Integration of new digital antenatal care tools using the WHO SMART guideline approach: Experiences from Rwanda and Zambia.

OBJECTIVES: Digital tools for decision-support and health records can address the protracted process of guideline adoption at local levels and accelerate countries' implementation of new health policies and programmes. World Health Organization (WHO) launched the SMART Guidelines approach to support the uptake of clinical, public health, and data recommendations within digital systems. SMART guidelines are a package of tools that include Digital Adaptation Kits (DAKs), which distill WHO guidelines into a format that facilitates translation into digital systems. SMART Guidelines also include reference software applications known as digital modules. METHODS: This paper details the structured process to inform the adaptation of the WHO antenatal care (ANC) digital module to align with country-specific ANC packages for Zambia and Rwanda using the DAK. Digital landscape assessments were conducted to determine potential integrations between the ANC digital module and existing systems. A multi-stakeholder team consisting of Ministry of Health technical officers representing maternal health, HIV, digital health, and monitoring and evaluation at district and national levels was assembled to review existing guidelines to adapt the DAK. RESULTS: The landscape analysis resulted in considerations for integrating the ANC module into the broader digital ecosystems of both countries. Adaptations to the DAK included adding national services not reflected in the generic DAK and modification of decision support logic and indicators. Over 80% of the generic DAK content was consistent with processes for both countries. The adapted DAK will inform the customization of country-specific ANC digital modules. CONCLUSION: Both countries found that coordination between maternal and digital health leads was critical to ensuring requirements were accurately reflected within the ANC digital module. Additionally, DAKs provided a structured process for gathering requirements, reviewing and addressing gaps within existing systems, and aligning clinical content.

Exploring contextual factors influencing the implementation of evidence-based care for hypertension in Rwanda: a cross-sectional study using the COACH questionnaire.

IMPORTANCE: Hypertension is the largest contributor to the Global Burden of Disease. In Rwanda, as in most low-income and middle-income countries, an increasing prevalence of hypertension and its associated morbidity and mortality is causing major healthcare and economic impact. Understanding healthcare systems context in hypertension care is necessary. OBJECTIVE: To study the hypertension healthcare context as perceived by healthcare providers using the Context Assessment for Community Health (COACH) tool. DESIGN: A cross-sectional cohort responded to the COACH questionnaire and a survey about hypertension training. SETTING: Three tertiary care hospitals in Rwanda. PARTICIPANTS: Healthcare professionals (n=223). PRIMARY OUTCOMES AND MEASURES: The COACH tool consists of 49 items with eight subscales: resources, community engagement, commitment to work, informal payment, leadership, work culture, monitoring services for action (5-point Likert Scale) and sources of knowledge (on a 0-1 scale). Four questions surveyed training on hypertension. RESULTS: Responders (n=223, 75% women; 56% aged 20-35 years) included nurses (n=142, 64%, midwives (n=42, 19%), primary care physicians (n=28, 13%) and physician specialists (n=11, 5%)). The subscales commitment to work, leadership, work culture and informal payment scored between 4.7 and 4.1 and the community engagement, monitoring services for action and organizational resources scored between 3.1 and 3.5. Sources of knowledge had a mean score of 0.6±0.3. While 73% reported having attended a didactic hypertension seminar in the past year, only 28% had received long-term training and 51% had <3-year experience working with hypertension care delivery. The majority (99%) indicated a need for additional training in hypertension care. CONCLUSIONS: There is a need for increased and continuous training in Rwanda. Healthcare responders stated a commitment to work and reported supportive leadership, while acknowledging limited resources and no monitoring systems. The COACH tool provides contextual guidance to develop training strategies prior to the implementation of a sustainable hypertension care programme.

NIH Workshop on HIV-Associated Comorbidities, Coinfections, and Complications: Summary and Recommendation for Future Research.

BACKGROUND: With potent antiretroviral therapy and simplified regimens, people living with HIV (PWH) are achieving near-normal lifespans but not necessarily a normal health span or healthy aging. PWH have a higher than expected risk of developing a number of non-AIDS comorbidities, coinfections, and complications (CCC), often against a background of stigma, poverty, and isolation. SETTING: To gain a better understanding of research needs for HIV-associated CCC, the NIH convened a 2-day workshop (HIV-associated CCC, or HIV ACTION). METHODS: A cross-institute NIH planning committee identified 6 key research areas: epidemiology and population research, pathogenesis and basic science research, clinical research, implementation science research, syndemics research and international research in low and middle income countries. Investigators were selected to lead working groups (WGs) to assess the state-of-the-art and identify 3-5 priority areas in each field before the workshop. A 2-day program at the NIH was developed which included presentations by invited experts and WG members. RESULTS: Over 400 participants attended the workshop. After general and individual WG discussions, the most pressing gaps, questions, or proposed action items were identified. Priority lists of pressing research issues were presented by cochairs of each WG. A detailed report is posted at the NHLBI website. This article reports the streamlined priority list and a summary of WG discussions to inform investigators of current priorities in the field. CONCLUSION: Collaborative efforts of many disciplines are needed to improve the health and wellbeing of PWH. Several common themes emerged across WG representing potential priorities for investigators and recommendations for the NIH.

Proactive prevention: Act now to disrupt the impending non-communicable disease crisis in low-burden populations.

Non-communicable disease (NCD) prevention efforts have traditionally targeted high-risk and high-burden populations. We propose an alteration in prevention efforts to also include emphasis and focus on low-risk populations, predominantly younger individuals and low-prevalence populations. We refer to this approach as "proactive prevention." This emphasis is based on the priority to put in place policies, programs, and infrastructure that can disrupt the epidemiological transition to develop NCDs among these groups, thereby averting future NCD crises. Proactive prevention strategies can be classified, and their implementation prioritized, based on a 2-dimensional assessment: impact and feasibility. Thus, potential interventions can be categorized into a 2-by-2 matrix: high impact/high feasibility, high impact/low feasibility, low impact/high feasibility, and low impact/low feasibility. We propose that high impact/high feasibility interventions are ready to be implemented (act), while high impact/low feasibility interventions require efforts to foster buy-in first. Low impact/high feasibility interventions need to be changed to improve their impact while low impact/low feasibility might be best re-designed in the context of limited resources. Using this framework, policy makers, public health experts, and other stakeholders can more effectively prioritize and leverage limited resources in an effort to slow or prevent the evolving global NCD crisis.

The TDR MOOC training in implementation research: evaluation of feasibility and lessons learned in Rwanda.

BACKGROUND: Hypertension (HTN) affects nearly 1 billion people globally and is a major cause of morbidity and mortality. In low- and middle-income countries (LMICs), HTN represents an unmet health care gap that can be addressed by strengthening national health care systems. The National Heart, Lung, and Blood Institute recently funded the T4 Translation Research Capacity Building Initiative in Low Income Countries (TREIN) program to build capacity in dissemination and implementation (D&I) research in HTN in LMICs. The Special Programme for Research and Training in Tropical Diseases (TDR) at the World Health Organization (WHO) recently developed a massive open online course (MOOC) to train in D&I. Herein, we report on the use of the TDR WHO MOOC in D&I for the TREIN program in Rwanda, assessing feasibility of the MOOC and D&I competencies after MOOC training. METHODS: Participants in one-group MOOC training completed pre- and post-training questionnaires to assess dissemination and implementation (D&I) competency outcomes and feasibility. D&I competencies were measured by use of a scale developed for a US-based training program, with the change in competency scores assessed by paired t test. Feasibility was measured by completion of homework and final project assignment and analyzed using descriptive statistics. RESULTS: Of the 92 trainees enrolled, 35 (38%) completed all MOOC components. D&I competency scores showed strong evidence of improvements from pre- to post-test. The full-scale average score improved by an average of 1.09 points, representing an effect size of 1.25 (CI 0.48-2.00); all four subscales also showed strong evidence of improvements. Trainees reported challenges to MOOC course completion that included technological issues (i.e., limited internet access) and competing demands (i.e., work, family). CONCLUSIONS: In the context of LMIC training, the MOOC course was feasible and course completion showed improvement in D&I competency scores. While the program was designed with a focus on training for tropical diseases, there is potential for scalability to a wider audience of health care researchers, workers, administrators, and policymakers in LMIC interested in D&I research in non-communicable diseases.

Dissemination and Implementation Program in Hypertension in Rwanda: Report on Initial Training and Evaluation.

BACKGROUND: Cardiovascular disease (CVD) is the leading cause of morbidity and mortality worldwide and in low- and middle-income countries, and hypertension (HTN) is a major risk factor for CVD. Although effective evidence-based interventions for control of HTN in high-income countries exist, implementation of these in low- and middle-income countries has been challenging due to limited capacity and infrastructure for late-phase translational research. In Rwanda, the 2015 STEPS NCD (STEPwise Approach to Surveillance of Noncommunicable Diseases) risk survey reported an overall prevalence of HTN of 15% (95% confidence interval [CI]: 13.8 to 16.3) for those ages 15 to 64 years; prevalence increased with increasing age to 39% (95% CI: 35.7 to 43.1) for those ages 55 to 64 years; CVD was the third most common cause of mortality (7%). Suboptimal infrastructure and capacity in Rwanda hinders research and community knowledge for HTN control. OBJECTIVES: To address the issue of suboptimal capacity to implement evidence-based interventions in HTN, this project was designed with the following objectives: 1) to develop a regional needs assessment of infrastructure for dissemination and implementation (D & I) strategies for HTN-CVD control; 2) to develop HTN-CVD research capacity through creation of countrywide resources such as core research facilities and training in the fields of HTN-CVD, D & I, and biostatistics; and 3) to engage and train multiple stakeholders in D & I and HTN-CVD evidence-based interventions. METHODS: A weeklong training program in HTN-CVD, biostatistics, and D & I was conducted in Rwanda in August 2018, and pre- and post-D & I training competency questionnaires were administered. RESULTS: Questionnaire results show a statistically significant increase in D & I knowledge and skills as a result of training (full scale pre- to post-test scores: 2.12 ± 0.78 vs. 3.94 ± 0.42; p < 0.0001). CONCLUSIONS: Using principles of community engagement and train-the-trainer methods, we will continue to adapt guidelines and treatments for HTN-CVD developed in high-income countries to the context of Rwanda with the goal of establishing a sustainable platform to address the burden of disease from HTN-CVD.

Impact of maternal ART on mother-to-child transmission (MTCT) of HIV at six weeks postpartum in Rwanda.

BACKGROUND: In 2010, Rwanda adopted ART for prevention of mother to child transmission of HIV from pregnant women living with HIV during pregnancy and breasfeeding period. This study examines rates of mother-to-child-transmission of HIV at 6-10 weeks postpartum and risk factors for mother-to-child transmission of HIV (MTCT) among HIV infected women on ART during pregnancy and breastfeeding. METHODS: A cross-sectional survey study was conducted between July 2011-June 2012 among HIV-exposed infants aged 6-10 weeks and their mothers/caregivers. Stratified multi-stage, probability proportional to size and systematic sampling to select a national representative sample of clients. Consenting mothers/caregivers were interviewed on demographic and program interventions. Dry blood spots from HIV-exposed infants were collected for HIV testing using DNA PCR technique. Results are weighted for sample realization. Univariable analysis of socio-demographic and programmatic determinants of early mother-to-child transmission of HIV was conducted. Variables were retained for final multivariable models if they were either at least of marginal significance (p-value < 0.10) or played a confounding role (the variable had a noticeable impact > 10% change on the effect estimate). RESULTS: The study sample was 1639 infants with HIV test results. Twenty-six infants were diagnosed HIV-positive translating to a weighted MTCT estimate of 1.58% (95% CI 1.05-2.37%). Coverage of most elimination of MTCT (EMTCT) program interventions, was above 80, and 90.4% of mother-infant pairs received antiretroviral treatment or prophylaxis. Maternal ART and infant antiretroviral prophylaxis (OR 0.01; 95%CI 0.001-0.17) and maternal age older than 25 years were significantly protective (OR 0.33; 95%CI 0.14-0.78). No disclosure of HIV status, not testing for syphilis during pregnancy and preterm birth were significant risk factors for MTCT. Factors suggesting higher socio-demographic status (flush toilet, mother self-employed) were borderline risk factors for MTCT. CONCLUSION: ART for all women during pregnancy and breastfeeding was associated with the estimated low MTCT rate of 1.58%. Mothers who did not receive a full package of anti-retroviral therapy according to the Rwanda EMTCT protocol, and young and single mothers were at higher risk of MTCT and should be targeted for support in preventing HIV infection.

Caring for perinatally HIV-infected children: call for mental care for the children and the caregivers.

Antiretroviral therapy has dramatically improved the survival rate of perinatally HIV-infected children. For them to thrive, it is necessary to understand better their mental health issues. Caregivers play an important role in children's daily care and caregiver mental health may relate to children's mental health. However, this association has rarely been studied. Accordingly, the present study examined the associations between depression of caregivers and that of perinatally HIV-infected children in Kigali, Rwanda. We conducted a cross-sectional study of 475 perinatally HIV-infected children aged 7-14 years and their caregivers. We collected children's depression score data via face-to-face interviews with children using the Beck Depression Inventory for Youth. We also collected sociodemographic data using a semi-structured questionnaire with caregivers. In addition, we measured children's weight, height, and collected their clinical records. Data were analyzed via linear and logistic regression analyses. Of all children, 22% had symptoms of depression. Among those who had depressive symptoms (n= 105), 49% had never received psychological support. In both the linear and logistic regression analysis, caregiver's high depression scores were positively associated with children's higher depression scores (AOR: 3.064, 95% CI: 1.723, 4.855, and AOR: 1.759, 95% CI: 1.129, 2.740, respectively). Taking Efavirenz and low height-for-age were also positively associated with higher depression scores among HIV-infected children. Mental health needs to be addressed to improve quality of life of perinatally HIV-infected children. Caregiver's depression was positively associated with children's depressive symptoms. Caring for both children and the caregivers' mental health may prevent the mutual fostering of depression.

Validating the Children's Depression Inventory in the context of Rwanda.

BACKGROUND: Depression is often co-morbid with chronic conditions, and when combined with HIV it can increase progression and reduce survival. A brief and accurate screening tool for depression among children living with HIV is necessary to increase access to mental health care and improve HIV-related outcomes in the long-term. METHODS: A validation study was conducted, comparing the Children's Depression Inventory (CDI) with a structured clinical assessment as the gold standard among children living with HIV ages 7-14 years in Rwanda. The response rate was 87 % and the analysis was performed among 100 study participants. RESULTS: Twenty-five percent of children had a diagnosis of depression based on the clinical interview. Sensitivity of the CDI ranged from 44 to 76 % and specificity was 92 to 100 % for cut-off scores from 5 to 9. The area under the curve (AUC) for receiver operating characteristic analysis, an estimate of overall accuracy, was 0.87 (95 % confidence interval: 0.77 - 0.97). CONCLUSIONS: The significant prevalence of depression among children living with HIV in Rwanda reflects a critical need to advance mental health care in this population. Although overall accuracy of the CDI is reasonable in this context, further research needs to be done to develop a more sensitive measure of depression in this vulnerable population. Development of a highly sensitive screening measure will be a fundamental step towards improving access to mental health care among children living with HIV, potentially improving health outcomes and quality of life in the long-term as this vulnerable population transitions into adulthood.

Assessing Odor Level when Using PrePex for HIV Prevention: A Prospective, Randomized, Open Label, Blinded Assessor Trial to Improve Uptake of Male Circumcision.

The PrePex is a WHO--prequalified medical device for adult male circumcision for HIV prevention. The Government of Rwanda was the first country to implement the PrePex device and acts as the leading center of excellence providing training and formal guidelines. As part of the Government's efforts to improve PrePex implementation, it made efforts to improve the psychological acceptability of device by men, thus increasing uptake with VMMC in sub-Saharan Africa. Some men who underwent the PrePex procedure complained of foreskin odor while wearing the PrePex 3-7 days after it was placed. This complaint was identified as potential risk for uptake of the device. Researchers from Rwanda assumed there is a possible relation between the level of foreskin odor and patient foreskin hygiene technique. The Government of Rwanda decided to investigate those assumptions in a scientific way and conduct a trial to test different hygiene-cleaning methods in order to increase the acceptability of PrePex and mitigate the odor concern. The main objective of the trial was to compare odor levels between three arms, having identical personal hygiene but different foreskin hygiene techniques using either clear water with soap during a daily shower, soapy water using a syringe, or chlorhexidine using a syringe. One hundred and one subjects were enrolled to the trial and randomly allocated into three trial arms. Using chlorhexidine solution daily almost completely eliminated odor, and was statistically significant more effective that the other two arms. The trial results suggest that odor from the foreskin, while wearing the PrePex device, could be related to the growth of anaerobic bacteria, which can be prevented by a chlorhexidine cleaning method. This finding can be used to increase acceptability by men when considering PrePex as one of the leading methods for HIV prevention in VMMC programs.

Effect of selenium supplementation on CD4+ T-cell recovery, viral suppression and morbidity of HIV-infected patients in Rwanda: a randomized controlled trial.

OBJECTIVE: To examine the effect of selenium supplementation on CD4 T-cell counts, viral suppression, and time to antiretroviral therapy (ART) initiation in ART-naive HIV-infected patients in Rwanda. METHODS: A multicenter, double-blinded, placebo-controlled, randomized clinical trial was conducted. Eligible patients were HIV-infected adults (≥21 years) who had a CD4 cell count between 400 and 650 cells/µl (ART eligibility was ≤350 cells/µl throughout the trial), and were willing to practice barrier methods of birth control. Patients were randomized to receive once-daily 200 µg selenium tablets or identical placebo. They were followed for 24 months with assessments every 6 months. Declines in CD4 cell counts were modeled using linear regressions with generalized estimating equations and effect modification, and the composite outcome (ART eligible or ART initiation) using Cox proportional-hazards regression, both conducted with intention to treat. RESULTS: Of the 300 participants, 149 received selenium, 202 (67%) were women, and median age was 33.5 years. The rate of CD4 depletion was reduced by 43.8% [95% confidence interval (CI) 7.8-79.8% decrease] in the treatment arm - from mean 3.97 cells/µl per month to mean 2.23 cells/µl per month. We observed 96 composite outcome events - 45 (47%) in the treatment arm. We found no treatment effect for the composite outcome (hazard ratio 1.00, 95% CI 0.66-1.54) or viral suppression (odds ratio 1.18, 95% CI 0.71-1.94). The trial was underpowered for the composite outcome due to a lower-than-anticipated event rate. Adverse events were comparable throughout. CONCLUSIONS: This randomized clinical trial demonstrated that 24-month selenium supplementation significantly reduces the rate of CD4 cell count decline among ART-naive patients.

Hepatitis B and C seroprevalence among health care workers in a tertiary hospital in Rwanda.

BACKGROUND: Hepatitis B (HBV) and hepatitis C (HCV) are significant global public health challenges with health care workers (HCWs) at especially high risk of exposure in resource-poor settings. We aimed to measure HBV and HCV prevalence, identify exposure risks and evaluate hepatitis-related knowledge amongst Rwandan tertiary hospital HCWs. METHODS: A cross sectional study involving tertiary hospital employees was conducted from October to December 2013. A pre-coded questionnaire was used to collect data on HCWs' socio-demographics, risk factors and knowledge of blood-borne infection prevention. Blood samples were drawn and screened for hepatitis B surface antigen (HBsAg) and anti-HCV antibodies. RESULTS: Among 378 consenting HCWs, the prevalence of HBsAg positivity was 2.9% (11/378; 95% CI: 1.9 to 4.6%) and anti-HCV positivity 1.3% (5/378; 95% CI: 0.7 to 2.7%). Occupational exposure to blood was reported in 57.1% (216/378). Of the 17 participants (4.5%; 17/378) who reported having received the HBV vaccine, only 3 participants (0.8%) had received the three-dose vaccination course. Only 42 HCWs (42/378; 11.1%) were aware that a HBV vaccine was available. Most HCW (95.2%; 360/378) reported having been tested for HIV in the last 6 months. CONCLUSIONS: Despite their high workplace exposure risk, HBV and HCV sero-prevalence rates among HCWs were low. The low HBV vaccination coverage and poor knowledge of preventative measures among HCWs suggest low levels of viral hepatitis awareness despite this high exposure.

What makes orphans in Kigali, Rwanda, non-adherent to antiretroviral therapy? Perspectives of their caregivers.

INTRODUCTION: Every year, approximately 260,000 children are infected with HIV in low- and middle-income countries. The timely initiation and high level of maintenance of antiretroviral therapy (ART) are crucial to reducing the suffering of HIV-positive children. We need to develop a better understanding of the background of children's ART non-adherence because it is not well understood. The purpose of this study is to explore the background related to ART non-adherence, specifically in relation to the orphan status of children in Kigali, Rwanda. METHODS: We conducted 19 focus group discussions with a total of 121 caregivers of HIV-positive children in Kigali. The primary data for analysis were verbatim transcripts and socio-demographic data. A content analysis was performed for qualitative data analysis and interpretation. RESULTS: The study found several contextual factors that influenced non-adherence: among double orphans, there was psychological distance between the caregivers and children, whereas economic burden was the primary issue among paternal orphans. The factors promoting adherence also were unique to each orphan status, such as the positive attitude about disclosing serostatus to the child by double orphans' caregivers, and feelings of guilt about the child's condition among non-orphaned caregivers. CONCLUSIONS: Knowledge of orphan status is essential to elucidate the factors influencing ART adherence among HIV-positive children. In this qualitative study, we identified the orphan-related contextual factors that influenced ART adherence. Understanding the social context is important in dealing with the challenges to ART adherence among HIV-positive children.

Non-surgical adult male circumcision using the PrePex device: task-shifting from physicians to nurses.

The Republic of Rwanda is implementing a program of voluntary male circumcision (MC) to reduce HIV transmission but lacks the infrastructure for conventional surgical MC on a nationwide scale. Nonsurgical MC using the PrePex device was first assessed in 5 subjects on an inpatient basis. Subsequent procedures were on an outpatient basis. Physicians performed 100 outpatient procedures (Phase 1 of this study) and trained nurses in the technique; the nurses then independently performed 47 procedures (Phase 2). All subjects achieved complete circumcision and healing within 6 weeks. There were no cases of infection or bleeding. In Phase 1, one case of transient moderate diffuse edema occurred. In Phase 2, no adverse events were reported. Thus, outcomes of MC performed by nurses using the PrePex device were not inferior to outcomes achieved by physicians, suggesting that task-shifting MC by this method from physicians to nurses is feasible in Rwanda.

Rwanda 20 years on: investing in life.

Two decades ago, the genocide against the Tutsis in Rwanda led to the deaths of 1 million people, and the displacement of millions more. Injury and trauma were followed by the effects of a devastated health system and economy. In the years that followed, a new course set by a new government set into motion equity-oriented national policies focusing on social cohesion and people-centred development. Premature mortality rates have fallen precipitously in recent years, and life expectancy has doubled since the mid-1990s. Here we reflect on the lessons learned in rebuilding Rwanda's health sector during the past two decades, as the country now prepares itself to take on new challenges in health-care delivery.

High attrition before and after ART initiation among youth (15-24 years of age) enrolled in HIV care.

OBJECTIVES: To compare pre and post-ART attrition between youth (15-24 years) and other patients in HIV care, and to investigate factors associated with attrition among youth. DESIGN: Cohort study utilizing routinely collected patient-level data from 160 HIV clinics in Kenya, Mozambique, Tanzania, and Rwanda. METHODS: Patients at least 10 years of age enrolling in HIV care between 01/05 and 09/10 were included. Attrition (loss to follow-up or death 1 year after enrollment or ART initiation) was compared between youth and other patients using multivariate competing risk (pre-ART) and traditional (post-ART) Cox proportional hazards methods accounting for within-clinic correlation. Among youth, patient-level and clinic-level factors associated with attrition were similarly assessed. RESULTS: A total of 312,335 patients at least 10 years of age enrolled in HIV care; 147,936 (47%) initiated ART, 17% enrolling in care and 10% initiating ART were youth. Attrition before and after ART initiation was substantially higher among youth compared with other age groups. Among youth, nonpregnant women experienced lower pre-ART attrition than men [sub-division hazard ratio = 0.90, 95% confidence interval (CI): 0.86-0.94], while both pregnant [adjusted hazard ratio (AHR) = 0.85, 95% CI: 0.74-0.97] and nonpregnant (AHR = 0.79, 95% CI: 0.73-0.86) female youth experienced lower post-ART attrition than men. Youth attending clinics providing sexual and reproductive health services including condoms (AHR = 0.47, 95% CI: 0.32-0.70) and clinics offering adolescent support groups (AHR = 0.73, 95% CI: 0.52-1.0) experienced significantly lower attrition after ART initiation. CONCLUSION: Youth experienced substantially higher attrition before and after ART initiation compared with younger adolescents and older adults. Adolescent-friendly services were associated with reduced attrition among youth, particularly after ART initiation.

How do you circumcise a nation? The Rwandan case study.

Voluntary medical male circumcision has been conclusively demonstrated to reduce the lifetime risk of male acquisition of HIV. The strategy has been adopted as a component of a comprehensive strategy towards achieving an AIDS-free generation. A number of countries in which prevalence of HIV is high and circumcision is low have been identified as a priority, where innovative approaches to scale-up are currently being explored. Rwanda, as one of the priority countries, has faced a number of challenges to successful scale-up. We discuss here how simplifications in the procedure, addressing a lack of healthcare infrastructure and mobilizing resources, and engaging communities of both men and women have permitted Rwanda to move forward with more optimism in its scale-up tactics. Examples from Rwanda are used to highlight how these barriers can and should be addressed.