Jean Pierre Nyemazi

Rwanda 20 years on: investing in life

Two decades ago, the genocide against the Tutsis in Rwanda led to the deaths of 1 million people, and the displacement of millions more. Injury and trauma were followed by the effects of a devastated health system and economy. In the years that followed, a new course set by a new government set into motion equity-oriented national policies focusing on social cohesion and people-centred development. Premature mortality rates have fallen precipitously in recent years, and life expectancy has doubled since the mid-1990s. Here we reflect on the lessons learned in rebuilding Rwandas health sector during the past two decades, as the country now prepares itself to take on new challenges in health-care delivery.

Multi-Country Analysis of Treatment Costs for HIV/AIDS (MATCH): Facility-Level ART Unit Cost Analysis in Ethiopia, Malawi, Rwanda, South Africa and Zambia

Background Todays uncertain HIV funding landscape threatens to slow progress towards treatment goals. Understanding the costs of antiretroviral therapy (ART) will be essential for governments to make informed policy decisions about the pace of scale-up under the 2013 WHO HIV Treatment Guidelines, which increase the number of people eligible for treatment from 17.6 million to 28.6 million. The study presented here is one of the largest of its kind and the first to describe the facility-level cost of ART in a random sample of facilities in Ethiopia, Malawi, Rwanda, South Africa and Zambia. Methods & Findings In 2010–2011, comprehensive data on one year of facility-level ART costs and patient outcomes were collected from 161 facilities, selected using stratified random sampling. Overall, facility-level ART costs were significantly lower than expected in four of the five countries, with a simple average of

Cell phone-based and internet-based monitoring and evaluation of the National Antiretroviral Treatment Program during rapid scale-up in Rwanda: TRACnet 2004-2010.

208 per patient-year (ppy) across Ethiopia, Malawi, Rwanda and Zambia. Costs were higher in South Africa, at

Shared learning in an interconnected world: innovations to advance global health equity

682 ppy. This included medications, laboratory services, direct and indirect personnel, patient support, equipment and administrative services. Facilities demonstrated the ability to retain patients alive and on treatment at these costs, although outcomes for established patients (2–8% annual loss to follow-up or death) were better than outcomes for new patients in their first year of ART (77–95% alive and on treatment). Conclusions This study illustrated that the facility-level costs of ART are lower than previously understood in these five countries. While limitations must be considered, and costs will vary across countries, this suggests that expanded treatment coverage may be affordable. Further research is needed to understand investment costs of treatment scale-up, non-facility costs and opportunities for more efficient resource allocation.

HIV-free survival among nine- to 24-month-old children born to HIV-positive mothers in the Rwandan national PMTCT programme: a community-based household survey

Background:Monitoring and evaluation of antiretroviral treatment (ART) scale-up has been challenging in resource-limited settings. We describe an innovative cell-phone-based and internet-based reporting system (TRACnet) utilized in Rwanda. Methods:From January 2004 to June 30, 2010, all health facilities with ART services submitted standardized monthly aggregate reports of key indicators. National cohort data were analyzed to examine trends in characteristics of patients initiating ART and cumulative cohort outcomes. Estimates of HIV-infected patients eligible for ART were obtained from Joint United Nations Program on HIV/AIDS (Estimation and Projection Package-Spectrum, 2010). Results:By June 30, 2010, 295 (65%) of 451 health centers, District and referral hospitals provided ART services; of these, 255 (86%) were located outside Kigali, the capital. Cell phone–based and internet-based reporting was used by 253 (86%) and 42 (14%), respectively. As of June 30, 2010, 83,041 patients were alive on ART, 6171 (6%) had died, and 9621 (10%) were lost-to-follow-up. Of those alive on ART, 7111 (8.6%) were children, 50,971 (61.4%) were female, and 1823 (2.2%) were on a second-line regimen. The proportion of all patients initiating ART at World Health Organization clinical stages 3 and 4 declined from 65% in 2005 to 27% in 2010. National ART coverage of eligible patients increased from 13% in 2005 to 79% in 2010. Conclusions:Rwanda has successfully expanded ART access and achieved high national ART coverage among eligible patients. TRACnet captured essential data about the ART program during rapid scale-up. Cell phone-based and internet-based reporting may be useful for monitoring and evaluation of similar public health initiatives in other resource-limited settings.

High retention among HIV-infected children in Rwanda during scale-up and decentralization of HIV Care and treatment programs 2004 to 2010

The notion of “reverse innovation”--that some insights from low-income countries might offer transferable lessons for wealthier contexts--is increasingly common in the global health and business strategy literature. Yet the perspectives of researchers and policymakers in settings where these innovations are developed have been largely absent from the discussion to date. In this Commentary, we present examples of programmatic, technological, and research-based innovations from Rwanda, and offer reflections on how the global health community might leverage innovative partnerships for shared learning and improved health outcomes in all countries.

Taking health systems research to the district level: a new approach to accelerate progress in global health

BackgroundOperational effectiveness of large-scale national programmes for the prevention of mother to child transmission (PMTCT) of HIV in sub-Saharan Africa remains limited. We report on HIV-free survival among nine- to 24-month-old children born to HIV-positive mothers in the national PMTCT programme in Rwanda.MethodsWe conducted a national representative household survey between February and May 2009. Participants were mothers who had attended antenatal care at least once during their most recent pregnancy, and whose children were aged nine to 24 months. A two-stage stratified (geographic location of PMTCT site, maternal HIV status during pregnancy) cluster sampling was used to select mother-infant pairs to be interviewed during household visits. Alive children born from HIV-positive mothers (HIV-exposed children) were tested for HIV according to routine HIV testing protocol. We calculated HIV-free survival at nine to 24 months. We subsequently determined factors associated with mother to child transmission of HIV, child death and HIV-free survival using logistic regression.ResultsOut of 1448 HIV-exposed children surveyed, 44 (3.0%) were reported dead by nine months of age. Of the 1340 children alive, 53 (4.0%) tested HIV positive. HIV-free survival was estimated at 91.9% (95% confidence interval: 90.4-93.3%) at nine to 24 months. Adjusting for maternal, child and health system factors, being a member of an association of people living with HIV (adjusted odds ratio: 0.7, 95% CI: 0.1-0.995) improved by 30% HIV-free survival among children, whereas the maternal use of a highly active antiretroviral therapy (HAART) regimen for PMTCT (aOR: 0.6, 95% CI: 0.3-1.07) had a borderline effect.ConclusionsHIV-free survival among HIV-exposed children aged nine to 24 months is estimated at 91.9% in Rwanda. The national PMTCT programme could achieve greater impact on child survival by ensuring access to HAART for all HIV-positive pregnant women in need, improving the quality of the programme in rural areas, and strengthening linkages with community-based support systems, including associations of people living with HIV.

Transitioning to Country Ownership of HIV Programs in Rwanda

Background: Efforts to scale-up HIV treatment in high burden countries have resulted in wider access to care, improved survival and decreased morbidity for HIV-infected children. The country of Rwanda has made significant achievements in expanding coverage of pediatric HIV services. Methods: We describe the extent of and factors associated with mortality and lost to follow-up (LTF) in children (<15 years) enrolled in HIV care at 39 ICAP-supported facilities across Rwanda from 2004 to 2010 by antiretroviral treatment (ART) status. We estimated the 1-year cumulative incidence of death and LTF among all children enrolled in care (pre-ART) and children on ART. Survival analysis was used to evaluate factors associated with death and LTF in both groups. Results: Between January 2004 and June 2010, 3244 children with a median age of 5.7 years (interquartile range 2.8–9.6) enrolled in HIV care. One-year cumulative incidence for death and LTF among pre-ART children was 4% (95% confidence interval [CI]: 3–5%) and 5% (95% CI: 4–6%), respectively. Overall, 2035 (63%) children initiated ART, median age 6.3 years (interquartile range 3.3–10.4): 1-year Kaplan–Meier estimates of death and LTF were 3% (95% CI: 3–4%) and 1% (95% CI: 1–2%), respectively. Factors associated with an increased hazard for death among pre-ART children included being <18 months old versus ≥5 years (adjusted sub hazard ratio [aSHR] = 4.4, 95% CI: 2.9–6.8) and World Health Organization stage IV versus I (aSHR = 4.1, 95% CI: 2.0–8.4), whereas children entering care through prevention of mother-to-child transmission had lower hazard than those from voluntary counseling and testing (aSHR = 0.50, 95% CI: 0.25–1.0). Markers of advanced disease, including severe immunosuppression (aSHR = 0.25, 95% CI: 0.12–0.54), and enrollment in care in rural versus urban clinics (aSHR = 0.71, 95% CI: 0.53–0.97) were protective against LTF. For children on ART, factors associated with hazard of death included younger age (adjusted hazard ratio [aHR] <18 months versus ≥5 years = 2.1, 95% CI: 1.3–3.6), severe malnutrition versus not malnourished (aHR = 3.2, 95% CI: 1.3–8.1), advanced World Health Organization stage (aHR IV versus I = 9.8, 95% CI: 3.5–27.4) and severe immunodeficiency versus no evidence (aHR = 2.3, 95% CI: 1.7–3.3). No associations were observed with LTF among children on ART. Conclusions: The results demonstrate very high retention among children enrolled in HIV care in Rwanda. Younger children continue to be particularly vulnerable, underscoring the urgent need for early identification, rapid treatment initiation and long-term retention in care.

Moving the goalposts for tuberculosis targets in Africa

The world recently marked the tenth anniversaries of the launch of both The Global Fund to Fight AIDS, Tuberculosis, and Malaria and the United States President’s Emergency Plan for AIDS Relief (PEPFAR). A decade ago, few could have possibly imagined how different the world would look today from the future we feared — a future where the country where one lived determined if one lived and where the rich increasingly tried to seal themselves off from the poor. Due to the courage of tens of thousands of activists across the globe who put their bodies on the line, the innovation of scientists who refused to relent in the face of complexity, and the vision of policymakers across six continents who imagined a more just and healthy future, we live today in a world that has started to be defined more by our connections than our differences. This is global health: We have come a long way, but the work is not finished. As the world learned through the challenge of scaling up access to prevention, care, and treatment for HIV, tuberculosis, and malaria in countries with sparse health infrastructure, simply having the tools is not enough. Bypassing the public sector — weak as it might be at the outset — to get pills to patients faster may have been easier and did address some of the symptoms of decades of nonexistent access to quality health care. But this approach could never guarantee the poorest and most vulnerable access to health as a right[1]. That, it is now clear, requires a financially and geographically accessible health system complete with robust supply chains, an adequately staffed workforce with the right skill level and skill mix, and feedback loops driven by information and research — all rooted in the foundation of accountability provided by a strong and transparent public sector is required [2].

Discrepant estimates of key indicators for Millennium Development Goals 4 and 5: the public sector's experience in Rwanda

Agnes Binagwaho and colleagues describe how Rwanda achieved country ownership of its HIV programs.