Rwanda faces a generalized epidemic, with an HIV prevalence rate of 3.1 percent among adults ages 15 to 49. The prevalence rate has remained relatively stable, with an overall decline since the late 1990s, partly due to improved HIV surveillance methodology. In general, HIV prevalence is higher in urban areas than in rural areas, and women are at higher risk of HIV infection than men. Young women ages 15 to 24 are twice as likely to be infected with HIV as young men in the same age group. Populations at higher risk of HIV infection include people in prostitution and men attending clinics for sexually transmitted infections.
Rwanda is among the world's least developed countries, ranking 160 of 189 in the United Nations Development Program's 2019 Human Development Index. Some 60 percent of the population lives in poverty. During the three months of genocide in 1994, mass rape, sexual torture and psychological trauma were common. Massive population flows following the Rwandan genocide of 1994 have resulted in an increase in the urban population. The shortage of human resources throughout the health sector is a significant constraint. Of Rwandans killed or displaced during the genocide, a disproportionate number were highly skilled and educated members of society, including doctors, nurses and other health workers. Many health centers lack essential physical facilities, equipment and supplies. Electricity supply is erratic throughout Rwanda, affecting hospitals, health centers and laboratories. Blood safety, data management and drug storage are all impacted by the erratic electricity supply. While stigma continues to be a problem for people living with HIV/AIDS, the situation is slowly improving due to good information sharing at all levels about HIV/AIDS."2008 Country Profile: Rwanda". U.S. Department of State (2008). Accessed August 25, 2008. The President Paul Kagame has made many efforts in improving the situation, through different awareness raising initiatives." HIV/AIDS, Malaria and Other Diseases" UN in Rwanda (2014) Accessed May 20, 2016.
Overview
History and emergence in Africa Acquired immune deficiency syndrome (AIDS) is a disease comprising associated conditions caused by a human immunodeficiency virus (HIV) infection. Despite myriad research studies, unresolved questions about origins and epidemic emergence of HIV/AIDS remain. At the beginning of the global AIDS epidemic in the early 1980s, HIV/AIDS was considered a disease exclusive to homosexual men and intravenous drug users, but in Africa, new HIV/AIDS cases were observed across numerous subpopulations. Proposed reasons for the emergence of HIV in Africa in the 20th century include, but are not limited to, rapid population growth, change in population structure, and clinical interventions that provided the opportunity for rapid human-to-human transmission.
Emergence and prevalence of HIV in Rwanda The prevalence of HIV/AIDS is a major public health concern in Rwanda as HIV/AIDS-related mortality has substantial negative social and economic consequences for residents and the government. The first case of HIV infection in Rwanda was reported in 1983. The estimated incidence rate for HIV in Rwanda is 0.11%; this is a stable rate.
According to the 2014–2015 Rwanda Demographic and Health Survey (RDHS), "In Rwanda, much of the information on national HIV prevalence is derived from the antenatal care (ANC) sentinel surveillance system. Although surveillance data do not provide estimates of HIV prevalence for the general population, they do provide results specific to women attending antenatal clinics. The inclusion of HIV testing in the 2005, 2010, and 2014–15 RDHS surveys offer[ed] the opportunity to better understand the magnitude and patterns of infection in the general population of reproductive age, including men age 15–59 who are not tested as part of antenatal sentinel surveillance. The 2014–15 RDHS is the third RDHS survey to anonymously link HIV testing results with key behavioral and sociodemographic characteristics of both male and female respondents, the first being the 2005 RDHS. These surveys provide national, population-based trend data on HIV prevalence among women age 15–49 and men age 15–59. In addition, for the first time, the 2014–15 RDHS included HIV testing of children age 0–14."
In Rwanda, HIV prevalence has been stable since 2005 and remains at 3% among adults age 15–49 (4% among women and 2% among men). The prevalence of HIV is higher in urban areas (6%) than rural areas (2%); HIV prevalence is 6% in the capital city of Kigali and 2–3% in each of the other provinces.
The HIV prevalence increases with age. Less than 1% of children (ages 0–14) are living with HIV. Across age groups, the highest HIV prevalence is observed among women age 40–44 (8%) and men age 45–49 (9%).
Regardless of sex, HIV prevalence is closely related to marital status. Fifteen percent of widows and 8% of those divorced or separated reported being HIV positive, as compared with only 3% of those who were married at the time of the survey.
By wealth, HIV prevalence is highest among both young women and young men in the highest wealth quintile. However, the relationship between HIV prevalence and household wealth quintile is not linear.
Among youth in Rwanda, HIV prevalence by educational attainment. Five percent of young women with no education are HIV-positive whereas 2% of young women with a primary education and 1% with a secondary education or higher are HIV-positive. Among young men, HIV prevalence is higher among those with any education than among those with none.
National policy and programmatic responses to the HIV/AIDS epidemic
History of Rwanda's HIV/AIDS response
Early responses Rwanda's HIV/AIDS surveillance efforts began in 1984 with the establishment of a national AIDS case reporting system in hospitals and health centers. The country's early response to its HIV/AIDS epidemic was relatively rapid and sustained. In 1985, the Rwandan Ministry of Health and the Red Cross established one of the first and most effective blood donor screening programs in Africa. In 1986, Rwanda was the first country in the world to conduct and report on a nationally representative HIV/AIDS seroprevalence survey. In 1987, the National AIDS Program was established in collaboration with the World Health Organization (WHO).
The 1990–1994 civil war and genocide Rwanda's civil war began in 1990. Between April and July 1994, genocide claimed the lives of an estimated 800,000 Rwandese, displaced nearly four million people, and had a devastating impact on national health infrastructure. In addition to severe limitations being placed on the ability of the Rwandan government to prevent and treat HIV/AIDS during the genocide, the International Criminal Tribunal for Rwanda noted the use of 'genocidal rape' as a weapon of war during this time, with between 250,000 and 500,000 women and girls being subjected to rape. Deliberate infection with HIV was observed as a pattern of warfare. The exact effect of these actions on HIV/AIDS prevalence is, however, not known.
Rebuilding after the civil War After the civil war and the genocide, Rwanda's health system had been devastated, with life expectancy at just 30 years and one out of four children dying before their fifth birthday. Between 1990 and 2002, the country recorded steadily increasing numbers of new AIDS cases with between 1,000 and 4,000 new case reports per year. This was followed more recently by dramatic increases in cases in 2003 and 2004 (over 6,000 and 12,000 cases reported, respectively). Overall, HIV prevalence is thought to have stabilized since its peak in the early 1990s, partly also due to the effects of the genocide.
Rwanda adopted a community-based healthcare model (called Mutuelles de Santé, the insurance requires community members to pay a premium based on their income and a 10% upfront charge for each visit) to counter shortages in skilled professionals and prioritized national ownership of healthcare as a central aspect of its health reconstruction efforts after the war.
Vision 2020, the national development plan which aims to make Rwanda a lower-middle income-country by 2020, includes health as a central aspect of development and guides the national allocation of resources. Rwanda favors a multi-sectoral approach to health care, and, while funding for the health system is heavily dependent on donor aid, State ownership and control over policy is strong.
HIV/AIDS policies and programs in the past There has been growing availability of HIV testing, care, and treatment services in Rwanda since 2000. Anti-retroviral therapy (ART) was first introduced in 1999. The 2005–2009 Health Sector Strategic Plan names as one of its goals the curbing and reversal of the spread of HIV infection by 2015. It also includes as goals increasing demand for HIV prophylaxis and treatment through the development of public education campaigns and 'gender-specific' implementation. In 2006, it was reported that voluntary testing and counseling was available at 226 sites. Large-scale Prevention of Mother to Child Transmission (PMTCT) and health promotion initiatives were also reported in at least 208 sites.
In 2009, Rwanda published its first National Strategic Plan on HIV and AIDS, outlining the overarching goals for the country's multi-sector response. "It is based on the most up-to-date understanding of the epidemic and the strengths and weaknesses of the systems and mechanisms that are used to respond." The Plan calls for "universal access to HIV and AIDS services". In addition, it counts the reduction of infections, reduced morbidity and mortality and equal opportunities for persons living with HIV/AIDS as goals. The plan also targeted behavior change and risk reduction as important outcomes. In 2012, it was estimated that 80% of people in need of ART were able to access it through the community-based healthcare system. The National Strategic Plan (2009–2012) was succeeded by the Second National Strategic Plan on HIV and AIDS (2013–2018).
Current legal and policy framework HIV/AIDS is prioritized in several policy instruments, including Vision 2020 and the Economic Development and Poverty Reduction Strategy 2013–2018 (EDPRS II), which includes a framework for multi-sectoral responses to HIV/AIDS. Each sector within EDPRS II has specific HIV mainstreaming strategies and targets, including education, health, labor, military, transport, gender, young people, agriculture, finance and social welfare. The third Health Sector Strategic Plan (HSSP-III) is a framework document for the development and shaping of health policy in Rwanda. Among its goals are the reduction of HIV infections, reduction of HIV-related morbidity and mortality, strengthened management of HIV/AIDS and equal opportunities for people living with HIV.
Second National Strategic Plan on HIV and AIDS (National Strategic Plan 2013–2018)
Source:
The National Strategic Plan is a reference document for all sectors, institutions and partners involved in the fight against HIV and AIDS. The National Strategic Plan goals include: Lowering the new infection rate by two thirds from an estimated 6,000 per year currently to 2,000; Halving the number of HIV-related deaths from 5,000 to 2,500 per year; and Ensuring that people living with HIV have the same opportunities as all others.