Controlling hepatitis C in Rwanda: a framework for a national response.

With the introduction of direct-acting antiviral drugs, treatment of hepatitis C is both highly effective and tolerable. Access to treatment for patients, however, remains limited in low- and middle-income countries due to the lack of supportive health infrastructure and the high cost of treatment. Poorer countries are being encouraged by international bodies to organize public health responses that would facilitate the roll-out of care and treatment on a national scale. Yet few countries have documented formal plans and policies. Here, we outline the approach taken in Rwanda to a public health framework for hepatitis C control and care within the World Health Organization hepatitis health sector strategy. This includes the development and implementation of policies and programmes, prevention efforts, screening capacity, treatment services and strategic information systems. We highlight key successes by the national programme for the control and management of hepatitis C: establishment of national governance and planning; development of diagnostic capacity; approval and introduction of direct-acting antiviral treatments; training of key personnel; generation of political will and leadership; and fostering of key strategic partnerships. Existing challenges and next steps for the programme include developing a detailed monitoring and evaluation framework and tools for monitoring of viral hepatitis. The government needs to further decentralize care and integrate hepatitis C management into routine clinical services to provide better access to diagnosis and treatment for patients. Introducing rapid diagnostic tests to public health-care facilities would help to increase case-finding. Increased public and private financing is essential to support care and treatment services.

Grâce à l'introduction d'antiviraux à action directe, le traitement de l'hépatite C est à la fois très efficace et bien toléré. Néanmoins, l'accès des patients au traitement demeure limité dans les pays à revenu faible et intermédiaire en raison du manque d'infrastructures sanitaires de soutien et du coût élevé du traitement. Les pays pauvres sont encouragés par des organismes internationaux à élaborer des mesures de santé publique qui faciliteraient la mise en place de soins et de traitements à l'échelle nationale. Peu de pays ont cependant établi des politiques et des plans officiels. Dans cet article, nous présentons l'approche adoptée au Rwanda à l'égard d'un cadre de santé publique pour le contrôle de l'hépatite C et les soins qui lui sont associés dans le contexte de la stratégie du secteur de la santé contre l'hépatite de l'Organisation mondiale de la Santé. Cela inclut le développement et la mise en œuvre de politiques et de programmes, d'efforts de prévention, de capacités de dépistage, de services de traitement et de systèmes d'information stratégiques. Nous mettons en avant les principaux succès du programme national pour le contrôle et la gestion de l'hépatite C: l'établissement d'une gouvernance et d'une planification nationales; le renforcement des capacités de diagnostic; l'approbation et l'introduction de traitements antiviraux à action directe; la formation de personnel d'encadrement; le développement d'une volonté et d'un leadership politiques; et la promotion de partenariats stratégiques clés. Les enjeux actuels et les prochaines étapes du programme incluent l'élaboration d'un cadre détaillé de suivi et d'évaluation, ainsi que des outils pour le suivi de l'hépatite virale. Le gouvernement doit favoriser la décentralisation des soins et intégrer la gestion de l'hépatite C aux services cliniques courants afin de fournir aux patients un meilleur accès au diagnostic et au traitement. L'utilisation de tests de diagnostic rapide dans les établissements publics de santé permettrait d'améliorer le dépistage. Il est essentiel d'augmenter les financements publics et privés pour soutenir les services de soins et de traitement.

Con la introducción de los fármacos antivíricos de acción directa, el tratamiento de la hepatitis C es altamente eficaz y tolerable. Sin embargo, el acceso al tratamiento por parte de los pacientes sigue siendo limitado en los países de ingresos medios y bajos, debido a la falta de infraestructuras sanitarias de apoyo y a los altos costos del tratamiento. Los organismos internacionales alientan a los países más pobres a organizar respuestas de salud pública que podrían facilitar la puesta en marcha de atención y tratamiento a escala nacional. Sin embargo, son pocos los países que han documentado planes y políticas formales. En el presente estudio, esbozamos el enfoque adoptado en Rwanda para un marco de salud pública para el control y la atención de la hepatitis C dentro de la estrategia del sector de la salud contra la hepatitis de la Organización Mundial de la Salud. Este incluye la elaboración y aplicación de políticas y programas, medidas preventivas, capacidad de cribado, servicios de tratamiento y sistemas de información estratégica. Destacamos los éxitos clave del programa nacional para el control y tratamiento de la hepatitis C: establecimiento de la gobernanza y planificación nacional; desarrollo de capacidad diagnóstica; aprobación e introducción de tratamientos antivíricos de acción directa; formación de personal clave; generación de voluntad política y liderazgo; y promoción de asociaciones estratégicas clave. Los desafíos actuales y los próximos pasos del programa incluyen el desarrollo de un marco de seguimiento y evaluación detallado, así como herramientas para el seguimiento de la hepatitis viral. El gobierno necesita descentralizar todavía más la atención e integrar la gestión de la hepatitis C en los servicios clínicos corrientes para proporcionar un mejor acceso al diagnóstico y tratamiento de los pacientes. La introducción de pruebas diagnósticas rápidas en los centros de atención de salud pública ayudaría a aumentar la búsqueda de casos. El aumento de la financiación pública y privada es esencial para apoyar los servicios de atención y tratamiento.

Drug resistance mutations after the first 12 months on antiretroviral therapy and determinants of virological failure in Rwanda.

OBJECTIVE: To evaluate HIV drug resistance (HIVDR) and determinants of virological failure in a large cohort of patients receiving first-line tenofovir-based antiretroviral therapy (ART) regimens. METHODS: A nationwide retrospective cohort from 42 health facilities was assessed for virological failure and development of HIVDR mutations. Data were collected at ART initiation and at 12 months of ART on patients with available HIV-1 viral load (VL) and ART adherence measurements. HIV resistance genotyping was performed on patients with VL ≥1000 copies/ml. Multiple logistic regression was used to determine factors associated with treatment failure. RESULTS: Of 828 patients, 66% were women, and the median age was 37 years. Of the 597 patients from whom blood samples were collected, 86.9% were virologically suppressed, while 11.9% were not. Virological failure was strongly associated with age <25 years (adjusted odds ratio [aOR]: 6.4; 95% confidence interval [CI]: 3.2-12.9), low adherence (aOR: 2.87; 95% CI: 1.5-5.0) and baseline CD4 counts <200 cells/µl (aOR 3.4; 95% CI: 1.9-6.2). Overall, 9.1% of all patients on ART had drug resistance mutations after 1 year of ART; 27% of the patients who failed treatment had no evidence of HIVDR mutations. HIVDR mutations were not observed in patients on the recommended second-line ART regimen in Rwanda. CONCLUSIONS: The last step of the UNAIDS 90-90-90 target appears within grasp, with some viral failures still due to non-adherence. Nonetheless, youth and late initiators are at higher risk of virological failure. Youth-focused programmes could help prevent further drug HIVDR development.

Household survey of HIV incidence in Rwanda: a national observational cohort study.

BACKGROUND: In Rwanda, HIV prevalence among adults aged 15-49 years has been stable at 3% since 2005. The aim of this study was to characterise HIV incidence across Rwanda. METHODS: We did a nationally representative, prospective HIV incidence survey for the period of 2013-14, which used two-stage sampling. We randomly selected 492 villages in the first sampling stage and 14 households per village in the second stage. Participants completed a questionnaire and 14 140 people were tested for HIV. 13 728 participants were HIV negative, and were enrolled in the incidence cohort. Participants were retested and surveyed again after 12 months. Weights were calculated as the inverse of the probability to select the villages and the households. FINDINGS: The study period was from Nov 5, 2013, to Nov 15, 2014. Among 14 222 respondents from 6792 households, 14 140 were tested for HIV and 13 728 were HIV negative. Of 12 593 people who participated in the endpoint data collection activities, 5965 (47·4%) were men and the mean age was 30 years (SD 10·8). 11 237 (89·2%) participants lived in rural areas, 4826 (38·3%) were single, and 7140 (56·7%) were married or cohabitating. During the year, 35 participants had seroconversion, including 13 men and 22 women, resulting in an overall incidence of 0·27 per 100 person-years (95% CI 0·18-0·35). Incidence was 0·21 per 100 person-years (0·10-0·32) in men and 0·32 per 100 person-years (0·19-0·45) in women. Our findings suggested multiple breakouts, with multiple seroconversions occurring in three villages and two households. Incidence was higher in adults aged 36-45 years (0·37 per 100 person-years, 0·12-0·62; adjusted hazard ratio [aHR] 4·49, 95% CI 1·30-14·70) relative to those aged 16-25, higher in western province (0·57 per 100 person-years, 0·31-0·87; aHR 5·90, 1·33-25·28) relative to the northern province, and higher in urban areas (0·65 per 100 person-years, 0·23-1·07; aHR 3·10, 1·28-6·99) than in rural areas. INTERPRETATION: The incidence of HIV in Rwanda was higher than that previously estimated from models, with outbreaks seeming to contribute to the ongoing epidemic. Characterisation of incident infections can help the national HIV programmes to plan for preventive interventions tailored to the most at risk populations. FUNDING: Global Fund to Fight HIV, Tuberculosis and Malaria, WHO Rwanda, UNAIDS Rwanda, and the Government of Rwanda.