Before and after study of a national complementary and supplementary feeding programme in Rwanda, 2017-2021.

To address high rates of malnutrition among children from vulnerable households in Rwanda, the government initiated a national food supplementation programme. A before and after evaluation, using repeat cross-sectional surveys in randomly selected villages was conducted; aimed at assessing the effectiveness of providing fortified blended food (FBF) to children 18-23 months of age, pregnant and lactating women in the lowest tier of Rwanda's social support system. Data were collected in 2017, 2018 and 2021 through interviews with caregivers; anthropometric measurements and a capillary blood sample were obtained from children. The primary statistical analysis compared the nutritional status of children before and after the introduction of FBF. We enroled 724 children during each survey. The prevalence of stunting declined from 47% to 35% between 2017 and 2021; in 2018, the prevalence of stunting was 43%. Children had a 42% reduction in the odds of being stunted (adjusted odds ratio [AOR]: 0.58, 95% confidence interval [CI]: 0.47-0.74, p < 0.001) from 2017 to 2021 even after adjusting for inherent, distal, proximal, and intermediate covariates. The reduction in stunting observed within the first year of the programme was not statistically significant (AOR: 0.83, 95% CI: 0.67-1.03, p < 0.091). We observed meaningful reductions in the prevalence of stunting among children which coincided with the introduction of Government-led initiative to reduce malnutrition. The Rwandan Government has committed to improving the living conditions of vulnerable households and has made strong investments in reducing malnutrition. The impact of these investments can be seen in the overall trend towards improved nutritional status highlighted in this evaluation.

Case review of perinatal deaths at hospitals in Kigali, Rwanda: perinatal audit with application of a three-delays analysis.

BACKGROUND: Perinatal audit and the three-delays model are increasingly being employed to analyse barriers to perinatal health, at both community and facility level. Using these approaches, our aim was to assess factors that could contribute to perinatal mortality and potentially avoidable deaths at Rwandan hospitals. METHODS: Perinatal audits were carried out at two main urban hospitals, one at district level and the other at tertiary level, in Kigali, Rwanda, from July 2012 to May 2013. Stillbirths and early neonatal deaths occurring after 22 completed weeks of gestation or more, or weighing at least 500 g, were included in the study. Factors contributing to mortality and potentially avoidable deaths, considering the local resources and feasibility, were identified using a three-delays model. RESULTS: Out of 8424 births, there were 269 perinatal deaths (106 macerated stillbirths, 63 fresh stillbirths, 100 early neonatal deaths) corresponding to a stillbirth rate of 20/1000 births and a perinatal mortality rate of 32/1000 births. In total, 250 perinatal deaths were available for audit. Factors contributing to mortality were ascertained for 79% of deaths. Delay in care-seeking was identified in 39% of deaths, delay in arriving at the health facility in 10%, and provision of suboptimal care at the health facility in 37%. Delay in seeking adequate care was commonly characterized by difficulties in recognising or reporting pregnancy-related danger signs. Lack of money was the major cause of delay in reaching a health facility. Delay in referrals, diagnosis and management of emergency obstetric cases were the most prominent contributors affecting the provision of appropriate and timely care by healthcare providers. Half of the perinatal deaths were judged to be potentially avoidable and 70% of these were fresh stillbirths and early neonatal deaths. CONCLUSIONS: Factors contributing to delays underlying perinatal mortality were identified in more than three-quarters of deaths. Half of the perinatal deaths were considered likely to be preventable and mainly related to modifiable maternal inadequate health-seeking behaviours and intrapartum suboptimal care. Strengthening the current roadmap strategy for accelerating the reduction of maternal and neonatal morbidity and mortality is needed for improved perinatal survival.

Transitioning to Country Ownership of HIV Programs in Rwanda.

Agnes Binagwaho and colleagues describe how Rwanda achieved country ownership of its HIV programs.

Social equity in perinatal survival: a case-control study at hospitals in Kigali, Rwanda.

AIM: Rwanda has invested heavily in improving maternal and child health, but knowledge is limited regarding social equity in perinatal survival. We analysed whether perinatal mortality risks differed between social groups in hospitals in the country's capital. METHODS: A case-control study was carried out on singleton births aged at least 22 weeks of gestation and born in district or tertiary referral hospitals in Kigali from July 2013 to May 2014. Perinatal deaths were recorded as they occurred, with the next two surviving neonates born in the same hospital selected as controls. Conditional logistic regression was used to determine social determinants of perinatal death after adjustments for potential confounders. RESULTS: We analysed 234 perinatal deaths and 468 controls. Rural residence was linked to an increased risk of perinatal death (OR = 3.31, 95% CI 1.43-7.61), but maternal education or household asset score levels were not. Having no health insurance (OR = 2.11, 95% CI 0.91-4.89) was associated with an increased risk of perinatal death, compared to having community health insurance. CONCLUSION: Living in a rural area and having no health insurance were associated with an increased risk of perinatal mortality rates in the Rwandan capital, but maternal education and household assets were not.

Evaluating Helping Babies Breathe: training for healthcare workers at hospitals in Rwanda.

AIM: To evaluate the educational effectiveness of the Helping Babies Breathe programme. METHODS: Knowledge of trainees from two district hospitals and one tertiary referral hospital was evaluated before and after training in 2010. A postcourse practical skills evaluation was performed on a Neonatalie Newborn Simulator. Participants underwent a re-evaluation after 3 months. RESULTS: One hundred eighteen trainees completed the course. The percentages of correct answers on a written test significantly increased from 77 ± 15% to 91 ± 9% (p < 0.01) after training. The mean score obtained on a postcourse skill evaluation was 89 ± 9%; 64% of the trainees achieved passing scores. Retesting 3 months later showed that knowledge remained at the same level, while practical skills decreased to 83 ± 16%, and the pass rate dropped significantly to 43% (p < 0.01). CONCLUSION: Healthcare workers who participate in a Helping Babies Breathe programme can significantly improve their knowledge. While such knowledge is retained for at least 3 months, skills dropped to unsatisfactory levels in that period of time, indicating the need for retraining in the interim or the acquisition of practical experience by such healthcare workers.

Acquired HIV drug resistance among adults living with HIV receiving first-line antiretroviral therapy in Rwanda: A cross-sectional nationally representative survey.

BACKGROUND: We assessed the prevalence of acquired HIV drug resistance (HIVDR) and associated factors among patients receiving first-line antiretroviral therapy (ART) in Rwanda. METHODS: This cross-sectional study included 702 patients receiving first-line ART for at least 6 months with last viral load (VL) results ≥1000 copies/mL. Blood plasma samples were subjected to VL testing; specimens with unsuppressed VL were genotyped to identify HIVDR-associated mutations. Data were analysed using STATA/SE. RESULTS: Median time on ART was 86.4 months (interquartile range [IQR], 44.8-130.2 months), and median CD4 count at ART initiation was 311 cells/mm3 (IQR, 197-484 cells/mm3). Of 414 (68.2%) samples with unsuppressed VL, 378 (88.3%) were genotyped. HIVDR included 347 (90.4%) non-nucleoside reverse transcriptase inhibitor- (NNRTI), 291 (75.5%) nucleoside reverse transcriptase inhibitor- (NRTI) and 13 (3.5%) protease inhibitor (PI) resistance-associated mutations. The most common HIVDR mutations were K65R (22.7%), M184V (15.4%) and D67N (9.8%) for NRTIs and K103N (34.4%) and Y181C/I/V/YC (7%) for NNRTIs. Independent predictors of acquired HIVDR included current ART regimen of zidovudine + lamivudine + nevirapine (adjusted odds ratio [aOR], 3.333 [95% confidence interval (CI): 1.022-10.870]; p = 0.046) for NRTI resistance and current ART regimen of tenofovir + emtricitabine + nevirapine (aOR, 0.148 [95% CI: 0.028-0.779]; p = 0.025), zidovudine + lamivudine + efavirenz (aOR, 0.105 [95% CI: 0.016-0.693]; p = 0.020) and zidovudine + lamivudine + nevirapine (aOR, 0.259 [95% CI: 0.084-0.793]; p = 0.019) for NNRTI resistance. History of ever switching ART regimen was associated with NRTI resistance (aOR, 2.53 [95% CI: 1.198-5.356]; p = 0.016) and NNRTI resistance (aOR, 3.23 [95% CI: 1.435-7.278], p = 0.005). CONCLUSION: The prevalence of acquired HIV drug resistance (HIVDR) was high among patient failing to re-suppress VL and was associated with current ART regimen and ever switching ART regimen. The findings of this study support the current WHO guidelines recommending that patients on an NNRTI-based regimen should be switched based on a single viral load test and suggests that national HIV VL monitoring of patients receiving ART has prevented long-term treatment failure that would result in the accumulation of TAMs and potential loss of efficacy of all NRTI used in second-line ART as the backbone in combination with either dolutegravir or boosted PIs.

Hypertension and Associated Inflammatory Markers Among HIV-Infected Patients in Tanzania.

There remains a dearth of data regarding the association between chronic inflammation and hypertension (HTN) in sub-Saharan Africa, a region that accounts for >70% of the global burden of HIV infection. Therefore, we assessed the levels of biomarkers among HIV+ individuals and its associations with HTN in Tanzania. A cross-sectional study was conducted at one of the largest clinics in Tanzania and data from 261 HIV+ patients were analyzed. Standardized tools were used to collect data. Blood pressure was measured using Omron® M2 blood pressure monitor. Enzyme-linked immunosorbent assay was used to test for inflammatory markers [C-reactive protein (CRP), interleukin (IL)-6, IL-18, soluble tumor necrosis factor receptor type I (sTNFRI), sTNFRII]. Bivariate and multivariable analysis was conducted to examine association between the biomarkers and HTN. We further conducted age-sex-alcohol-adjusted models to control for any confounders. The prevalence of HTN was 43% with a high prevalence reported in female (70%) participants and those older than 55 years of age (77%). Being women, older than 55 years of age, married, and being overweight was associated with HTN. The highest correlations were observed between TNR2 and CRP (ɤ = 0.13, P = 0.044), and TNR2 and IL-18 (ɤ = 0.13, P = 0.034). Participants who had elevated CRP levels were 2 times more likely to experience HTN in the age-adjusted model [odds ratio (OR) = 3.5, 95% confidence interval (CI) = 1.1-11.3], age-sex-adjusted model (OR = 3.3, 95% CI = 1.0-10.9), and the full model (OR = 2.9, 95% CI = 0.8-10.0). Our study shows that high CRP levels are significantly associated with the higher prevalence of HTN notwithstanding all other markers, which showed a positive association with HTN despite not being significant. These findings point to the importance of creating awareness, education, and screening for HTN among HIV patients in high epidemic countries. More rigorous studies are needed to know the exact pathway mechanisms of inflammation in HIV patients.

Viral Suppression in a Nationwide Sample of HIV-Infected Children on Antiretroviral Therapy in Rwanda.

Rwanda has made significant progress in expanding pediatric antiretroviral treatment coverage. This was a nationwide, cross-sectional study of pediatric HIV suppression rates. Of 292 children on antiretroviral treatment ≥12 months, 68.8% achieved viral suppression < 40 copies/ml, respectively. Rwanda achieved good pediatric viral suppression rates, comparable to those from other resource-limited settings, yet more efforts are needed to achieve the UNAIDS 90-90-90 target.

Patient-level outcomes and virologic suppression rates in HIV-infected patients receiving antiretroviral therapy in Rwanda.

The Rwanda national HIV program has been successful at scaling up antiretroviral therapy (ART) to achieve universal access. The AIDSRelief Model of Care focuses on four key principles: (1) earlier initiation of ART; (2) use of durable, highly-potent, and sequence-friendly first-line ART regimens; (3) early detection of treatment failure; and (4) provision of community-based care and support to ensure optimal adherence and follow up/engagement in care. We conducted a retrospective cohort study of randomly-selected HIV-infected patients at AIDSRelief-supported sites using a stratified, random sample of 583 adults (>15 years) who initiated ART from 30 June 2008 to 1 February 2010. At ART initiation, the median patient age was 38 years, and 67% were female. The baseline median CD4+ cell count was 309 cells/mm3. Overall virologic suppression was 91%. Married/ever married status (adjusted prevalence odds ratio [aPOR] 3.75, 95% confidence interval [CI] 1.30-10.78) and self-reported adherence ≥95% in the past month (aPOR 2.76, 95% CI 1.00-7.62) were significantly associated with viral suppression in the multivariable model. Excellent virologic outcomes were achieved in Rwandan AIDSRelief sites utilizing the AIDSRelief Model of Care during the scale-up of ART in the country.

Hepatitis C treatment outcomes using interferon- and ribavirin-based therapy in Kigali, Rwanda.

BACKGROUND: Hepatitis C virus (HCV) treatment data in sub-Saharan Africa are limited. This study was to determine HCV sustained virologic response(SVR) at 24 weeks in patients undergoing HCV therapy in Kigali, Rwanda. METHODS: The paper presents data for all patients treated for HCV with ribavirin/interferon at King Faisal Hospital in Kigali, Rwanda, from 1 January 2007 to 31 December 2014. RESULTS AND CONCLUSIONS: There were 69 evaluable patients. HCV genotype 4(61%, 42/69) predominated. 24-week SVR was 70%(26/37) by per-protocol and 32%(26/69) by intention-to-treat analysis. HCV treatment in Rwanda is feasible. SVR with interferon/ribavirin was acceptable in the per-protocol analysis. Transition to newer direct acting antivirals is urgently needed in Rwanda and sub-Saharan Africa more generally to improve treatment outcomes.

Detectable Viral Load in Late Pregnancy among Women in the Rwanda Option B+ PMTCT Program: Enrollment Results from the Kabeho Study.

There are limited viral load (VL) data available from programs implementing "Option B+," lifelong antiretroviral treatment (ART) to all HIV-positive pregnant and postpartum women, in resource-limited settings. Extent of viral suppression from a prevention of mother-to-child transmission of HIV program in Rwanda was assessed among women enrolled in the Kigali Antiretroviral and Breastfeeding Assessment for the Elimination of HIV (Kabeho) Study. ARV drug resistance testing was conducted on women with VL>2000 copies/ml. In April 2013-January 2014, 608 pregnant or early postpartum HIV-positive women were enrolled in 14 facilities. Factors associated with detectable enrollment VL (>20 copies/ml) were examined using generalized estimating equations. The most common antiretroviral regimen (56.7%, 344/607) was tenofovir/lamivudine/efavirenz. Median ART duration was 13.5 months (IQR 3.0-48.8); 76.1% of women were on ART at first antenatal visit. Half of women (315/603) had undetectable RNA-PCR VL and 84.6% (510) had <1,000 copies/ml. Detectable VL increased among those on ART > 36 months compared to those on ART 4-36 months (72/191, 37.7% versus 56/187, 29.9%), though the difference was not significant. The odds of having detectable enrollment VL decreased significantly as duration on ART at enrollment increased (AOR = 0.99, 95% CI: 0.9857, 0.9998, p = 0.043). There was a higher likelihood of detectable VL for women with lower gravidity (AOR = 0.90, 95% CI: 0.84, 0.97, p = 0.0039), no education (AOR = 2.25, (95% CI: 1.37, 3.70, p = 0.0004), nondisclosure to partner (AOR = 1.97, 95% CI: 1.21, 3.21, p = 0.0063) and side effects (AOR = 2.63, 95% CI: 1.72, 4.03, p<0.0001). ARV drug resistance mutations were detected in all of the eleven women on ART > 36 months with genotyping available. Most women were receiving ART at first antenatal visit, with relatively high viral suppression rates. Shorter ART duration was associated with higher VL, with a concerning increasing trend for higher viremia and drug resistance among women on ART for >3 years.

HIV drug resistance mutations among patients failing second-line antiretroviral therapy in Rwanda.

BACKGROUND: Studies of patients failing second-line antiretroviral therapy (ART) in resource-limited settings (RLS) are few. Evidence suggests most patients who appear to be virologically failing do so not due to drug resistance but to poor adherence, which, if properly addressed, could allow continued use of less expensive first- and second-line regimens. Drug resistant mutations (DRMs) were characterized among patients virologically failing second-line ART in Rwanda. METHODS: A total of 128 adult patients receiving second-line ART for at least 6 months were invited to participate; 74 agreed and had HIV-1 viral load (VL) measured. Resistance genotypes were conducted in patients with virological failure (VF; that is, VL ≥1,000 copies/ml). RESULTS: In total, 35 patients met the criteria for VF. The median time on lopinavir/ritonavir-based second-line ART was 2.7 years. Of 30 successful resistance genotype analyses, 13 (43%) had ≥1 nucleoside reverse transcriptase inhibitor (NRTI) mutation, 18 (60%) had at least 1 non-NRTI mutation and 5 (17%) had at least 1 major protease inhibitor mutation. Eleven (37%) had virus without significant mutations that would be fully sensitive to first-line ART; 12 (40%) had DRM to first-line ART but sensitive to second-line ART. Only 7 patients (23%) demonstrated a DRM profile requiring third-line ART. CONCLUSIONS: Among 30 genotyped samples of patients with VF on second-line ART, more than one-third had no significant DRMs, implicating poor adherence as the primary cause of VF. The majority of patients (77%) would not have required third-line ART. These findings reinforce the need for intensive adherence assessment and counselling for patients who appear to be failing second-line ART in RLS.

Trends and social differentials in child mortality in Rwanda 1990-2010: results from three demographic and health surveys.

BACKGROUND: Rwanda has embarked on ambitious programmes to provide equitable health services and reduce mortality in childhood. Evidence from other countries indicates that advances in child survival often have come at the expense of increasing inequity. Our aims were to analyse trends and social differentials in mortality before the age of 5 years in Rwanda from 1990 to 2010. METHODS: We performed secondary analyses of data from three Demographic and Health Surveys conducted in 2000, 2005 and 2010 in Rwanda. These surveys included 34 790 children born between 1990 and 2010 to women aged 15-49 years. The main outcome measures were neonatal mortality rates (NMR) and under-5 mortality rates (U5MR) over time, and in relation to mother's educational level, urban or rural residence and household wealth. Generalised linear mixed effects models and a mixed effects Cox model (frailty model) were used, with adjustments for confounders and cluster sampling method. RESULTS: Mortality rates in Rwanda peaked in 1994 at the time of the genocide (NMR 60/1000 live births, 95% CI 51 to 65; U5MR 238/1000 live births, 95% CI 226 to 251). The 1990s and the first half of the 2000s were characterised by a marked rural/urban divide and inequity in child survival between maternal groups with different levels of education. Towards the end of the study period (2005-2010) NMR had been reduced to 26/1000 (95% CI 23 to 29) and U5MR to 65/1000 (95% CI 61 to 70), with little or no difference between urban and rural areas, and household wealth groups, while children of women with no education still had significantly higher U5MR. CONCLUSIONS: Recent reductions in child mortality in Rwanda have concurred with improved social equity in child survival. Current challenges include the prevention of newborn deaths.

Palliative care and support for persons with HIV/AIDS in 7 African countries: implementation experience and future priorities.

To combat morbidity and mortality from the worldwide epidemic of the human immunodeficiency virus (HIV), the United States Congress implemented a President's Emergency Plan for AIDS Relief (PEPFAR) in 30 resource-limited countries to integrate combination antiretroviral therapy (ART) for both prevention and cure. Over 35% of eligible persons have been successfully treated. Initial legislation cited palliative care as an essential aspect of this plan but overall health strengthening became critical to sustainability of programming and funding priorities shifted to assure staffing for care delivery sites; laboratory and pharmaceutical infrastructure; data collection and reporting; and financial management as individual countries are being encouraged to assume control of in-country funding. Given infrastructure requisites, individual care delivery beyond ART management alone has received minimal funding yet care remains necessary for durable viral suppression and overall quality of life for individuals. Technical assistance staff of one implementing partner representing seven African countries met to clarify domains of palliative care compared with the substituted term "care and support" to understand potential gaps in on-going HIV care. They prioritized care needs as: 1) mental health (depression and other mood disorders); 2) communication skills (age-appropriate disclosure of HIV status); 3) support of care-providers (stress management for sustainability of a skilled HIV workforce); 4) Tied Priorities: symptom management in opportunistic infections; end-of-life care; spiritual history-taking; and 5) Tied Priorities: attention to grief-related needs of patients, their families and staff; and management of HIV co-morbidities. This process can inform health policy as funding transitions to new priorities.