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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 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 (continued) C. Accomplishments and Outcomes 3. Project Outcomes HIV/STI seroprevalence By 1983, when the first case of AIDS was documented in Rwanda1, several physicians in Europe had already been treating African immigrants affected with AIDS. In Rwanda, a few physicians noted in the early 1980's that they were treating several patients suffering from unusual symptoms, such as esophageal candidiasis. These symptoms may have been indicative of the presence of HIV in Rwanda before 1983. When the first epidemiological studies on HIV in Rwanda were conducted in the early 1980's, high rates of seropositivity were discovered among urban adults. Among female commercial sex workers in Butare, levels reached 88%2. The rates were alarming enough to cause the Red Cross to begin routine HIV screening procedures at all its blood collection centers in 1985. Nevertheless, many people who received transfusions between 1980 and 1985 were given HIV tainted blood and became seropositive, (45% of the total according to Allen)3. This mode of transmission, however, accounts for only a small fraction of the total number of HIV infections in Rwanda. In 1986, the first national HIV serological survey indicated that HIV seroprevalence was slightly over 1% in rural areas, and around 18% in the general urban population. Among urban adults between the ages of 26 and 40, levels reached 30%4. A year later, the Government of Rwanda decided to establish a national AIDS prevention program, "Programme National de Lutte contre le SIDA" (PNLS), under the aegis of the Ministry of Health. Benefiting originally from the World Health Organization and the Belgian Co-operation, PNLS facilities consisted of a documentation/resource center, a research and intervention staff, and a fully equipped and staffed medical laboratory. Shortly before the outbreak of the civil war in 1994, AIDSCAP was in final negotiations to become a significant funder of and collaborator with the PNLS. Although there were a few hopeful signs in Rwandan cities in the early 1990's that the epidemic might have reached its saturation point, seroprevalence in rural areas of the country was continuing to slowly increase. General HIV prevalence there was estimated at around 2% to 2.5% in 1992, but some areas of the countryside were being hit worse than this figure would indicate. Along routes used by long distance truck drivers, for example, where one finds bars, brothels, and motels, seroprevalence levels ranged between 8 and 10%5. Shortly before the resumption of hostilities in April 1994, seroprevalence among the Rwandan population as a whole was probably around 3%6. In December of 1988 a sentinel surveillance system was established in Rwanda to monitor HIV incidence and prevalence among pregnant women attending antenatal clinics, representing the general population aged 15 to 45, and STI patients, representing a population with high risk behavior. In Kigali, for example, there were five such posts, two STI clinics and three prenatal clinics that begun functioning in 1988. HIV data collected over a four year period prior to the war is summarized in the tables below. Table 1: HIV seroprevalence in Kigali's sentinel posts: (MOH, PNLS, Department of Epidemiology)
Table 2: HIV seroprevalence from sentinel posts : (MOH, PNLS, Department of Epidemiology)
Data from prenatal clinics in Kigali show that HIV seroprevalence was increasing among pregnant women living in Kigali by about 3% or more per year between 1988 and 19907. However, data in 1991 from both prenatal and STI clinics show decreases in seroprevalence in both categories. For some researchers this was indicative that a plateau in new infections had been reached in 1989 or 1990, at least among some sectors of the population8 and was perhaps the first tangible indicator that educational measures and condom promotion implemented prior to the war were beginning to have a modest effect. Before the resumption of the war in April 1994, the HIV epidemic in Rwandan cities was continuing to take many lives, but there were some signs that the epidemic had reached a plateau. Before leveling off in 1991-1992, new infections had been increasing at an annual rate of 3 to 5% between 1988 and 19909. AIDS was, however, still exacting a high toll both in morbidity and mortality. As of 1992, a total of 7,875 cases of AIDS had been reported to WHO10, and this figure probably underestimates the true extent of the problem. Despite promising signs of stabilization, HIV infection spread dramatically during the war. A variety of factors associated with the war are believed to have affected the epidemiological profile of Rwanda, including rapes and massive migrations, both internal as well as beyond the borders. The prevalence of HIV/AIDS in the region was also affected by the formation of huge refugee camps in Zaire and Tanzania. A cross-sectional study was conducted during May, 1995 at the Centre Hospitalier de Kigali during which 500 pregnant women were screened for syphilis and HIV11. The syphilis prevalence was found to be 10% and the HIV prevalence was 24.5%. HIV prevalence did not differ according to place of residence before the war, although 41.8% of the overall study population were recent migrants to Kigali. Table 3: HIV seroprevalence among ANC clinic attendees, Centre Hospitalier de Kigali , 1995.
In 1996, with assistance from the Belgian Cooperation, the PNLS reactivated the pre-war serosurveillance system, establishing ten sentinel posts in rural and urban areas. The latest data from the surveillance system covers the period from April though September 199612. During this time, 3,488 pregnant women and 1,859 STI patients were registered. HIV infection rates in pregnant women ranged from 3.6% in Ruli, or rural Kigali, to 32.6% in Kigali itself. In three of the ten sites, rates exceeded 22%. Among under twenty year olds the overall infection rate was 9.7%. Data on STI patients are more limited since the minimum sample size of patients was only reached in four of the ten sites. In these sites, 71.6% and 27.9% of the patients were female and male, respectively, which is unusual. This imbalance may reflect, in part, the current gender imbalance in the general population or it may reflect different patterns of health-seeking behavior between men and women. However, the overall HIV-prevalence for STI patients was not significantly different between men and women. In the under 20-year-old group, the rate was 27.%. Plans are underway to undertake a validation study of the sentinel surveillance system using funds from the World Bank. Table 4: HIV seroprevalence among STI patients from sentinel posts (PNLS, 1996)
Behavioral Data For the purpose of evaluating AIDSCAP interventions, evaluation activities have taken place on a variety of different levels. On the most detailed level, process data exists for each individual subproject, specifying the number of outputs, such as people trained, workshops held, condoms distributed, etc., and are summarized in the PIF tables at the end of each subproject section. On the outcome level, the initial Country Plan of May 1993 for the AIDSCAP Rwanda Country Office called for a nationwide KABP, to build on a technical assessment that had been conducted in the Fall of 1992. In addition to the collection of behavioral data, the survey was to include the following: a comprehensive review of relevant data, including HIV and STI prevalence; an analysis of condom supply, distribution and promotion; an assessment of the status of STI case management; and an analysis of the national policy environment for AIDS prevention. Unfortunately, the war prevented the realization of these plans and the survey, designed to provide baseline data for all the different subprojects, was not conducted. It is therefore not possible to quantitatively assess changes in attitudes and behaviors as a result of specific interventions. However, a modified country baseline assessment and literature review and several quantitative surveys were conducted under the auspices of the AIDSCAP project. Quantitative Research
Both surveys carried out in Rwanda not only provide a great deal of interesting information but can be used as a baseline data point for future efforts. CARE International plans to conduct a follow-up survey under Phase II of their project, and the military hopes to receive funds from the World Bank to continue its intervention project, including a follow-up survey. The World Bank, under its Office of Health and Population Project, has designated funds for a nationwide KABP survey in the next year. In addition, a Demographic and Health Survey is tentatively planned for 1998. The AIDSCAP KABP findings will serve to provide valuable comparison points for future studies. Based on these early quantitative assessments, qualitative data was generated by Implementing Agencies to ensure that behavior change communication was targeted appropriately. In a country program characterized by civil unrest, and which had as its primary task the re-initiation of behavioral change activities derailed by the war, qualitative research (largely formative) was determined to be one of the most important tasks. Audience Research (Quantitative and Qualitative) The utility of the radio in disseminating IEC messages is generally acknowledged, especially in areas, like Rwanda, with a strong oral tradition and low rates of literacy. Radio time is, however, expensive and this study was to ensure the best use of limited radio time. CIDC surveyed 630 women and 630 youth in late 1995 and conducted Focus Group Discussions. The study was designed to determine exactly when young people and women were most likely to listen to Radio Rwanda, how specific prevention messages were being perceived, as well as how to reach these target groups most effectively. Researchers found that Radio Rwanda is the primary source of information about HIV for 63% of youth and 73.3% of women surveyed. The study also generated information allowing CIDC to refine the messages currently in circulation. Because of the absence of follow-up quantitative surveys, no conclusions can be made about the impact of interventions and outcome results are therefore limited. Data from Rwanda for the period 1995 - 1997 indicate that the level of knowledge about STIs, including HIV/AIDS, was relatively high. However, data also indicate high levels of at-risk behavior, including multiple partners and inconsistent condom usage. This is not surprising considering the level of social disruption experienced by most Rwandans. Primary findings on knowledge, sexual partners and condom USAGE are discussed briefly below. Outcome Because of the absence of follow-up quantitative surveys, no conclusions can be made about the impact of interventions and thus outcome results are limited. In general terms, AIDSCAP data from Rwanda for the period 1995 - 1997 indicate that, although there appears to be some confusion about differences between AIDS and HIV, the level of knowledge about STIs, including HIV/AIDS, was relatively high. Despite these high knowledge levels, however, data also indicate high levels of at-risk behavior, including multiple partners and inconsistent condom usage. Primary findings on knowledge, sexual partners and condom usage are discussed briefly below. Knowledge of HIV/AIDS and STIs Several of the earliest studies about HIV in Rwanda already show fairly high levels of knowledge about HIV, its consequences, and its modes of transmission13. Not surprisingly then, the KABP survey conducted by CARE in Gitarama in February, 1996 also revealed that knowledge among the general population relative to STIs, including HIV/AIDS, was high. The term SIDA and "virusi" were used during the KABP for AIDS and HIV respectively. When a respondent did not understand the term "virusi", the nearest Kinyarwanda equivalent of "agakoko" (meaning a tiny microbe) was used instead. The proportion of respondents who had heard about HIV and AIDS was 97.8% and 93.3% respectively. The difference is more pronounced in certain groups than in others. For example, 96% of adolescent females in the youngest age group had ever heard of AIDS compared with only 75% who had ever heard of HIV. Knowledge of prevention methods was also high and a total of 90% of male respondents and 76% of female respondents correctly reported that condoms can be used to prevent infection with HIV and yet a total 93% of males and 84% of females expressed the belief that condoms can protect against AIDS, again reflecting the confusion between the two terms. The KABP did show that, in general, the study population was more familiar with AIDS than with HIV. Respondents were also familiar with a wide range of STIs, and the only STI for which the level of knowledge was generally low was trichomoniasis. A KABP Among the military in July of 1995 documents that AIDS was well known in the army, with 95% stating that they were familiar with the disease. Knowledge of prevention methods was also high, with 67% knowing at least 2 ways to contract the virus, and 92% confirming that AIDS can be avoided. Only 4% believed that AIDS could be treated, although 7% were not sure. In Focus Group Discussions 19 months later, the majority of soldiers interviewed knew that STIs are transmitted sexually and were also able to identify the major symptoms associated with urethritis. Few of the soldiers interviewed in the FGDs noted false methods of transmission of HIV/AIDS, although the sharing of toilet facilities with someone infected with HIV was in some cases cited as a mode of transmission. There was no mention of transmission by way of mosquitoes, which was cited by 18% of the military in the earlier KABP study. Risk Perception Despite the relatively high level of knowledge documented by both the military and rural population KABP surveys, there are also indications of low levels of perceived personal risk. For example, more than half of the study population in Gitarama (57.8% of all males and 57.4% of all females of reproductive age) perceived they had "no chance" of becoming infected with HIV - even though only 40% of all males and 23% of all females of reproductive age reported using a condom during their most recent act of sexual intercourse with a non-regular partner. Condom use during last sexual act with a regular partner was lower, at 6% for males and 2.5% for females. According to the Gitarama data, the most vulnerable target group was adolescent girls between the ages of 15 and 20. Although no respondents in this age group reported any prior experience using condoms during sexual intercourse, more than half (57%) reported having at least one sexual partner within the previous three months. Nevertheless, almost three-fourths of these young women (71%) believed they had "no chance" of becoming infected with HIV. With regard to risk perception in the military, a large number of the respondents felt that they could contract HIV, but few recognized that this risk was directly related to their own personal behavior. Among those who were sexually active, many noted explicitly their partners' sexual activity as a major risk factor. Sexual Partners According to the Gitarama survey, 23% of all males and 9.3% of all females of reproductive age reported more than one sexual partner within the last 12 months. As noted above, the most vulnerable target group which emerges from the baseline data is adolescent girls between the ages of 15 and 20. Although no respondents in this age group reported any prior experience using condoms during sexual intercourse, more than half (57%) reported having at least one sexual partner within the previous three months. Nevertheless, as noted earlier, almost three-fourths of these young women (71%) believed they had "no chance" of becoming infected with HIV. In addition, 29% of these young women aged 15 to 20 commenced sexual activity before the age of 15.
The military baseline KABP survey showed multiple sexual partnering among the military, with only 17% of the respondents citing sexual activity exclusively with a spouse or regular partner. Although there is no quantitative information to compare to baseline, follow-up FGDs with military men in 1997 suggest that there have not been noticeable shifts on this count. Respondents agree that the practice of having many multiple sexual partners is widespread, indeed the norm. A number of personnel estimated that as many as three-quarters of their peers have many sexual partners (and yet, very few admitted to having many partners themselves). The reason offered for the continuing practice of having multiple partners included the young age of the personnel, their mobility, and the low perception of risk among most military personnel. Condom Use The CARE baseline KABP documents substantial knowledge about the efficacy of condoms in preventing HIV. A total of 90% of males and 76% of females of reproductive age living in Gitarama in 1996 cited condoms as a way to prevent the transmission of HIV. This can be contrasted to a KABP study conducted in 1989 by the Rwandan Ministry of Health, which found that only 3% of the rural population and 8% of the urban population mentioned condoms as an AIDS prevention method. Because we do not have any quantitative follow-up data, it is not possible to conclusively document changes in condom usage following the intervention period. However, qualitative research indicates that, despite high levels of knowledge about HIV prevention methods, condom usage can be characterized as inconsistent. For example, in the CARE baseline survey, despite the high knowledge level, one-third (33.9%) of all females of reproductive age could not correctly identify a condom when shown one by the researcher. For the youngest age group (15-20 years), this figure increased to 50%. And yet, 13.4% of all males and 6.1% of all females reported their first sexual intercourse on or before the age of 15. In fact, among the rural population of Gitarama, only 16.9% of men and 9.3% of women of reproductive age had ever used a condom. Only 9% of males and 4.4% of women stated that they had used a condom during their last sexual encounter. The CARE baseline KABP survey specifically identifies married women as a vulnerable target group, not necessarily as a result of their own high-risk sexual behavior, but because of their inability to negotiate condom use in the face of their husbands' infidelity. Almost seven times as many males reported using a condom during their most recent act of sexual intercourse with a non-regular sexual partner as compared with their regular sexual partners. Similarly, almost ten times as many females reported using a condom during their most recent act of sexual intercourse with a non-regular sexual partner compared with their regular sexual partners. Of course, many people of reproductive age choose not to use condoms in order to conceive. Women participating in FGDs frequently noted that society in Rwanda, as in other parts of Africa, places a high value on fertility. Added to this in the case of Rwanda is the desire to return to a normal life after the devastation of the war and, in some instances, to replace children that were lost in the course of the genocide. The very particular needs of widows also came to light -- the desire to have children even in the absence of a husband was said to outweigh the desire to reduce risk. Married women explicitly recognized that due to the gender imbalance (60-40 in favor of women), it is likely that their husbands will have other partners and thus expose them to risk of STIs and HIV. For those who do wish to use condoms, a variety of other impediments exist. CARE attempted to obtain a measure of self-efficacy, and found that 85.7% of all males and 62.9% of all females indicated that they could successfully negotiate condom use with a future sexual partner if they wanted to. However, these self-reports are probably over-estimates, and are not confirmed by the FGD which demonstrate a fear, especially on the part of women, to negotiate condoms with their partners, particularly with their spouses. This is even the case when women suspect that their partners have another sexual partner outside the marriage. One obstacle to condom usage revealed by both the quantitative survey and FGDs is the widely held perception that using condoms promotes promiscuity. Two-thirds of all males and females agreed with this statement in the KABP. Many people participating in focus group discussion held misconceptions about condoms and, at the same time that condoms are associated with promiscuity and sexual "vagabondage", others expressed the view that condoms were for "high class" people to use. And yet, it has also been noted that some of the same women who refuse to touch or accept a free condom during a peer education session later go out of their way to request one in private. The KABP survey with the military revealed that 90% of respondents knew of condoms and 63% reported to have used condoms at least once. However, only 1% of the respondents reported having used a condom during their last sexual encounter with a CSW, or occasional partner, and 6% during their last encounter with a regular partner. A total of 23% characterized condom use as frequent during the last three months and 46% characterized condom use during the last three months as rare. In the focus group discussions with the military 19 months after the KABP survey, soldiers were well aware that condoms are one of the primary methods of preventing HIV transmission, and yet almost half of the discussants report that they have never used one. Although some discussants stated that they use condoms with all partners, most of them who do use condoms say they use them only with casual partners. Those who never, or almost never use condoms give reasons such as the reduction of sexual pleasure, the reluctance or refusal of their partner, ignorance or the desire to have children. Both quantitative and qualitative data from Rwanda indicate that access to condoms is not the primary barrier to condom usage. In the KABP with the military, participants agreed unanimously that condoms were available and easy to obtain. The RPA directorate made it a requirement that every brigade in the country set up a booth where condoms could be distributed at no cost. All soldiers have access to free condoms on a self-serve basis. In the CARE study, 64% of men and 58% of women stated that they could find a condom if necessary and it is likely that condoms are more difficult to obtain in rural areas than is the case in Kigali or Gitarama city. However, it does appear that Rwandans are informed about HIV/AIDS, that it is a disease that can kill, and that abstinence, fidelity and condom use are the available modes of prevention. Despite this knowledge, and despite the relatively high prevalence of HIV seen in parts of Rwanda, surprisingly few Rwandans consider themselves at risk of HIV transmission and elect to change their behavior accordingly. Skills have been transferred to individuals in the respective implementing agencies through individual and group training. Workshops, seminars, training sessions and hands-on training can be seen as proxy evidence that technology has been transferred.
Endnotes
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