In-depth: Countdown to Universal Access

RWANDA: On course to achieve treatment-access targets

Photo: Keishamaza Rukikaire/IRIN

Decentralizing health care has been the key to Rwanda's success

Kigali, 14 August 2009 (PlusNews) - The tiny nation of Rwanda has emerged as the unlikely star of central Africa in making progress towards achieving universal access to HIV treatment, prevention and care.

More than 70 percent of its people who need life-prolonging antiretroviral (ARV) drugs have access to them, prevention of mother-to-child transmission (PMTCT) services reach 60 percent of women requiring them, and 60 percent of children needing ARVs are on treatment.

"Of pregnant women who come to our health facilities, 99 percent are accepting testing," said Jules Mugabo, head of the government's Treatment and Research AIDS Centre. "Now, with the participation of the [male] partners, 76 percent of partners have come to be tested in antenatal clinics ... we were able to test around one million last year."

Rwanda is extremely poor and still struggling to rebuild a health system decimated by the 1994 genocide, but larger and wealthier countries in the region, like Kenya and Uganda, are providing ARVs to fewer than half the people in need of them.

Unlike many other African countries, Rwanda's almost 10.5 million people speak only one indigenous language and are broadly culturally homogenous, making it easier to coordinate HIV-related media campaigns.

Between 1999, when the first PMTCT site was opened, and 2001, just over 11,000 Rwandan women were tested for HIV; by 2006 the number had grown to well over 200,000 annually.

Experts put these successes down to political commitment at the highest level, which has enabled HIV actors to expand programmes nationally; both President Paul Kagame and First Lady Jeanette Kagame have talked openly about HIV, encouraging the population to behave in sexually responsible ways.

One health worker noted that Rwandans have a "culture of obedience", which has contributed to the numbers of women attending antenatal clinics, accompanied by their male partners.

"Rwanda has a strong administrative structure right down to very ground level," said Asuka Leslie, a senior programme officer at the NGO, Family Health International. "Within this context the health system is trying to decentralize."

Each of Rwanda's 30 districts has at least one "one-stop" health centre providing HIV counselling, testing and treatment. Patients who test positive immediately give a blood sample and return a week later to receive the results of their CD4 count, which indicates immune system strength.

"When the patient receives the CD4 count he has to consult a doctor," said Jean Paul Balinda, a nurse at a clinic in the capital, Kigali. "If the patient has a 350 CD4 count under 350, he has to start ARVs."

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Patients return to the clinic for counselling and monitoring once during the first week of treatment and then once a month. Each village has two community healthcare workers trained in HIV care and support at the local level.

Yet experts say Rwandans living with HIV still experience severe stigma, which could hinder the race to universal access by preventing people from seeking testing or treatment.

Stigma, prevention still problematic

The results of a survey in May 2009 by the Association of Vulnerable Widows Infected and Affected by HIV/AIDS, and the Network of People Living with HIV, found that HIV-positive people faced most discrimination in society; other groups included sex workers and asylum seekers.

"If there is no stigma, more people come to testing, and with more people coming to testing we can put more people on ART [antiretroviral therapy]," said Dr Fulgence Africa, director of planning, coordination, monitoring and evaluation of HIV programmes at the National AIDS Control Council, CNLS.

Prevention is also a persistent problem; acceptance of condoms is low because they are still associated with promiscuity, while condom distribution is geographically uneven, and especially inadequate in rural areas.

Rwanda uses a broad prevention strategy of Education, Abstinence, Be faithful and correct and consistent Condom use, but there is scant knowledge about HIV among those most at risk, such as men who have sex with men, sex workers and truck drivers.

The latest universal progress report notes that the country needs to investigate the factors driving the pandemic to ensure that prevention efforts are coherent with HIV transmission patterns.

"Focus should be placed on 'knowledge of the epidemic' so as to be able to develop appropriate tailored interventions for the most at-risk populations," the progress report said. "In-depth analysis should also encompass the links between HIV, drugs and alcohol."

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[This article is the third part of an IRIN/PlusNews series on "Countdown to Universal Access"]