Design and methods for a quasi-experimental pilot study to evaluate the impact of dual active ingredient insecticide-treated nets on malaria burden in five regions in sub-Saharan Africa.

BACKGROUND: Vector control tools have contributed significantly to a reduction in malaria burden since 2000, primarily through insecticidal-treated bed nets (ITNs) and indoor residual spraying. In the face of increasing insecticide resistance in key malaria vector species, global progress in malaria control has stalled. Innovative tools, such as dual active ingredient (dual-AI) ITNs that are effective at killing insecticide-resistant mosquitoes have recently been introduced. However, large-scale uptake has been slow for several reasons, including higher costs and limited evidence on their incremental effectiveness and cost-effectiveness. The present report describes the design of several observational studies aimed to determine the effectiveness and cost-effectiveness of dual-AI ITNs, compared to standard pyrethroid-only ITNs, at reducing malaria transmission across a variety of transmission settings. METHODS: Observational pilot studies are ongoing in Burkina Faso, Mozambique, Nigeria, and Rwanda, leveraging dual-AI ITN rollouts nested within the 2019 and 2020 mass distribution campaigns in each country. Enhanced surveillance occurring in select study districts include annual cross-sectional surveys during peak transmission seasons, monthly entomological surveillance, passive case detection using routine health facility surveillance systems, and studies on human behaviour and ITN use patterns. Data will compare changes in malaria transmission and disease burden in districts receiving dual-AI ITNs to similar districts receiving standard pyrethroid-only ITNs over three years. The costs of net distribution will be calculated using the provider perspective including financial and economic costs, and a cost-effectiveness analysis will assess incremental cost-effectiveness ratios for Interceptor® G2, Royal Guard®, and piperonyl butoxide ITNs in comparison to standard pyrethroid-only ITNs, based on incidence rate ratios calculated from routine data. CONCLUSIONS: Evidence of the effectiveness and cost-effectiveness of the dual-AI ITNs from these pilot studies will complement evidence from two contemporary cluster randomized control trials, one in Benin and one in Tanzania, to provide key information to malaria control programmes, policymakers, and donors to help guide decision-making and planning for local malaria control and elimination strategies. Understanding the breadth of contexts where these dual-AI ITNs are most effective and collecting robust information on factors influencing comparative effectiveness could improve uptake and availability and help maximize their impact.

What do people benefit from a citizen science programme? Evidence from a Rwandan citizen science programme on malaria control.

BACKGROUND: Malaria control remains a challenge globally and in malaria-endemic countries in particular. In Rwanda, a citizen science programme has been set up to improve malaria control. Citizens are involved in collecting mosquito species and reporting mosquito nuisance. This study assessed what people benefit from such a citizen science programme. The analysis was conducted on how the citizen science programme influenced perceptions and behaviour related to malaria control. METHODS: This study employed a mixed-methods approach using dissemination workshops, a survey, and village meetings as the main data collection methods. Dissemination workshops and village meetings involved 112 volunteers of the citizen science programme and were conducted to explore: (1) the benefits of being involved in the programme and (2) different ways used to share malaria-related information to non-volunteers. The survey involved 328 people (110 volunteers and 218 non-volunteers) and was used to compare differences in malaria-related perceptions and behaviour over time (between 2017 and 2019), as well as between volunteers and non-volunteers. RESULTS: Malaria-related perceptions and behaviour changed significantly over time (between 2017 and 2019) and became favourable to malaria control. When the findings were compared between volunteers and non-volunteers, for perceptions, only perceived self-efficacy showed a significant difference between these two groups. However, volunteers showed significantly more social interaction, participation in malaria-related activities at the community level, and indoor residual spraying (IRS) acceptance. In addition, both volunteers and non-volunteers reported to have gained knowledge and skills about the use of malaria control measures in general, and mosquito species in particular among volunteers. CONCLUSION: The reported knowledge and skills gained among non-volunteers indicate a diffusion of the citizen science programme-related information in the community. Thus, the citizen science programme has the potential to provide individual and collective benefits to volunteers and society at large.

Malaria, anaemia and under-nutrition: three frequently co-existing conditions among preschool children in rural Rwanda.

BACKGROUND: Malaria, anaemia and under-nutrition are three highly prevalent and frequently co-existing diseases that cause significant morbidity and mortality particularly among children aged less than 5 years. Currently, there is paucity of conclusive studies on the burden of and associations between malaria, anaemia and under-nutrition in Rwanda and comparable sub-Saharan and thus, this study measured the prevalence of malaria parasitaemia, anaemia and under-nutrition among preschool age children in a rural Rwandan setting and evaluated for interactions between and risk determinants for these three conditions. METHODS: A cross-sectional household (HH) survey involving children aged 6-59 months was conducted. Data on malaria parasitaemia, haemoglobin densities, anthropometry, demographics, socioeconomic status (SES) and malaria prevention knowledge and practices were collected. RESULTS: The prevalences of malaria parasitaemia and anaemia were 5.9 and 7.0 %, respectively, whilst the prevalence of stunting was 41.3 %. Malaria parasitaemia risk differed by age groups with odds ratio (OR) = 2.53; P = 0.04 for age group 24-35 months, OR = 3.5; P = 0.037 for age group 36-47 months, and OR = 3.03; P = 0.014 for age group 48-60 months, whilst a reduced risk was found among children living in high SES HHs (OR = 0.37; P = 0.029). Risk of anaemia was high among children aged ≥12 months, those with malaria parasitaemia (OR = 3.86; P ≤ 0.0001) and children living in HHs of lower SES. Overall, under-nutrition was not associated with malaria parasitaemia. Underweight was higher among males (OR = 1.444; P = 0.019) and children with anaemia (OR = 1.98; P = 0.004). CONCLUSIONS: In this study group, four in 10 and one in 10 children were found stunted and underweight, respectively, in an area of low malaria transmission. Under-nutrition was not associated with malaria risk. While the high prevalence of stunting requires urgent response, reductions in malaria parasitaemia and anaemia rates may require, in addition to scaled-up use of insecticide-treated bed nets and indoor residual insecticide spraying, improvements in HH SES and better housing to reduce risk of malaria.

Long-lasting insecticidal net source, ownership and use in the context of universal coverage: a household survey in eastern Rwanda.

BACKGROUND: Universal long-lasting insecticidal net (LLIN) coverage (ULC) has reduced malaria morbidity and mortality across Africa. Although information is available on bed net use in specific groups, such as pregnant women and children under 5 years, there is paucity of data on their use among the general population. Bed net source, ownership and determinants of use among individuals from households in an eastern Rwanda community 8 months after a ULC were characterized. METHODS: Using household-based, interviewer-administered questionnaires and interviewer-direct observations, data on bed net source, ownership and key determinants of net use, including demographics, socio-economic status indicators, house structure characteristics, as well as of bed net quantity, type and integrity, were collected from 1400 randomly selected households. Univariate and mixed effects logistic regression modelling was done to assess for determinants of bed net use. RESULTS: A total of 1410 households and 6598 individuals were included in the study. Overall, the proportion of households with at least one net was 92 % while bed net usage was reported among 72 % of household members. Of the households surveyed, a total ownership of 2768 nets was reported, of which about 96 % were reportedly LLINs received from the ULC. By interviewer-physical observation, 88 % of the nets owned were of the LLIN type with the remaining 12 % did not carry any mark to enable type recognition. The odds of bed net use were significantly lower among males and individuals: from households of low socio-economic status, from households with

Malaria parasite carriage and risk determinants in a rural population: a malariometric survey in Rwanda.

BACKGROUND: Based on routine health facility case data, Rwanda has achieved a significant malaria burden reduction in the past ten years. However, community-based malaria parasitaemia burden and reasons for continued residual infections, despite a high coverage of control interventions, have yet to be characterized. Measurement of malaria parasitaemia rates and evaluation of associated risk factors among asymptomatic household members in a rural community in Rwanda were conducted. METHODS: A malariometric household survey was conducted between June and November 2013, involving 12,965 persons living in 3,989 households located in 35 villages in a sector in eastern Rwanda. Screening for malaria parasite carriage and collection of demographic, socio-economic, house structural features, and prior fever management data, were performed. Logistic regression models with adjustment for within- and between-households clustering were used to assess malaria parasitaemia risk determinants. RESULTS: Overall, malaria parasitaemia was found in 652 (5%) individuals, with 518 (13%) of households having at least one parasitaemic member. High malaria parasite carriage risk was associated with being male, child or adolescent (age group 4-15), reported history of fever and living in a household with multiple occupants. A malaria parasite carriage risk-protective effect was associated with living in households of, higher socio-economic status, where the head of household was educated and where the house floor or walls were made of cement/bricks rather than mud/earth/wood materials. Parasitaemia cases were found to significantly cluster in the Gikundamvura area that neighbours marshlands. CONCLUSION: Overall, Ruhuha Sector can be classified as hypo-endemic, albeit with a particular 'cell of villages' posing a higher risk for malaria parasitaemia than others. Efforts to further reduce transmission and eventually eliminate malaria locally should focus on investments in programmes that improve house structure features (that limit indoor malaria transmission), making insecticide-treated bed nets and indoor residual spraying implementation more effective.

High human immunodeficiency virus incidence in a cohort of Rwandan female sex workers.

BACKGROUND: Measurement of human immunodeficiency virus(HIV) incidence among female sex workers in Rwanda is a key part of preparing for HIV prevention trials. METHODS: HIV-negative, nonpregnant female sex workers (N =397) were tested for HIV-1, sexually transmitted infections, and pregnancy quarterly for 12 months, and again at a 1-time year 2 visit. Additional women (N=156) were tested for HIV at baseline and 6 to 12 months thereafter in a parallel study. RESULTS: A total of 19 participants seroconverted during follow-up,with 13 in the first 12 months. The 12-month HIV incidence rate (IR)was 3.5 (95% confidence interval: 1.6, 5.4) per 100 person-years (PY).There was a nonsignificant downward trend from 4.6/100 PY (1.6, 7.7)in the first 6 months to 2.2 (0.1, 4.4) in the second 6 months (IR ratio:2.1 [95% confidence interval: 0.7, 7.8]). The year 2 IR was 2.1 (0.4,3.7), and the HIV IR in the parallel study (in the absence of frequent study visits) was 3.3/100 PY (0, 7.0). HIV testing history, lifetime pregnancies, recent initiation of sex work, gonorrhea, syphilis, and change in reproductive intentions were associated with incident HIV infection. Incidence of pregnancy, herpes simplex virus-type 2,trichomoniasis, gonorrhea, chlamydia, and syphilis per 100 PY were as follows: 26.3 (21.9, 30.7), 8.7 (4.0, 13.4), 16.9 (12.7, 21.1), 12.1 (8.2,15.9), 8.1 (5.1, 11.2), and 6.2 (3.7, 8.7). CONCLUSIONS: The HIV/sexually transmitted infections burden int his group was high. HIV IR was highest in the first 6 months of the cohort, and in the parallel study in which there were no risk-reduction procedures. HIV prevention and family planning interventions are needed.

Willingness to Contribute to Bio-Larviciding in the Fight against Malaria: A Contingent Valuation Study among Rice Farmers in Rwanda.

There is broad consensus that successful and sustained larval source management (LSM) interventions, including bio-larviciding campaigns, require embeddedness in local community institutions. Ideally, these community structures should also be capable of mobilizing local resources to (co-)finance interventions. To date, farmer cooperatives, especially cooperatives of rice growers whose economic activity facilitates mosquito breeding, have remained under the radar in designing community-based bio-larviciding campaigns. This study explores the potential of rice farmer cooperatives in Bugesera district, Rwanda, to take up the aforementioned roles. To this purpose, we surveyed 320 randomly selected rice farmers who belonged to one of four rice cooperatives in the area and elicited their willingness-to-pay (WTP) for application of Bti, a popular bio-larvicide, in their rice paddies. Results from a (non-incentivized) bidding game procedure, which tested two alternative contribution schemes showed that financial contributions would be significantly different from zero and sufficient to carry a co-financing share of 15-25 per cent. A strong heterogeneity in mean WTP is revealed across cooperatives, in addition to variation among individual farmers, which needs to be anticipated when engaging farmer cooperatives in LSM.

Why (not) participate in citizen science? Motivational factors and barriers to participate in a citizen science program for malaria control in Rwanda.

This study explores the motivational factors and barriers to participate in a citizen science program for malaria control in Rwanda. It assesses the changes in motivational factors over time and compares these factors among age and gender groups. Using a qualitative approach, this study involved 44 participants. At the initial stage, people participated in the program because of curiosity, desire to learn new things, helping others, and willingness to contribute to malaria control. As the engagement continued, other factors including ease of use of materials to report observations, the usefulness of the program, and recognition also played a crucial role in the retention of volunteers. Lack of time and information about the recruitment process, perceived low efficacy of the mosquito trap, and difficulties in collecting observations were reported as barriers to get and stay involved. Some variations in the motivational factors were observed among age and gender groups. At the initial phase, young adults and adults, as well as men and women were almost equally motivated to contribute to malaria control. For the ongoing phase, for age, the two groups were almost equally motivated by recognition of their effort. Also, the opportunity for learning was an important factor among young adults while ease of use of the materials was central for adults. For gender, the usefulness of the project, ease of use of materials, and learning opportunities were important motivational factors among women, while men were more motivated by recognition of their efforts. A framework including motivational factors and barriers at each stage of participation is presented. This framework may be used to explore motivations and barriers in future citizen science projects and might help coordinators of citizen science programs to determine whom to target, by which message, and at what stage of participation to retain volunteers in citizen science projects.

HIV diagnosis, linkage to HIV care, and HIV risk behaviors among newly diagnosed HIV-positive female sex workers in Kigali, Rwanda.

OBJECTIVE: To evaluate linkage-to-care, sexual behavior change, and psychosocial experiences among newly HIV-diagnosed female sex workers (FSWs) in Rwanda. METHODS: FSWs (n = 800) with unknown serostatus were screened for HIV during 2007/2008. Women testing HIV positive (n = 192) were referred to care and asked to return for interviews and laboratory testing 12-36 months postdiagnosis. One hundred fourty-one women (73%) returned for the postdiagnosis visit. RESULTS: Median CD4 count at diagnosis was 460 cells per microliter [interquartile range (IQR): 308-628], with 32% eligible for antiretroviral therapy (ART) per national CD4 criteria (median CD4: 235, IQR: 152-303). Postdiagnosis, 92% of women reported having disclosed their HIV status to a friend or relative, 85% reported having enrolled in HIV care (median 30 days after diagnosis, IQR: 7-360), including 89% among ART-eligible women. Among ART-eligible women in care, 87% had initiated ART, with a median follow-up CD4 count of 354 cells per microliter (IQR: 213-456). Women who did not initiate ART experienced a 6-month CD4 count change of -14 cells per microliter (IQR: -41 to 13). Three-quarters of women reported reduced sexual risk behavior postdiagnosis, with only 64% continuing to identify as FSWs. However, 53% reported past month condom use only "sometimes." CONCLUSIONS: Timely linkage to care and ART uptake were high in this group of Rwandan FSWs. However, risky sexual behaviors remained common after enrollment in care. HIV-positive FSWs are an important and receptive group for targeted efforts to increase HIV diagnosis and linkage to care/treatment. Once in care, intensified and sustained HIV prevention education is necessary.

Dual testing algorithm of BED-CEIA and AxSYM Avidity Index assays performs best in identifying recent HIV infection in a sample of Rwandan sex workers.

BACKGROUND: To assess the performance of BED-CEIA (BED) and AxSYM Avidity Index (Ax-AI) assays in estimating HIV incidence among female sex workers (FSW) in Kigali, Rwanda. METHODOLOGY AND FINDINGS: Eight hundred FSW of unknown HIV status were HIV tested; HIV-positive women had BED and Ax-AI testing at baseline and ≥12 months later to estimate assay false-recent rates (FRR). STARHS-based HIV incidence was estimated using the McWalter/Welte formula, and adjusted with locally derived FRR and CD4 results. HIV incidence and local assay window periods were estimated from a prospective cohort of FSW. At baseline, 190 HIV-positive women were BED and Ax-AI tested; 23 were classified as recent infection (RI). Assay FRR with 95% confidence intervals were: 3.6% (1.2-8.1) (BED); 10.6% (6.1-17.0) (Ax-AI); and 2.1% (0.4-6.1) (BED/Ax-AI combined). After FRR-adjustment, incidence estimates by BED, Ax-AI, and BED/Ax-AI were: 5.5/100 person-years (95% CI 2.2-8.7); 7.7 (3.2-12.3); and 4.4 (1.4-7.3). After CD4-adjustment, BED, Ax-AI, and BED/Ax-AI incidence estimates were: 5.6 (2.6-8.6); 9.7 (5.0-14.4); and 4.7 (2.0-7.5). HIV incidence rates in the first and second 6 months of the cohort were 4.6 (1.6-7.7) and 2.2 (0.1-4.4). CONCLUSIONS: Adjusted incidence estimates by BED/Ax-AI combined were similar to incidence in the first 6 months of the cohort. Furthermore, false-recent rate on the combined BED/Ax-AI algorithm was low and substantially lower than for either assay alone. Improved assay specificity with time since seroconversion suggests that specificity would be higher in population-based testing where more individuals have long-term infection.

High burden of prevalent and recently acquired HIV among female sex workers and female HIV voluntary testing center clients in Kigali, Rwanda.

OBJECTIVES: To estimate HIV prevalence and risk factors in population-based samples of female sex workers (FSW) and female voluntary counseling and testing (VCT) clients in Rwanda. METHODS: We conducted a cross-sectional survey of 800 FSW and 1,250 female VCT clients in Rwanda, which included interviewing and testing for HIV-1/2, HSV-2 and pregnancy, and BED-CEIA and Avidity Index (AI) to identify recent infections among HIV-infected women. RESULTS: Prevalence of HIV-1, HSV-2, and pregnancy were 24% (95% CI: 21.0-27.0), 59.8% (56.4-63.2), and 7.6% (5.8-9.5) among FSW, and 12.8% (10.9-14.6), 43.2% (40.4-46.0), and 11.4% (9.7-13.3) among VCT clients, respectively. Thirty-five percent of FSW and 25% of VCT clients had never been HIV tested. Per national guidelines, 33% of newly HIV-diagnosed FSW and 36% of VCT clients were already eligible for ART based on CD4<350 cells/µl. Condom use at last sex was higher among FSW (74%) than VCT clients (12%). In age and district of residence-adjusted models, HIV-1 seropositivity was associated with HSV-2 co-infection; recent treatment for sexually transmitted infection (STI); genital symptoms; forced sex; imprisonment; widowhood; and alcohol consumption. Eleven percent of FSW and 12% of VCT clients had recently acquired HIV-1 per BED-CEIA and AI. HSV-2 infection and recent STI treatment were associated with recent HIV infection in both groups, and being married and vaginal cleansing were associated with recent infection before last sex among VCT clients. CONCLUSIONS: This population-based survey reveals a high HIV prevalence and incidence among FSW and female VCT clients in Kigali, the scale of which is masked by the low general-population HIV prevalence in Rwanda. HIV/STI and family planning services should be strengthened.