study is being conducted in selected urban, semi-urban, and rural facilities in Malawi, Rwanda, Kenya, and Swaziland. The primary objectives of the study are to determine:

  • What are the levels of retention 30 days after entry into the PMTCT program, at delivery, six weeks, two months (60 days), three months (90 days), six months, and 12 months post-delivery among women and infants on Option A and on Option B/B+?
  • How do the levels of retention vary by facility characteristics such as type of facility, higher versus lower volume PMTCT facility, rural/urban facility, and presence and type of follow-up (active/passive) among women and infants on Option A and on Option B/B+?
  • How do the levels of retention vary by demographic and clinical characteristics among women and infants on Option A and on Option B/B+?
  • What are the most modifiable characteristics associated with retention in Option A and in Option B/B+ sites?

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Kigali Antiretroviral and Breastfeeding Assessment for the Elimination of HIV (Kabeho Study) (USAID/PEPFAR: 2012-2015)

In 2010, the World Health Organization (WHO) released a series of guidelines for the prevention of mother-to-child transmission of HIV (PMTCT) with a focus on infant feeding guidance and on the use of antiretrovirals (ARVs) to make extended breastfeeding a safe option for HIV-positive women and children to optimize HIV-free survival. The Government of Rwanda (GoR) rapidly implemented a policy to initiate all HIV-positive women, regardless of CD4 count, on triple antiretroviral drugs for treatment/prophylaxis during pregnancy and through 18 months of breastfeeding followed by discontinuation for those not eligible for treatment (Option B). However, in June 2012 the country transitioned to a modified version where all HIV-positive women would be initiated on lifelong antiretroviral treatment (ART) (known as Option B+). In addition, the GoR provides an innovative infant feeding counseling and support program for HIV-positive women in the PMTCT programs. Determining the effectiveness of the Rwanda program, and the challenges and successes in its implementation, will provide critical information to the GoR as well as to the PMTCT field, particularly as there is no data on the use of Option B+ for PMTCT.

The Kabeho Study will take advantage of this unique research opportunity to determine 18-month HIV-free survival in a cohort of children born to HIV-positive pregnant women receiving universal lifelong ART (PMTCT Option B+), coupled with comprehensive infant feeding counseling and support, in selected high-volume antenatal clinic sites in Kigali, Rwanda. Also, individual and facility-level factors associated with optimal infant nutritional outcomes and with adherence to the universal ARV regimen among pregnant and postpartum women (Option B+) and their HIV-exposed children in the first 18 months postpartum will be determined. The study will utilize a prospective observational cohort design, and obtain individual and facility data through a mixed-methods approach with both quantitative and qualitative data. In addition, interviews with healthcare providers and PMTCT program leaders will be conducted to assess implementation successes and challenges and gather recommendations. The Elizabeth Glaser Pediatric AIDS Foundation (EGPAF) will lead implementation of the study in collaboration with our study partners and collaborating institutions including the National University of Rwanda, School of Public Health (NURSPH), the Rwanda Ministry of Health (MOH), the Rwanda Biomedical Center/Institute for HIV, Diseases and Control (RBC/IHDPC) and George Washington University School of Public Health and Health Services.

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Rwanda Family Health Program (USAID/Chemonics: 2012-2016)

The Rwanda Family Health Project works closely with local partners to improve and expand community-based family health services. Family health services include an integrated package of services related to family planning and reproductive health, HIV/AIDS, maternal, neonatal and child health, malaria prevention and treatment, nutrition, safe water and hygiene, and tuberculosis treatment. As a sub-grantee to Chemonics, EGPAF leads technical assistance efforts around:  

  • Adult and pediatric HIV/AIDS prevention, care, and treatment;
  • Tuberculosis;
  • Maternal and child health;
  • Nutrition;
  • Quality assurance.

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Call to Action (USAID/PEPFAR: 2002-2010)

Through funding from the United States Agency for International Development (USAID) and the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR), EGPAF implemented the eight‐year global Call to Action (CTA) project in 12 countries, including Rwanda (from 2004 through 2007). This project sought to improve access and expand care and support for quality prevention of mother-to-child transmission of HIV (PMTCT) services, while enhancing technical leadership and documenting successful program models. By project end, EGPAF had provided nearly four million women with access to PMTCT and antenatal care services.

In Rwanda, the CTA project supported healthcare facilities and non-governmental and community-based organizations in planning, implementing and/or expanding PMTCT programs. The CTA project also provided funding for community mobilization, training of health care workers, HIV counseling and testing, antiretroviral prevention regimens, and infant feeding education. Implemented within existing maternal child health settings, CTA helped enhance the general care of women and children in Rwanda and incorporated simple yet effective HIV preventative interventions into existing health care settings.

At the end of December 2007, EGPAF was supporting 35 health facilities. Among these facilities were six district hospitals, five maternity centers offering PMTCT services, 23 health centers offering PMTCT services, 28 facilities offering voluntary counseling and testing (VCT), and 19 facilities offering antiretroviral therapy (ART) services.

The successes of the CTA Project in Rwanda are notable: By project end, over 67,898 pregnant women were tested. Notably, nearly 100% returned for results. Through collaboration with local partners, EGPAF consistently promoted the use of the “Carte de Liaison” (a prenatal card), which notes whether the mother is eligible for prophylaxis. A majority of mothers presented with their cards during supervisory visits; consequently, the exposed infants were more easily identified and followed up for testing. Within the services of PMTCT, all HIV-positive women were referred for family planning services (except in the faith-based sites, which refer for family planning). EGPAF also led an HIV-family planning (FP) integration work group, which defined a model of HIV-FP integration that was used to train all facility nurses, including those in PMTCT, ART, VCT and infant follow-up services, to refill oral and injectable contraceptives during other visits.

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HIV Clinical Services Program (USAID/PEPFAR: 2007-2012)

Read the HIV Clinical Services Program End-of-Project Report

As one of the five PEPFAR HIV/AIDS clinical services partners in Rwanda, EGPAF was the lead provider of valuable HIV/AIDS support in the Eastern Rwandan province under this program, and extended support to a number of facilities in the city of Kigali. The project sought to strengthen management at the district, hospital, and health center levels with training, accountability, and partnership. EGPAF provided direct assistance to more than 45 districts and health facilities to support integrated HIV/primary health care networks through performance-based sub-grantee agreements. The project also sought to strengthen the network of care, integrate HIV and related health services and link HIV services to community programs and resources to contribute towards universal access to HIV clinical services. Furthermore, this program provided technical assistance on a national level for family planning/HIV, infant nutrition, pediatric care and treatment, prevention of mother-to-child transmission of HIV (PMTCT), and continued quality improvement. To accomplish the project’s goals, the Clinical Services Program:

  • Diminished barriers to access by maximally decentralizing HIV care services;
  • Assisted health facilities and districts to closely monitor and evaluate their health services to improve their performance;
  • Strengthened referrals within and outside of the health system;
  • Built highly performing partnerships and teams with all stakeholders to maximally support district health networks, appreciating the need for trust, collaboration, full information, and mutual responsibility across organizations and governments

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Health seeking behaviors of pregnant women in Rwanda: Contributing factors towards high drop out of pregnant women between 1st and 4th ANC visit (USAID: 2012)

Current guidance from the World Health Organization (WHO) recommends that pregnant women have a minimum of four focused antenatal care (FANC) visits during the time of their pregnancy, beginning in the first trimester. While 98 percent of pregnant women in Rwanda attend at least one ANC visit, less than 35 percent attend all four recommended visits, and only 38 percent come for their first visit during their first trimester. In addition, we see that 55 percent of HIV-positive women coming to EGPAF-supported sites for ANC were aware of their HIV-positive status at the time of their first ANC visit. Through interviews with women bringing their infants to vaccination clinics or coming to the health facility for antiretroviral (ART) services, this exploratory study aims to understand the reasons why women come late to ANC, why they come for less than four visits, and whether the pregnancies of known HIV-positive women are planned.

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Integration of HIV Services into Maternal and Child Health: A Post Implementation Evaluation of "One-Stop Model" in Rwanda (USAID: 2012)

EGPAF, in partnership with the Maternal and Child Health (MCH) department in the Ministry of Health (MOH), the HIV Division of the RBC/IHDPC, district hospitals, and selected health centers, developed a “one-stop model” to support the integration of MCH and HIV services. Prior to the one-stop model, clients received different services on different days from different providers. Under the integrated model, the woman-infant pair could receive all of these services on the same day, at the same appointment, from the same provider.

In 2010, an assessment was conducted in five selected health centers in three districts in the Eastern Province to determine the level of service integration that existed. The findings of the assessment were discussed at the district level and were used to inform the design of the model, the aim of which is to provide mother-child pairs with a comprehensive and integrated package of MCH-HIV services. The model has now been piloted for at least a year in each of the five health centers, and the evaluation being conducted by EGPAF is intended to assess how the implementation of the model was carried out, to determine the perceptions of the different stakeholders, and to make recommendations for possible scale-up of the model throughout Rwanda.

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Publications

Country adaptation of the 2010 World Health Organization recommendations for the prevention of mother-to-child transmission of HIV (2012): Download PDF download

Developing an Integrated MIYCN/PMTCT Counseling Package in Rwanda: From Harmonization to Implementation (2012): Download PDF download

Improving Quality of HIV Services in Rwanda: The Elizabeth Glaser Pediatric AIDS Foundation Experience (2012): Download PDF download