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Rwanda: HIV History and Reduction Success

Megan Smith
PIH Final Paper
February 20, 2015

Rwanda: HIV History and Reduction Success

Once classified among the 10 countries most severely affected by HIV (Source 1),
Rwanda was the first country to achieve universal HIV treatment in 2014 (Source 8). For a
country that endured a massive genocide, in which HIV was used as a weapon, Rwandas success
is particularly astounding (Source 13). Rwanda has made incredible gains through holistic
measures that have empowered and caused the community to grow and respond in unity to
combat HIV. Something different about Rwandas success is that it focuses on sustainable
efforts, and seeks to follow a bottom-up model; meaning that Rwanda seeks to empower and
encourage vulnerable populations to play an active role in healing their nation. Rwanda uniquely
utilizes social mobilization tactics, creates HIV prevention programs with elements of selfsufficiency by dually addressing poverty and through empowering women which also benefits
the entire family in a myriad of ways (Source 1).
Beginning in 1983, Rwanda was one of the first African countries to document AIDS
cases. Rwandas response to the HIV/AIDS epidemic was relatively rapid and sustained, as a
national AIDS case reporting system was established in hospitals and health centers in 1984 as a
major component of their HIV surveillance efforts (Source 7). As soon as 1985, one of the first
and most effective blood donor screening programs in all of Africa was established in Rwanda by
the Ministry of Health and the Red Cross (Source 7). In 1988 Kigali, Rwandas capital, had HIV
prevalence among pregnant women of 21%, which drastically increased to 33% by 1996. In rural
settings, there was a prevalence of 2% in 1988 that escalated to 12% in 1996 (Source 7). The
overall prevalence in Rwanda as a nation in 1986 was 17.8% in urban communities and 1.3% in
rural areas, while post genocide incidence rates in 1996 were 27% among urban populations,
and 6.9% in rural populations (Source 10). The atrocities of the genocide not only raised HIV

prevalence by its nature, but another contributing factor to the drastic increase in prevalence was
due to approximately 20% of the entire Rwandan population (800,000) being murdered in the
Rwandan genocide (Source 10).
The 1994 Rwandan genocide demolished the nation and devastated the national health
infrastructure. Over the course of 100 days, between 250,000 and 500,000 women were raped
and over 67% of these women were infected with HIV and AIDS (Source 13). Many of these
cases were a result of a systematic and planned use of rape by HIV+ men as a weapon of
genocide; and an estimated 20,000 children were born as a result of these rapes (Source 13).
HIV/AIDS continues to affect the country; a report from 2012 estimated that there are currently
120,000 AIDS orphans living under the age of 17 in Rwanda (Source 3). Despite severe
difficulty, and a decline of the health system post-genocide, Rwanda has made remarkable gains
and has made ambitious plans to strengthen its resources for health, both in quality and quantity,
to ensure a promising future for the health system (Source 4). Rwanda also continues to make
remarkable progress in developing national and local government institutions, maintaining
security, promoting reconciliation and strengthening the justice system which all promote the
strengthening of their nation and provide the infrastructure to rebuild the health system (Source
As testimony to their success, Rwanda was recently the first country to achieve universal
coverage in 2014 of HIV treatment under the WHO guidelines of 2009 which recommended
treatment for people with CD4 counts below 350 cells/mm3 (Source 2). This achievement has
resulted in over half of HIV diagnoses and annual incidence falling by 90% (Source 8; 5).
Currently, HIV prevalence is 2.9% of the adult population in Rwanda, roughly 210,000 people;
and over half are taking Antiretroviral therapy (ART) (Source 8; 5; 2). This is a great

improvement from 1990-1997 when the HIV prevalence was over twice as high, at 6%, with
much fewer people receiving ART (Source 14). With the current level of ART treatment, it is
estimated that the entire HIV-positive population is bringing down incidence at a year-on-year
rate of 23% (Source 2).
Rwandas reduction efforts were full-fledged and addressed the issue of HIV/AIDS from
many different perspectives, which has accelerated their reduction rates. The governments
ownership in addressing the problem as well as the ability to allow partners work with them have
caused Rwandas government-led initiative to have an impressive impact on HIV prevalence.
Epidemiologic research reports that the annual HIV incidence has dropped from 37,000 new
infections in 2007 to little more than 13,000 in 2013, the reduction of nearly 25,000 new
incidences within only six years is remarkable (Source 5). Impressively, the median CD4 counts
at the time of diagnosis is 300cells/mL, which is higher than what is generally seen in either the
U.S. of U.K. (Source 5). Not only is Rwanda achieving success in lowering prevalence, they are
also bringing more awareness of their populations HIV status by setting a higher CD4 count
level for a diagnosis. This in turn also helps to reduce prevalence because more people know
when they have HIV and can make more informed decisions about their sexual relations and
partners when they know their status.
The combination of government leadership and donor support has helped Rwanda make
strides in combating HIV by expanding access to HIV testing, enhancing knowledge, improving
coverage of key services, and stabilizing the epidemic (Source 9). Dr. Agnes Binagwaho,
Minister of Health of Rwanda, stated It has been a long journey and our partners have
accompanied us along the way, and the many partnerships and donors supporting the Rwandan
government have made all the difference (Source 9).

Recent years have been characterized by a dramatic increase in resources to fight the
HIV/AIDS epidemic. Partners have included, but have not been limited to, The Global Fund to
Fight AIDS, Tuberculosis and Malaria (The Global Fund), The World Bank, U.S. Centers for
Disease Control and Prevention (CDC), and various foundations (Source 1). The backbone that
has ensured the effectiveness of all the reduction activities is the promotion of a harmonized
approach by the Rwandan government, which has helped unite efforts to yield the most success
(Source 1). Rwandas quick and resolute decision committing to provide treatment to those with
HIV opened the door for partners and outside resources to come alongside them.
Support from the Clinton Foundation helped authorities develop a treatment plan, and
under the governments leadership, the Bank developed strong partnerships with the Clinton
Foundation, the Global Fund, and PEPFAR [The United States Presidents Emergency Plan for
AIDS Relief] to design, implement, and monitor the treatment program (Source 1).
USAID/PEPFAR on their own also collaborates with the Rwandan government to promote
HIV/AIDS prevention, counseling and testing, care and treatment, and reinforcement of health
care systems (Source 10). The World Bank also specifically recruited the CDC to do a baseline
assessment and to propose alternative models of care (Source 8). They conducted the analysis in
such a way that promoted ownership and ensured continuity in implementation and oversight,
as everything was done in close collaboration with the Treatment and Research Center on AIDS
of the Rwanda Ministry of Health (Source 1).
On top of aid from many partners such as these, religious missions also serve as an
invaluable partner to rebuilding Rwandas health infrastructure. Health facilities run by religious
missions administer roughly 40 percent of the health network in Rwanda, and they are integral
in actively expanding access to a full range of HIV-related services, including HIV testing,

prevention of mother-to-child transmission, and antiretroviral therapy (Source 1). These

services are also provided in an atmosphere of confidence and trust and in a spirit of
compassion and moral support, which draws in more patients, and many of these clinical
services are linked to community-based support, which gives AIDS patients access to an
essential integrated package of services (Source 1).
Putting people at the center of development and focusing on individual welfare has been
our overriding strategy, Minister Binagwaho said in light of Rwandas success (Source 9). She
also noted the importance of sustaining economic growth, as it is ultimately critical to reducing
our dependence on external financing (Source 9). Still, Rwanda celebrates recent gains in
poverty reduction, with one million lifted from poverty in a short time (Source 9). With all
programs collaborating and working in alliance with the government to assure effective
programs, Rwanda also believes in the importance of involving and empowering the community
in order to reach solidarity and as a nation to combat HIV/AIDS and supporting issues (i.e.
poverty) to foster ownership of community members own lives as well as the community and
nation as a whole. This approach that seeks to empower and involve vulnerable populations is
part of what makes Rwandas reduction success both unique and effective.
Along with involving the community there has been a strong emphasis on social behavior
through addressing the links in AIDS and poverty as well as increasing education in hopes of
changing behaviors. Rwanda strongly encourages HIV testing, as they believe enhanced
knowledge will lead to greater empathy and solidarity with people living with HIV. There is also
a stronger impetus on awareness campaigns to adapt behaviors and foster a culture of
responsibility, trust, and faithfulness within relationships (Source 1).

Rwanda intentionally targets their awareness and education campaigns. As the 1994
genocide left a generation of orphans and vulnerable children who are exposed to child labor,
sexual abuse, delinquency, and HIV, (Source 1) the Rwandan National Youth Council was
created to specifically reach out to youth and children who are vulnerable to build their
community while supplying them with valuable education and services. The youth council is an
innovative voucher program for expanding HIV testing that allows children to visit local health
facilities on certain designated days. The program is also innovative in that youth and orphans
become involved and then in turn reach out to other orphans to raise education about HIV and
supply the vouchers for health services. The program has been successful in combining income
generating activities with HIV/AIDS and reproductive education as well as teaching life skills;
many of the youths reach out to other orphans and marginalized children in their communities
to raise awareness about the risk of HIV and how to protect themselves, this education is
invaluable as knowledge empowers these marginalized children to live healthier lives (Source 1).
Another foundation that helps to uplift vulnerable populations is Foundation Rwanda.
Founded in July 2008, the three goals of Foundation Rwanda are to Provide funding for
education of children born from rape during the 1994 genocide; Link their mothers to
psychological and medical services and income generating activities; and to Create awareness
about the consequences of genocide and sexual violence through photography and new media
(Source 6). This foundation was started as a response to an estimated 20,000 children born as a
result of sexual crimes during the genocide, and to help give mothers who had been shunned by
their own communities and families due to the stigma of rape fulfill their desire for their
children to have a brighter future even though they were unable to provide the money to pay for

their education (Source 6). Investing in women is another major investment that sets Rwandas
HIV reduction apart and has contributed to its success.
Many studies and projects around the globe have found empowering women enhances the
healthcare and education within the entire family (Source 1). Through being invested in, women
who are widows or orphans of the genocide or AIDS have come together o find common
solutions and break the cycle of poverty and AIDS (Source 1). An example of this in Rwanda
was when authorities helped a woman, and her coworkers, who participated in sex work form an
association among themselves of former sex workers and to design their own income generating
activities. Now these women engage in productive trade, free from stigma, have stable incomes,
and have regained self-esteem (Source 1). The governments role in empowering these women is
revolutionary as it did not eek to help make their circumstance better in some way, but they
helped them transform their circumstance completely. Through allowing the women to take
ownership of these projects, their lives were transformed. A former mayor of Kanombe district,
Charles Muyara, said the first step in turning the tide against AIDS is when women take control
of their lives (Source 9). Allowing women to be a part of the solution changes everything and
gives them the confidence they need to make adjustments in their life, as well as the resources
needed to begin. These women were once trapped because their families rejected them; they
were at risk of exploitation, abuse, and AIDS; and they were not considered suitable to marry.
But as new opportunities for work and healthcare came their way they were able to find a new
life, and the work continues today through cooperatives (Source 7). However, behavioral
change takes time and is contingent upon sustainable income-generating activities. These women
need ongoing support from their local leaders and program managers as they face new hurdles
and challenges, as the program managers know that these women remain highly vulnerable

and could easily get disillusioned and resume their former line of work," as is unfortunately
common for many women (Source 1). Rwanda did not settle and stop at helping women sex
workers know their HIV status, but they took the opportunity to build solidarity and tackle their
underlying vulnerability.
It has been a long journey and our partners have accompanied us along the way, said
Dr. Agnes Binagwaho, Minister of Health of Rwanda (Source 9). Emerging from a legacy of
genocide, Rwanda has used this past decade to build trust and respect with their various partners
and they have established a relationship of trust and confidence as Rwanda has continued to
produce efficient results (Source 9). When HIV/AIDS funding is used strategically, as in
Rwanda, it can have a long-term impact that goes far beyond the treatment and care of those
living with HIV/AIDS (Source 9). The 2012 Millennium Development Goals Report cites
Rwanda as providing access to ATR so that at least 80% of those who need treatment receive it
(Source 9). As a result of these gains, Rwanda is considering moving to treating people with
CD4 counts under 500 cells/mm3, in accordance with the 2013 WHO guidelines [ ] the
increased coverage would cost $US12.7 million over five years, but that it would save $27.3
million because of fewer deaths and infections, a net gain of $14.6 million. There would be 6400
fewer AIDS-related deaths and 7586 fewer new HIV infections (Source 2). I propose not that
Rwanda change their trajectory, but that they keep moving forward with the same dedication and
resolution that began their fight against HIV/AIDS. Raising the budget, although costly at first
seems more than reasonable when looking at the future pay off as well as lives saved and quality
of life elevated. I would also propose continued and expanded funding to vulnerable women,
such as sex workers, so they have the opportunity to change their profession. Sex work can be a
choice, but more often than not it is a result of very few, poor, or impossible choices and

women are desperately driven to sex work as a way to make money. Through enhancing
foundation and community support to help women form coops and make an income in a healthy
sustainable way, it builds up and empowers women as well as enhances the probability for them
to raise healthy, educated families. Investing in women is a way to invest in the future of Rwanda
as women are raising the next generations. Its about health, and its also about empowerment
and instilling value and ownership so that people have the opportunity to rise up and make

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