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This report comprehensively summarizes the FHI/AIDSCAP program in Rwanda (1993-1997). The report includes a discussion of background and context, as well as accomplishments, constraints, implementation and management issues, outcomes, and lessons learned and recommendations for each of two components.
Table of Contents I. Country Program Description A. Introduction (See Below) B. Country Context (See Below) C. Accomplishments and Outcomes D. Implementation and Management Issues II. Lessons Learned and Recommendations III. Refugee Intervention in Tanzania IV. Subproject Highlights I. Country Program Description A. Introduction The HIV/AIDS situation in Rwanda is one of the most serious in the world. When the AIDSCAP/Rwanda strategic document was developed in 1993 HIV seroprevalence rates among women attending antenatal clinics (ANC) ranged from just over two percent in rural areas to almost 27 percent in the capital city of Kigali. The prevalence of STIs in this population was also relatively high. Behavioral research data at the time showed that despite high knowledge of HIV/AIDS and primary modes of transmission, the use of condoms was very low. Therefore, the AIDSCAP Program focused on three primary technical strategies: behavior change communication activities aimed at reducing high risk behavior, STI control through improved STI service delivery systems, and increased consumer reach of existing condom social marketing projects in Rwanda. The major strategies were to be supported by extensive behavior research, policy dialogue and evaluation. The implementation of this comprehensive strategy was interrupted by the violence and ethnic killing that followed the assassination of the presidents of Rwanda and Burundi. The war spread throughout the country and claimed the lives of close to a million Rwandans. In addition, millions of people were displaced internally and/or fled across borders to Burundi, Tanzania, Uganda and Zaire. However, despite a one year interruption in prevention activities, the loss of human and material resources, AIDSCAP/Rwanda managed a successful, albeit scaled-down, post-conflict intervention program. The original AIDSCAP/Rwanda project was designed to contribute to the national efforts to reduce the rate of sexual transmission of HIV by building the capacity of local governmental and nongovernmental organizations to implement AIDS prevention interventions. The project design responded to needs unmet by government services or other organizations working in Rwanda. The project was to support comprehensive, integrated and targeted interventions in selected commercial, trading, or high density population centers or areas. National level scope activities were proposed in the areas of organizational strengthening of the PNLS, condom social marketing, communication materials and media programming, and selected activities in strengthening STI services. The AIDSCAP/Rwanda program officially started in October 1993 with the arrival of the Behavioral Specialist, followed by the Resident Advisor in late December. It was funded through a cooperative agreement between Family Health International and USAID. Following the eruption of civil war on April 6, 1994, US embassy and USAID Mission operations were suspended. AIDSCAP/Rwanda and subproject expatriate staff were evacuated and the implementation of the program suspended. By July 1994, AIDSCAP had reoriented its activities to the Rwandan population living in refugee camps in northwestern Tanzania along Rwanda's eastern border. When the political situation stabilized inside Rwanda, AIDSCAP/Rwanda reopened its office in October 1994, the first agency concerned with HIV/STI prevention activities to do so since the war. The management of the office was taken over by the former Deputy Resident Advisor, a Rwandan national. The reactivated program, with a reduced budget of just over $3 million1, was prepared in an expeditious manner in order to get activities moving without further delay. Following discussions between USAID, the Ministry of Health and the National AIDS Control Program (PNLS), the program targeted basically the same groups as outlined in the original country strategic plan: those living in population centers, military personnel, women and men with STIs, youth, single women, and commercial sex workers. Displaced persons were being targeted separately through the AIDSCAP Rwandan refugee project managed by CARE International in Tanzania. The post-conflict AIDSCAP/Rwanda program was implemented by the PNLS of the Ministry of Health, in collaboration with the Medical Services of the Ministry of Defense, the Gitarama Health Region, and CIDC, as well as international NGOs. The national interventions included the condom social marketing program implemented by PSI, support to the PNLS to coordinate nationwide prevention efforts, with an emphasis on STI control using the syndromic approach, and the mass media program implemented by CIDC. The population centers integrated and targeted activities included interventions with STI patients, youth, single and married women, and military personnel. The post-conflict activities, however, were reduced in scope and geographic coverage. This reduction was due to the reduced financial and human resources available to the Rwanda project, including the non-return of expatriate personnel for security reasons. The post-war activities included two distinct programs: the AIDSCAP Rwanda program implemented by the AIDSCAP country office, and the AIDSCAP intervention with Rwandan refugees implemented by CARE International in Tanzania, which was managed directly by the AIDSCAP Regional Office. Because of its uniqueness, the refugee program has it own separate section in this report. This report gives a summary of the accomplishments, constraints and results, highlights and lessons learned from each subproject collectively and individually. Rwanda is a small, mountainous country in the lake region of eastern central Africa with an estimated pre-war population of 7.2 million. As a result of the 1994 genocide, an estimated one million Rwandans were killed and millions of Rwandans were internally displaced or fled the country. Up until the recent events in the Great Lakes region, over one million Rwandans lived in refugee camps in Burundi, Zaire and Tanzania 2. The closing of refugee camps in Tanzania in December 1996 and the civil unrest in Zaire subsequently forced hundreds of thousands of refugees to return to Rwanda by the middle of 1997. In addition, over a million Tutsis refugees, whose families fled the country in 1959, returned to Rwanda from Burundi and Uganda. Rwanda historically has had one of the lowest urbanization rates in Africa, with about six percent of the population living in areas considered to be urban and four percent in areas considered to be periurban. Close to 90 percent of the population are subsistence farmers. Kinyarwanda is the universally spoken language, with French and now English also being widely spoken. Rwanda always had a good physical infrastructure with paved roads connecting major towns, and in spite of the war, this remains the case. Electricity and telephones have been restored to all major towns, including Kigali. Prior to the outbreak of the conflict, Rwanda had a well-developed primary health care infrastructure extending throughout the country. Infant and child mortality rates were 117 and 198 respectively per 1,000 live births, with malaria, diarrhoeal diseases and acute respiratory infection being the principal causes of mortality and morbidity. During prenatal visits around 28 percent of urban pregnant women were found to be HIV-positive in Kigali. By April 1994, the AIDS epidemic had reached a critical stage in Rwanda. In addition to the high prevalence figures for urban pregnant women, among patients seeking treatment for STIs at the Bilyogo Health Center in Kigali, 65.5 percent (80 percent of women and 54 percent of men) were seropositive in 1991. Seroprevalence among high risk groups, such as commercial sex workers, was estimated at 90 to 100 percent. The number of STI cases seen in health facilities, particularly in areas of military concentration, were also on the increase. It was estimated by the PNLS that as many as 220,000 adults in Rwanda may have been infected by the end of 1991. Information from regional hospitals and health centers indicated substantial increases in AIDS-related diseases such as tuberculosis and herpes zoster. Following the Rwanda Patriotic Army's (RPA) victory in July 1994, people displaced by the war began returning to their homes. Significant populations, however, remained in refugee camps in Zaire and Tanzania until quite recently. Since the end of the 1994 war, a number of factors have contributed to a situation favoring an acceleration of HIV transmission. Among them:
Because of the 1994 war, changes in population due to the migration and acts of violence were believed to have modified the epidemiological profile of Rwanda. With assistance from the Belgian Cooperation, the PNLS set up a new serosurveillance system based on ten sentinel posts in rural and urban areas. Two types of populations continue to be surveyed: pregnant women receiving antenatal care and STI patients. These two groups are considered to represent the general population aged 15 to 45 and the population with high risk behavior, respectively. The war also changed the demographics of the Rwandan population. According to the GOR , women now constitute 60 percent of the population, compared to 51.2 percent before the war. Forty percent of Rwandan women are now either widowed, single, separated or divorced; prior to war, this figure was 12 percent. Population movements too have been massive. Over a million refugees, some of whom fled during earlier civil disturbances in 1959 have returned to the country to date. This situation is further complicated by the fact that many of these returnees have not resided in Rwanda for nearly 30 years. Community networks are being rebuilt; however, especially in Kigali, the shifting population has made reaching target populations with prevention efforts via community organizations particularly difficult. Endnotes
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