Effectiveness of Direct-acting Antivirals for the Treatment of Chronic Hepatitis C in Rwanda: A Retrospective Study.

BACKGROUND: Direct-acting antivirals (DAAs) are becoming accessible in sub-Saharan Africa. This study examined the effectiveness of DAAs in patients treated through the Rwandan national health system and identified factors associated with treatment outcomes. METHODS: This retrospective study used data from the national hepatitis C virus (HCV) program for patients who initiated DAAs between November 2015 and March 2017. Sustained virological response at 12 weeks after treatment (SVR12) was the primary outcome. Logistic regression models were fit to estimate the relationship between patients' clinical and demographic characteristics and treatment outcome. RESULTS: 894 patients started treatment during the study period; 590 completed treatment and had SVR12 results. Among the 304 patients without SVR12 results, 48 were lost to follow-up and 256 had no SVR12 results but clinical data indicated they likely completed treatment; these patients were classified as nonvirological failure because viral clearance could not be determined. In a per-protocol analysis of 590 patients with SVR12 results, SVR12 was achieved in 540 (92%), and virological failure occurred in 50 (8%). Pretreatment HCV RNA above the median split was associated with virological failure. Intention-to-treat analyses including all patients showed that SVR12 was achieved in 540 (60%), with nonvirological failure in 304 (34%) and virological failure in 50 (6%). Patients in Western Province were more likely to experience nonvirological failure than patients in Kigali, likely owing to the 5-7-hour travel required to access testing and treatment. CONCLUSIONS: DAAs were effective when implemented through the Rwandan national health system. Decentralization and enhanced financing are underway in Rwanda, which could improve access to treatment and follow-up as the country prepares for HCV elimination.

Retention in care and virological failure among adult HIV+ patients on second-line ART in Rwanda: a national representative study.

BACKGROUND: Currently, there is limited evidence on the effectiveness of second-line antiretroviral therapy (ART) in sub-Saharan Africa. To address this challenge, outcomes of second-line protease inhibitor (PI) based ART in Rwanda were assessed. METHODS: A two-stage cluster sampling design was undertaken. 49 of 340 health facilities linked to the open-source electronic medical record (EMR) system of Rwanda were randomly sampled. Data sampling criteria included adult HIV positive patients with documented change from first to second-line ART regimen. Retention in care and treatment failure (viral load above 1000 copies/mL) were evaluated using multivariable Cox proportional hazards and logistic regression models. RESULTS: A total of 1688 patients (60% females) initiated second-line ART PI-based regimen by 31st December 2016 with a median follow-up time of 26 months (IQR 24-36). Overall, 92.5% of patients were retained in care; 83% achieved VL ≤ 1000 copies/ml, 2.8% were lost to care and 2.2% died. Defaulting from care was associated with more recent initiation of ART- PI based regimen, CD4 cell count ≤500 cells/mm3 at initiation of second line ART and viral load > 1000 copies/ml at last measurement. Viral failure was associated with younger age, WHO stage III&IV at ART initiation, CD4 cell count ≤500 cells/mm3 at switch, atazanavir based second-line ART and receiving care at a health center compared to hospital settings. CONCLUSIONS: A high proportion of patients on second-line ART are doing relatively well in Rwanda and retained in care with low viral failure rates. However, enhanced understandings of adherence and adherence interventions for less healthy individuals are required. Routine viral load measurement and tracing of loss to follow-up is fundamental in resource limited settings, especially among less healthy patients.

The role of community health workers and local leaders in reducing attrition among participant in the AIDS indicator survey and HIV incidence in a national cohort study in Rwanda.

BACKGROUND: Retention of participants in longitudinal prospective surveys can challenging for population health researchers. Community health workers (CHWs) may help reduce attrition. METHODS: We used data came from a longitudinal prospective household-based survey targeting women and men in Rwanda, collected between June 2013 and December 2014. The sample was drawn from a population that included all residents of all 30 districts, 416 sectors, and 14,837 villages in Rwanda. The outcome measure was time to loss-to-follow-up. Follow up visits occurred at three, six and nine, and 12 months. A Cox proportional hazards model was constructed to identify factors independently associated with time to loss-to-follow-up. RESULTS: Overall, 14,222 respondents consented to be interviewed at baseline. At the end of 12 months of follow up, 13,728 were revisited and consented to participate at 12 months of follow up. The overall attrition rate was 8.0%. A majority of those lost (54.3%) were less than 25 years of age, male (55.1%), not living in union (67.3%), had no education level or had primary education level (71.4%), or were in the highest wealth index (54.2%). Compared to illiterate, secondary education was negatively associated with attrition. CONCLUSION: The Rwanda AIDS indicator and HIV incidence survey recorded a very high retention of participants after 12 months. CHWs and local leaders played a major role to reduce attrition rate and identifying factors associated with loss-to-follow-up can help CHWs strengthen the quality of longitudinal survey data.

Syphilis and HIV prevalence and associated factors to their co-infection, hepatitis B and hepatitis C viruses prevalence among female sex workers in Rwanda.

BACKGROUND: Human Immunodeficiency Virus (HIV), syphilis, Hepatitis B Virus (HBV) and Hepatitis C Virus (HCV) are sexually transmitted infections (STIs) and share modes of transmission. These infections are generally more prevalent among female sex workers (FSWs). METHODS: This is a cross-sectional study conducted among female sex workers (FSWs) in Rwanda in 2015. Venue-Day-Time (VDT) sampling method was used in recruiting participants. HIV, syphilis, HBV, and HCV testing were performed. Descriptive analyses and logistic regression models were computed. RESULTS: In total, 1978 FSWs were recruited. The majority (58.5%) was aged between 20 and 29 years old. Up to 63.9% of FSWs were single, 62.3% attained primary school, and 68.0% had no additional occupation beside sex work. Almost all FSWs (81.2%) had children. The majority of FSWs (68.4%) were venue-based, and most (53.5%) had spent less than five years in sex work. The overall prevalence of syphilis was 51.1%; it was 2.5% for HBV, 1.4% for HCV, 42.9% for HIV and 27.4% for syphilis/HIV co-infection. The prevalence of syphilis, HIV, and syphilis + HIV co-infection was increasing with age and decreasing with the level of education. A positive association with syphilis/HIV co-infection was found in: 25 years and older (aOR = 1.82 [95% CI:1.33-2.50]), having had a genital sore in the last 12 months (aOR = 1.34 [95% CI:1.05-1.71]), and having HBsAg-positive test (aOR = 2.09 [1.08-4.08]). CONCLUSION: The prevalence of HIV and syphilis infections and HIV/syphilis co-infection are very high among FSWs in Rwanda. A strong, specific prevention program for FSWs and to avert HIV infection and other STIs transmission to their clients is needed.

Hepatitis C virus and HIV co-infection among pregnant women in Rwanda.

BACKGROUND: Hepatitis C virus (HCV) infection is a pandemic causing disease; more than 185 million people are infected worldwide. An HCV antibody (Ab) prevalence of 6.0% was estimated in Central African countries. The study aimed at providing HCV prevalence estimates among pregnant women in Rwanda. METHODS: HCV surveillance through antibody screening test among pregnant women attending antenatal clinics was performed in 30 HIV sentinel surveillance sites in Rwanda. RESULTS: Among 12,903 pregnant women tested at antenatal clinics, 335 (2.6% [95% Confidence Interval 2.32-2.87]) tested positive for HCV Ab. The prevalence of HCV Ab in women aged 25-49 years was 2.8% compared to 2.4% in women aged 15-24 years (aOR = 1.3; [1.05-1.59]); This proportion was 2.7% [2.37-2.94] in pregnant women in engaged in non-salaried employment compared to 1.2% [0.24-2.14] in those engaged in salaried employment (aOR = 3.2; [1.60-6.58]). The proportion of HCV Ab-positive co-infected with HIV was estimated at 3.9% (13 cases). Women in urban residence were more likely to be associated with HCV-infection (OR = 1.3; 95%CI [1.0-1.6]) compared to those living in rural setting. CONCLUSION: HCV is a public health problem in pregnant women in Rwanda. Few pregnant women were co-infected with HCV and HIV. Living in urban setting was more likely to associate pregnant women with HCV infection.

Hepatitis B virus and HIV co-infection among pregnant women in Rwanda.

BACKGROUND: Hepatitis B virus (HBV) affects people worldwide but the local burden especially in pregnant women and their new born babies is unknown. In Rwanda HIV-infected individuals who are also infected with HBV are supposed to be initiated on ART immediately. HBV is easily transmitted from mother to child during delivery. We sought to estimate the prevalence of chronic HBV infection among pregnant women attending ante-natal clinic (ANC) in Rwanda and to determine factors associated with HBV and HIV co-infection. METHODS: This study used a cross-sectional survey, targeting pregnant women in sentinel sites. Pregnant women were tested for hepatitis B surface antigen (HBsAg) and HIV infection. A series of tests were done to ensure high sensitivity. Multivariable logistic regression was used to identify independent predictors of HBV-HIV co-infection among those collected during ANC sentinel surveillance, these included: age, marital status, education level, occupation, residence, pregnancy and syphilis infection. RESULTS: The prevalence of HBsAg among 13,121 pregnant women was 3.7% (95% CI: 3.4-4.0%) and was similar among different socio-demographic characteristics that were assessed. The proportion of HIV-infection among HBsAg-positive pregnant women was 4.1% [95% CI: 2.5-6.3%]. The prevalence of HBV-HIV co-infection was higher among women aged 15-24 years compared to those women aged 25-49 years [aOR = 6.9 (95% CI: 1.8-27.0)]. Women residing in urban areas seemed having HBV-HIV co-infection compared with women residing in rural areas [aOR = 4.3 (95% CI: 1.2-16.4)]. Women with more than two pregnancies were potentially having the co-infection compared to those with two or less (aOR = 6.9 (95% CI: 1.7-27.8). Women with RPR-positive test were seemed associated with HBV-HIV co-infection (aOR = 24.9 (95% CI: 5.0-122.9). CONCLUSION: Chronic HBV infection is a public health problem among pregnant women in Rwanda. Understanding that HBV-HIV co-infection may be more prominent in younger women from urban residences will help inform and strengthen HBV prevention and treatment programmes among HIV-infected pregnant women, which is crucial to this population.

Sexual and physical violence and associated factors among female sex workers in Rwanda: a cross-sectional survey.

Female sex workers (FSWs) frequently face violence in their working place. This study assessed the physical and sexual violence and associated factors among FSWs in Rwanda. A cross-sectional study was conducted among FSWs in Rwanda in 2015. Venue-Day-Time sampling method was used for recruitment. Descriptive analyses and logistic regression models were computed to assess factors associated with violence. In total, 1978 FSWs were recruited. A large proportion (18.3%) had been sexually abused outside of the family circle, and 37.8% had faced physical violence before 15 years of age. Clients were most often reported (67.0%) as perpetrators of physical violence in sex work. Being aged 25 years old and above, and having sexually transmitted infections (STIs) were positively associated with sexual violence (aOR = 2.1[95%CI: 1.80-2.39]) and (aOR = 3.0[95%CI: 1.01-2.14], respectively). Being aged 25 years old and above (aOR = 0.8[95%CI: 0.76-0.89]) and drinking alcohol every day (aOR = 0.6[95%CI: 0.42-0.87]) were negatively associated with physical violence. Sexual and physical violence was common among FSWs in Rwanda. Single FSWs are the most vulnerable to sexual violence. Alcohol consumption and having STIs are associated with violence against FSWs. Human rights and social protection as well as health promotion among FSWs is needed.

Sexual risk behaviors and practices of female sex workers in Rwanda in over a decade, 2006-2015.

Female sex workers (FSWs) are at high risk for HIV. Cross-sectional surveys using a venue-day-time approach for recruitment were conducted among FSWs in Rwanda in 2006, 2010 and 2015. Chi square test for trends was computed to determine behavior changes. Logistic regression models were computed to determine risk factors associated with consistent condom use for the 2015 survey. There were 1041, 1338, and 1978 FSWs surveyed in 2006, 2010, and 2015, respectively. Condom use at the last sexual encounter with a client was similar in all surveys: 84.2%, 64.1%, and 83.3% (p = 1.0), respectively. Comprehensive HIV knowledge among FSWs was higher in 2015 than in 2006: 18.4%, 53.1%, and 71.1% (p = 0.00), respectively. Living in Kigali City and the Western province (aOR = 1.9 [95% CI: 1.3-2.8] and aOR = 2.0 [95% CI: 1.4-2.9], respectively) and higher level of education (OR = 2.0 [95% CI: 1.4-2.9]) were positively associated with consistent condom use with a client. Street-based FSWs (aOR = 0.7 [95% CI: 0.6-0.9]); FSWs with sex work as sole occupation (aOR = 0.6 [95% CI: 0.5-0.7]); FSWs who experienced sexually transmitted infections in the last year (aOR = 0.7 [95% CI: 0.5-0.8]) and HIV-positive FSWs (aOR = 0.8 [95% CI: 0.6-0.9]) were less likely to report consistent condom use. HIV prevention methods have evolved among FSWs in RWanda over the last decade, but HIV prevalence remains high. Condom use among many FSWs is inconsistent. New approaches for behavior change and income-generating activities are needed to reduce the vulnerability of FSWs in Rwanda.

The Prevalence of Syphilis Infection and Its Associated Factors in the General Population of Rwanda: A National Household-Based Survey.

Background. The prevalence of syphilis among HIV-infected people is a public health concern, but there is limited literature to describe the true burden of syphilis in resource-limited settings. We conducted this survey in 2013 to estimate the prevalence of syphilis. Methods. A cross-sectional survey. Participants were tested for syphilis and HIV. Factors associated with syphilis infection were identified. Results. The prevalence of syphilis was 0.9% (95% CI: 0.7-1.1). This prevalence was higher in the 25-49-year-old age (1.1% [95% CI: 0.8-1.3]) than in the 15-24-year-old age (0.6% (95% CI: 0.4-0.9)). Women with lower education had a higher prevalence of syphilis (1.2% (95% CI: 0.9-1.5)) compared to others (0.4% (95% CI: 0.2-0.8)). This prevalence among HIV-infected people was six times higher: 4.8% (95% CI: 2.9-7.9) compared to HIV-negative people (0.8% (95% CI: 0.6-1.0)). The prevalence of syphilis among HIV-infected females was 5.9% (95% CI: 3.4-10.0). HIV-infected or concurrent sexual partners was associated with increased syphilis prevalence with aOR = 4.2 (95% CI: 2.5-7.2) and aOR = 4.2 (95% CI: 2.8-6.5), respectively. Conclusions. The prevalence of syphilis was significantly higher among HIV-infected patients. HIV infection and concurrent sexual partners are associated with an increased prevalence of syphilis. Preventing HIV might help in preventing syphilis.