United Nations General Assembly Special Session on HIV/AIDS

Transcription

1 REPUBLIC OF RWANDA January December 2007 United Nations General Assembly Special Session on HIV/AIDS Country Report - Rwanda Draft

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3 UNGASS COUNTRY PROGRESS REPORT REPUBLIC OF RWANDA Reporting Period: January 2006 December 2007 Submission Date: January 2008 DRAFT

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5 Acknowledgements The National AIDS Control Commission acknowledges the national institutions, civil society, development partners, stakeholders and individuals who contributed to the development of the Rwanda United Nations General Assembly Special Session on HIV and AIDS Country Progress Report for All ten national umbrellas in Rwanda have played a remarkable role in consulting their members throughout the country to ensure that the views expressed in this report are representative of civil society, including faith-based organisations and people living with handicaps. Special thanks go to the umbrellas of people living with HIV for their leadership for not only organising consultations and brilliantly conducting the consensus meeting over the achievements of Rwanda in the last two years, but also for openly recognising the gaps and helping to determine the way forward. Thanks also to the several human rights organisations who participated and contributed to the meeting. We assure all civil society groups that the government values their continued support of the HIV response in the country, and that their views are critical components in charting the way forward. Various Government ministries and departments are also acknowledged, in particular the Ministry of Health, CAMERWA and the Ministry of Finance and Economic Planning for their close collaboration in carrying out the National AIDS Spending Assessments. A special thanks to TRAC Plus - Center for Infectious Disease Control (TRAC, PNILP, PNILT), the National Reference Laboratory, the National Blood Transfusion Centre, the National Institute of Statistics, the Ministry of Education, the Ministry of Gender and Family Promotion, the CDLS and all of the key government authorities that have been so supportive in timely providing the necessary information. Several development partners and programs have been instrumental in collecting and validating the information reported here. Among others, we cite the United Nations agencies (United Nations Development Programme, United Nations Population Fund, The Office of the UN High Commissioner for Refugees, United Nations Children s Fund, the United Nations Development Fund for Women, the World Food Programme, and the World Health Organisation), the United States Agency for International Development/ the President s Emergency Plan for AIDS Relief, the Global Fund to fight AIDS, Tuberculosis and Malaria, the World Bank Multisectoral AIDS Programme, The Clinton Foundation, Population Services International and Family Health International. A special mention goes to the Joint United Nations Programme on HIV and AIDS (UNAIDS) for the technical and financial assistance provided in the development of this Report. This is the fourth progress report of the 2001 UNGASS commitments to fight HIV in Rwanda. We are proud of the enormous and increasing progress we are achieving, made possible through joint efforts guided by a clear national vision. We are now ready to collectively embrace the challenges ahead.

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7 TABLE OF CONTENTS 1 STATUS AT A GLANCE Report Preparation Process Status of the Epidemic Policy and Programmatic Response Overview Table of UNGASS Indicator Data OVERVIEW OF THE AIDS EPIDEMIC Institutional Context HIV Prevalence in the General Population HIV Prevalence in Most-at-risk Populations NATIONAL RESPONSE TO THE AIDS EPIDEMIC National Commitment HIV and AIDS Expenditure Policy/Strategy Development and Implementation Programme Implementation Prevention, Care, Treatment, and Support Knowledge and Behaviour Impact Alleviation BEST PRACTICES MAJOR CHALLENGES AND REMEDIAL ACTIONS Progress Made on Key Challenges Reported in Challenges Faced in 2007 and Remedial Actions Planned SUPPORT FROM DEVELOPMENT PARTNERS Key Support Received from Development Partners Actions Necessary to the Achievement of the UNGASS Targets MONITORING AND EVALUATION ENVIRONMENT Overview of the Current Monitoring and Evaluation System Challenges to the Implementation of a Comprehensive Monitoring and Evaluation System Remedial Actions Planned to Overcome Monitoring and Evaluation Challenges ANNEXES...44 Annex 1: Consultation/Preparation Process for the UNGASS Country Report 45 Annex 2: National Composite Policy Index Questionnaire

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9 ACRONYMS Acronym ADB AESD AIDS ANC ART ARV BCC BSS CAMERWA CDLS CI CNLS CNTS CRIS CSOs CTS DFID DOTS EABC EDPRS FARG FBO FHI GDP GFATM HSP HSSP HIV IDUs IEC KAP M&E MAP MDGs MIFOTRA MIGEPROFE MIJESPOC MINAFET MINAGRI MINALOC MINECOFIN MOE / MINEDUC MOH / MINISANTE MOU MSM MTCT NASA NCPI NGO NHA NISR NRL OIs OOP OVC PEPFAR PLHIV PM&E PMTCT PNILT PSI RDHS-II, III RRP+ RwF STI SWAp TB TRAC TRACNet African Development Bank Action of Evangelical Churches for the Promotion of Health and Development Acquired Immunodeficiency Syndrome (Syndrome d Immunodéfience Acquise) Antenatal Clinic Anti-retroviral Therapy Anti-retroviral Behavioural Change Communication Behavioural Surveillance Survey Central Purchasing of Essential Medicines in Rwanda District AIDS Control Committee (Comité de District de Lutte contre le SIDA) Confidence Interval National AIDS Control Commission (Commission Nationale de Lutte contre le Sida) National Blood Transfusion Centre (Centre National de Transfusion Sanguine) Country Response Information System Civil Society Organisations Blood Transfusion Centre (Centre de Transfusion Sanguine) Department for International Development (UK) Directly Observed Therapy Short-course Education, Abstain, Be faithful, use a Condom Economic Development and Poverty Reduction Strategy Genocide Survivors Fund (Fonds des Rescapés du Génocide) Faith-based Organisation Family Health International Gross Domestic Product The Global Fund to Fight AIDS, Tuberculosis and Malaria Health Sector Policy Health Sector Strategic Plan Human Immunodeficiency Virus Injecting Drug Users Information Education Communication Knowledge, Attitudes and Practices Monitoring and Evaluation Multisectoral AIDS Project (World Bank) Millennium Development Goals Ministry of Public Sector and Labour Ministry of Gender and Family Promotion Ministry of Youth, Sports and Culture Ministry of Foreign Affairs Ministry of Agriculture, Animal Husbandry and Forestry Ministry of Local Government, Community Development and Social Affairs Ministry of Finance and Economic Planning Ministry of Education Ministry of Health Memorandum of Understanding Men who have Sex with Men Mother-to-child Transmission National AIDS Spending Assessment National Composite Policy Index Non-governmental Organisation National Health Accounts National Institute of Statistics of Rwanda National Reference Laboratory Opportunistic Infections Out of Pocket Orphans and other Vulnerable Children President s Emergency Plan for AIDS Relief People Living with HIV Planning, Monitoring and Evaluation Prevention of Mother-to-child Transmission Integrated National Program of Fight against Leprosy and Tuberculosis (Programme Nationale Intégré de la Lutte contre la Lèpre et la Tuberculose) Population Services International Rwanda Demographic and Health Surveys II, III Network of Associations of People Living With HIV/AIDS (Le Réseau Rwandais des Personnes Vivant avec le VIH) Rwandan Francs Sexually Transmitted Infections Health Sector-wide Approach Tuberculosis Treatment and AIDS Research Center Information System for Monitoring HIV and AIDS medical component at TRAC

10 TWG Technical Working Group UNAIDS Joint United Nations Programme on HIV and AIDS UNDP United Nations Development Programme UNFPA United Nations Population Fund UNGASS United Nations General Assembly Special Session on HIV and AIDS UNICEF United Nations Children s Fund USAID United States Agency for International Development USD United States Dollars USG United States Government VCT Voluntary Counselling and Testing WHO World Health Organisation

11 1 STATUS AT A GLANCE 1.1 Report Preparation Process At the United Nations General Assembly Special Session (UNGASS) on HIV and AIDS in June 2001, 189 Member States, including Rwanda, adopted the Declaration of Commitment on HIV and AIDS, a framework for halting and beginning to reverse the HIV epidemic by This commitment encompasses global, regional, and countrylevel responses with regard to prevention, care, treatment, and impact mitigation and requires the cooperation of governments, private industry and labour groups, faith-based organisations (FBOs), nongovernmental organisations (NGOs), human rights groups, and other civil society entities, including organisations of people living with HIV (PLHIV). In order to monitor the progress in achieving the concrete, time-bound targets set out in the Declaration of Commitment on HIV and AIDS, countries report on a core set of indicators at the national level. In February 2006, the Republic of Rwanda released an UNGASS country report covering the reporting period of January 2003 through December Following on the previous report, this 2008 UNGASS report aims to present data for Rwanda for the reporting period of January 2006 through December 2007, while identifying problems and constraints and recommending actions to accelerate achievement of the targets. In Rwanda, the 2008 UNGASS reporting process began with a briefing of all partners by the National AIDS Control Commission (CNLS). Two national consultants were contracted and trained to conduct the National AIDS Spending Assessment (NASA). AIDS expenditure data was collected from leading stakeholders, and collated in accordance with the NHA survey. At the same time, the National Composite Policy Index (NCPI) Questionnaire Part B was distributed to all NGO partners, including several human rights organisations, the umbrella organisation for people living with HIV, RRP+, and other umbrella NGOs. Following consultation with their constituencies, the NGOs completed and returned the questionnaires accordingly. On 1 November 2007, civil society organisations (CSOs) brought together a large number of stakeholders to discuss the results of the completed questionnaires and build consensus. To ensure full independence of the responses, the government did not participate to that meeting. Part A of the NCPI Questionnaire was completed by the CNLS, District AIDS Control Committees (CDLS), the Treatment and AIDS Research Center (TRAC), and the umbrella for the public sector. Data collection for Indicators 3-25 was carried out by the CNLS in consultation with TRAC, the Joint United Nations Programme on HIV and AIDS (UNAIDS) and other key actors. Participatory workshops, involving participants from the national and decentralised levels, were held to endorse the report prior to its approval by national authorities.

12 1.2 Status of the Epidemic The most recent Rwanda Demographic and Health Survey (RDHS) was conducted in In this nationally representative population-based survey, adult HIV prevalence was found to be 3.0% (95% CI ). According to the national estimates (through the Spectrum 1 software), the total number of people currently living with HIV in Rwanda is 150,347 (2007). At the time of the RDHS in 2005, great variation was observed between urban areas (7.3%) and rural areas (2.2%). In spite of the differences by location at that time, given the high population density in Rwanda and the relative ease of movement within this small country, the 83% rural population is at risk of increased infection due to frequent contact with people in urban areas. Substantial differences in prevalence were also found between men and women. HIV prevalence among men was 2.3% while HIV prevalence among women was 3.6%. The available information about most-at-risk populations in Rwanda is limited. Although the existence of sex workers is increasingly acknowledged, and a behavioural surveillance survey (BSS) was recently conducted for a small sample of female sex workers, no surveillance data to indicate seroprevalence for male or female sex workers have been gathered. No research has yet been conducted regarding men who have sex with men (MSM), either to determine seroprevalence or to conduct a basic needs assessment for HIV prevention, treatment, care, and support. Truck drivers, prisoners and military personnel are also considered to be highly at risk for HIV in Rwanda. 1.3 Policy and Programmatic Response The NCPI Questionnaire Parts A and B were used as a guide for collecting information on policy and strategy development and implementation over the past two years. Detailed responses from the Government and civil society can be found in the full questionnaire annexed to this document. Government respondents completed Part A of the questionnaire, covering aspects of the policy development and implementation that included strategic planning, political support, prevention, treatment, care, and support, and monitoring and evaluation (M&E). Strategic planning efforts were rated very highly for both 2005 and The planning process is deemed to be well-organised, representative, and efficient. Political support was rated as ten out of a possible ten. Efforts in prevention, treatment, care and support were also rated highly, and planning processes are consistently noted as exemplary. However, an urgent need was identified to conduct assessments for most-atrisk populations to feed into the development of evidence-informed approaches to meet the needs of these groups. Coverage of services was identified as an area that still requires scale-up. Components of the M&E system were reported as being overall aligned and harmonised. Civil society representatives reached consensus regarding responses for Part B of the questionnaire covering human rights, civil society involvement, prevention, and treatment, care, and support. The overall rating of policies, laws, and regulations in place to promote and protect human rights in relation to HIV and AIDS on a scale of nought to ten was six for 2005, and eight for Free access to antiretroviral therapy (ART) since 2005, the increased involvement of FBOs and handicapped people, improved interventions for orphans and other vulnerable children (OVC), and increased understanding of HIV from a human rights perspective were listed as some of the major achievements in the past two years. The level of political support has been significant, with high-level officials regularly speaking about HIV at public events. However, access to financial and technical support for civil society was rated moderately. 1 EPP and Spectrum are a suite of mathematical models used for making national HIV estimates and projections. For instance, through the AIM module, the number of people living with HIV, new HIV infections, people needing treatment, AIDS deaths, and orphans can be estimated. These models takes into account complex demographic and epidemiological factors, leading to more accurate estimates than previous methods of calculation were able to provide. The estimates presented here are based on the best and most recent epidemiological and demographic data available for Rwanda. Every precaution was taken to ensure that the epidemic curve had the most probable fit for Rwanda epidemic and reflected observations from the field. Nevertheless, coverage figures inferred from the model for PMTCT and ART could be overestimated when compared to coverage expected from field observations. In the absence of better evidenced based data, for programming purpose, the CNLS has advised national institutions to proceed with previous scale-up targets for 2008, to avoid shortage of commodities, and to conduct field studies, before the end of 2008, to validate the results presented here. 10 For example. the downward tendency of the prevalence curve, as estimated by EPP from the median prevalence of sentinel surveillance surveys from pregnant women attending antenatal clinics and subsequently calibrated with the DHS prevalence data point for the general population in 2005, appears to be in contrast with the increasing number of adults under treatment and the difficulties in getting sustained results from behavioural change interventions (low condom use, fidelity to partners) and time embedded in implementing a scale up circumcision program. Evidence based studies on the field will provide the elements to validate the results of EPP and Spectrum modelling.

13 1.4 Overview Table of UNGASS Indicator Data Table 1: Overview of UNGASS Indicator Data Core Indicators for the Implementation of the Declaration of Commitment on HIV and AIDS Indicators 2006 Reporting 2008 Reporting National Commitment and Action 1. Domestic and international AIDS spending by categories and financing sources USD 7.7 million USD 40.3 million USD 78.5 million USD 87.6 million % of expenditure by government = 5% - 2. National Composite Policy Index See Annex of 2006 Report See Annex 2 of this Report National Programmes 3. Percentage of donated blood units screened for HIV in a quality assured manner 29, % 38,539/ 38,539=100% 4. Percentage of adults and children with advanced HIV infection receiving antiretroviral therapy 4,189 patients 8,355 patients 19,058 patients Adult Men: 11,302/ 24,614 = 46% Adult women: 20,077/ 34,740 = 58% Total adults : 31,379/ 59,354 = 53% Children: 2,757/ (0-14) 6,736 = 41% Total: 34,136/ 66,090= 52% Through Sept. 2007: Adult Men : 14,444/ 25,594= 56% Adult women: 26,163/35,951 = 73% Male children:1,913/3,255 = 59% Female Children:1,875/3,234 = 58% Total: 44,395/ 68,034 = 65% 5. Percentage of HIV-positive pregnant women who received antiretrovirals to reduce the risk of mother-tochild transmission 6. Percentage of estimated HIV-positive incident TB cases that received treatment for TB and HIV 7. Percentage of women and men aged who received an HIV test in the last 12 months and who know their results - - 5,762 6,611/10,932 = 61% New indicator New indicator Numerator: 2201 (TRAC) Denominator: Estimated number of incident TB cases in adult PLHIV = 3,696 (in 2005) = 60% From previous reporting period: RDHS 2005: Women: 11.6%; Men: 11.0% (15-49) BSS 2006: Female: 2000 (15-19): 0.8%; 2006 (15-24): 12.6% Male: 2000 (15-19): 0.9%; 2006 (15-24): 11.3% Through Sept. 2007: 5,945/10,782 = 56% Through Sept. 2007: 3,283 (TRAC) Sources National AIDS Spending Assessments and NHA National Centre for Blood transfusion Numerator: TRAC Denominator: Spectrum estimates Numerator: TRAC Denominator: Spectrum Estimates Numerator: PNILT, TRAC Denominator: WHO, en (2005) RDHS 2005, BSS

14 8. Percentage of most-at-risk populations that have received an HIV test in the last 12 months and who know their results Not reported Sex Workers: 2000: 35.9%; 2006: 65.3% Truck Drivers: 2000: 26.8%; 2006: 55.6% 9. Percentage of most-at-risk populations reached with HIV prevention programmes 10. Percentage of orphaned and vulnerable children aged 0 17 whose households received free basic external support in caring for the child 11. Percentage of schools that provided life skillsbased HIV education in the last academic year Not reported Not available - Not reported Not available 0-17: 12.6% at least one type of support 0.2%: all of the types of support Knowledge and Behaviour 12. Current school attendance among orphans and Ratio: urban: 83%, rural: 79% (DHS 2000) among non-orphans aged Percentage of young women and men aged who both correctly identify ways of preventing the sexual transmission of HIV and who reject major misconceptions about HIV transmission 14. Percentage of most-at-risk populations who both correctly identify ways of preventing the sexual transmission of HIV and who reject major misconceptions about HIV transmission 15. Percentage of young women and men aged who have had sexual intercourse before the age of 15 All: 22%; Female: 23%; Male: 20% (RDHS 2000) Not reported 15-19: Female: 3%; Male: 9% (RDHS 2000) All: 52%; Female: 51%; Male: 54% All: 6.6%; Female: 3.9%; Males: 13.2% Lost both parents: Male: 70.1%; Female:78.8%; All: 74.6 Both parents alive and living with at least one parent: Male: 90.7%; Female: 91.6%; All: 91.2 BSS 2006: Youth, Female: 2000: 9.1%; 2006: 12.9% Youth, Male: 2000: 9.7%; 2006: 16.8% From the previous reporting period: RDHS 2005: Male: 15-19: 49 %; 20-24: 59% Female: 15-19: 45.3%; 20-24: 57.1% Sex Workers: 2000: 26.8%; 2006: 36.2% Truck Drivers: 2000: 32.0%; 2006: 39.1% From the previous reporting period Female: 15-19: 5.2%; 20-24: 2.6% Male: 15-19: 15.3%; 20-24: 10.8% BSS 2006 Definition used: Have undergone an HIV test and received the results (ever instead of in last 12 months) RDHS 2005 RDHS 2005 BSS 2006, RDHS 2005 BSS 2006 RDHS

15 16. Percentage of women and men aged who have had sexual intercourse with more than one partner in the last 12 months 17. Percentage of women and men aged who had more than one sexual partner in the past 12 months reporting the use of a condom during their last sexual intercourse 18. Percentage of female and male sex workers reporting the use of a condom with their most recent client 19. Percentage of men reporting the use of a condom the last time they had anal sex with a male partner 20. Percentage of injecting drug users reporting the use of a condom the last time they had sexual intercourse 21. Percentage of injecting drug users reporting the use of sterile injecting equipment the last time they injected Impact 22. Percentage of young women and men aged who are HIV infected 23. Percentage of most-at-risk populations who are HIV infected 24. Percentage of adults and children with HIV known to be on treatment 12 months after initiation of antiretroviral therapy 25. Percentage of infants born to HIV-infected mothers who are infected New indicator 15-24: All: 39% Female: 23% Male: 55% (RDHS 2000) Not reported Not reported 15-24: All: 30% Female: 26.4% Male: 39.5% From the previous reporting period: Female: 15-19: 2.3%; 20-24: 0.8%; 25-29: 0.5%; 30-39: 0.6%; 40-49: 0.3%; Total 15-49: 0.6% Male: 15-19: 4.9%; 20-24: 4.3%; 25-29: 4.7%; 30-39: 5.0%; 40-49: 5.6%; Total 15-49: 5.1% From the previous reporting period: Female: 15-19: 27.6%; 20-24: 25.5%; 25-29: 21.6% : 15.6%; 40-49: 6.2% - Total 15-49: 19.7% Male: 15-19: 37%; 20-24: 40.8%; 25-29: 61.8%; 30-39: 37.2%; 40-49: 16.0%; Total 15-49: 40.9% Sex workers (female): 2000: 81.8%; 2006: 86.6% Not available Not reported Not available Not reported Not available 15-19: 4.8% 20-24: 4.5% (Sentinel Surveillance, 2002) 15-19: 5.2% 20-24: 4.3% (Sentinel Surveillance, 2003) Women : 15-19: 0.6% 20-24: 2.5% Men : 15-19: 0.4% 20-24: 0.5% (RDHS 2005) Not reported Not available 23.4% (TRAC) 10% (TRAC) 11.9% (TRAC) 11% (TRAC) Women : 15-19: 3.7%; 20-24: 3.5% (Sentinel Surveillance 2005) Numerator: 3,175 Denominator (sample): 3,482 Percentage: 91.1% RDHS 2005 RDHS 2005 BSS 2006 Sentinel Surveillance Previous reporting periods: RDHS 2005 TRAC (Evaluation study covering 2004 and 2005) Modelled at UNAIDS Headquarters 1 The purpose of this indicator is to assess progress towards preventing relative disadvantage in school attendance among orphans versus non-orphans. For the purposes of this indicator, an orphan is defined as a child who has lost both parents; and a non-orphan is defined as a child whose parents are both alive and who is living with at least one parent. 13

16 2 OVERVIEW OF THE AIDS EPIDEMIC 2.1 Context The is a small, land-locked country in East Africa with one of the highest population densities in the world at 344 people per square kilometre. Most recent 2007 statistics indicate a population size of 9,241,661 (National Institute of Statistics of Rwanda (NISR), 2007). The population is relatively young, with 42.1% of the total population under 15 years old, 55.2% in the year age bracket and only 2.7% of the population 65 years old and older (Millennium Development Goals (MDGs) Country Report, 2007). The gross domestic product (GDP) per capita is $250 (NISR), making Rwanda one of the poorest countries in the world. With a current human resources crisis and a desperate need for qualified health professionals, addressing the HIV epidemic has been a difficult challenge. There is only one doctor for every 50,000 people, and one nurse for every 3,900 people. The problem is much worse in rural areas (Ministry of Finance and Economic Planning (MINECOFIN), Ministry of Health (MOH)). The genocide in 1994 and conflicts in 1996 through to 2000 have had a devastating and lasting effect on the country. However, the Government is focused on increasing production and reducing poverty while creating an environment of good governance. A strong political leadership in HIV and AIDS has acted as a critical catalyst for action on a nationwide level. 2.2 HIV Prevalence in the General Population (Ref. indicator 22) The most recent RDHS was conducted in In this nationally representative population-based survey, adult HIV prevalence was found to be 3.0% (95% CI ). A network of sentinel surveillance sites is in place, with the objective of determining HIV prevalence among pregnant women attending antenatal clinics (ANC). Between 1998 and 2005, data from these sites showed a difference in HIV prevalence between urban and rural women, with the urban women having higher prevalence rates. Nonetheless, since 1998 a decline in HIV prevalence among the urban women has been observed. Figure 1: Trends in HIV Prevalence at Sentinel Surveillance Sites Trends in HIV Prevalence at Sentinel Surveillance Sites Prévalence VIH dans les sites sentinelles de 1998 à 2005 HIV Prevalence Prévalence (%) VIH (%) Kigali K a li Other A u trecities s ville s R u ra lrural Milieu Type des sites of Site Source: Ministry of Health: HIV surveillance by sentinel sites among pregnant women attending ANC;

17 Sentinel Surveillance results from 2005 show that prevalence among urban populations is around 6.2% compared to the RDHS where the prevalence is estimated at 7.3%. Kigali continues to show a very high rate of prevalence (12.8%), while a prevalence rate of 5% is observed among other towns and one of 2.2% among the rural areas. In spite of the differences by location, given how densely populated Rwanda is and the relative ease of movement within this small country, the 83% of the population that is based in rural areas is at risk for increased infection due to frequent contact with populations in urban areas. An analysis by age group shows that the percentage of young women who are HIV infected remains high: 3.7% (15-19 years) and 3.5% (20-24 yrs) while per RDHS data (2005) prevalence was 0.6% (15-19 yrs) and 2.5% (20-24 yrs). Women aged are the more greatly affected, with a prevalence of between 4.9% and 6.8%. A comparison of prevalence among legally married women and among those living with their partners shows that the latter have higher rates. With the exception of Kigali, educated women are more affected (6.9%) than uneducated ones. A similar trend was reported in the RDHS (4.9%). According to national estimates (Spectrum software) the total number of people living with HIV was 151,504 in 2006 and 150,347 in Variations by Sex Substantial differences in prevalence were found between men and women when the RDHS was conducted in HIV prevalence among men was 2.3% while HIV prevalence among women was 3.6%. A complex combination of social, economic, and biological factors increases the vulnerability of women to HIV. Given the increasing feminisation of the epidemic in Sub-Saharan Africa, examination of these factors in the local context and appropriate tailored interventions are critical. While the level of education of women in Rwanda is one of the highest in the region, economic development and equitable distribution of wealth remains a great challenge. Women s choices and negotiating power are still largely limited by gender-based social expectations within marriage. Constraints are thus placed on a woman s ability to protect herself and to negotiate safer sex with her partner. The experience of violence remains a fact of life ingrained in the experiences of women across Rwanda, most often occurring in the home. Among women, 31% have experienced violence since the age of 15, most often from a husband or partner. Many women also experienced sexual violence during the genocide in 1994 when HIV was transmitted to countless women through rape. However, the experience of sexual violence did not end in In the first three months of 2007, of all crimes reported, the crime that outnumbered all others was rape. When considering the fact that rape is consistently the most underreported crime across the world, these numbers do not even begin to quantify the numbers of women who actually experience rape (GFATM Proposal 2007). Sexually Transmitted Infections Statistics regarding HIV testing in patients attending sexually transmitted infections (STI) clinics have been recorded since In 1990, 56% of tests among male STI patients and 74% of tests among female STI patients were positive. In 1996, data from two urban sites indicated that 42% of tests among STI patients were positive. During the same year, outside the urban areas, 42% of tests among STI patients in Kabgayi and 13% of tests among STI patients in Ruli were positive (World Health Organisation (WHO) Epidemiological Fact Sheet on HIV/AIDS and STIs, 2006). The table below depicts the annual numbers of registered cases of STIs from 2001 to Table 3 : Registration of STIs in Rwanda: Years Total STI Neonatal conjunctivitis Urethral discharge Genital ulceration (females) Genital ulcerations (males) Source: Ministry of Health; National Guide for the care of sexually transmitted infections 15

18 In secondary analysis of BSS data with a comparison of data from 2002 and from 2006, Kayitesi et al. 2 found an increase in the knowledge of STI symptoms, a decrease in declared prevalence for both young males and females, and a moderate increase in STI treatment-seeking among female respondents. 2.3 HIV Prevalence in Most-at-risk Populations (ref. indicator 23) The information available about most-at-risk populations in Rwanda is limited. Although the existence of sex workers in Rwanda is increasingly being acknowledged and behavioural surveillance was recently conducted for a small sample of female sex workers, to date there has been no systematic collection of HIV seroprevalence data for male or female sex workers. Data from Population Services International (PSI) project sites show a prevalence of 18.9% among sex workers accessing Voluntary Counselling and Testing (VCT) services. This data refers to select groups of sex workers, thus it is not possible to generalise the findings to the entire population of sex workers. Data is also available from a Family Health International (FHI) intervention which provides STI care and other support services to female sex workers in a Social and Health Centre in Kigali. From November 2005 to August 2006, 146 women were enrolled in this project. At the time of first visit, 77% of enrolled women reported having engaged in sexual activity in the past week. Among these women, 53% reported having sex with more than two partners and 30% reported inconsistent condom use. Out of all women enrolled in the programme, 54% had at least one STI confirmed. 71% of the women were HIV+. Likewise, no research has been conducted regarding men who have sex with men, either to determine seroprevalence or to conduct a basic needs assessment for HIV prevention, treatment, care and support. Injecting drug users (IDUs) appear to be rare in Rwanda; however, a comprehensive study of injecting drug use in Rwanda is yet to be conducted. Action of Evangelical Churches for the Promotion of Health and Development (AESD) has released a project report indicating that although youth are using drugs that impair their judgement and put them at greater risk for contracting HIV through unprotected sex, no person has yet indicated that they have engaged in injecting drug use. Truck drivers, prisoners and military personnel are also considered highly at risk in Rwanda. A 2004 knowledge, attitudes and practices (KAP) study in several prisons revealed an urgent need for comprehensive prevention and VCT services within prisons (PSI, 2007). Data from PSI project sites shows that 16.1% among truck drivers and 4.6% among prisoners participating in VCT were HIV positive. As this data comes from select groups of truck drivers and prisoners, the results are not able to be generalised. Orphans and Other Vulnerable Children (OVC) According to the RDHS 2005 estimates, there are 1,350,820 OVC in Rwanda between the ages of 0 and 17. HIV is contributing to this alarming quantity. The number of children (0-14 years old) having lost one or both parents because of HIV is estimated to be about 224,288 in 2006 (Spectrum estimates). Kayitesi C et al. (2007). Changes in HIV knowledge, sexual risk, and utilization of VCT among youth in Rwanda: Behavioral Surveillance Results from Rwanda Third Annual Research on HIV Conference. Abstract I-C-1. Kigali. March

19 3 NATIONAL RESPONSE TO THE AIDS EPIDEMIC 3.1 NATIONAL COMMITMENT HIV AND AIDS EXPENDITURE (Ref, Indicator 1) Methodology used for data collection To track HIV-related expenditure for 2006, Rwanda used two different frameworks, the National AIDS Spending Assessment (NASA) and the National Health Accounts (NHA) with particular focus on the HIV and AIDS subaccount. Data from an existing household survey on out-of-pocket spending by people living with HIV (PLHIV) 3 commissioned by CNLS were also included. The subaccounts and NASA matrix differ slightly to cater to different groups of stakeholders, but both report on HIV spending in a calendar year (as is the case in Rwanda). The subaccounts preserve the distinction between health and non-health expenditures to help meet the needs of health stakeholders. The NASA approach aims to inform a multisectoral AIDS perspective and can contribute to the HIV and AIDS resource gap estimation process. The computation of NASA data was lead by CNLS in collaboration with the Joint United Nations Programme on HIV and AIDS (UNAIDS). Two national consultants collected secondary data (declared expenditure) from the state budget execution report of 2006 from the Ministry of Finance and Economic Planning (MINECOFIN), relevant line ministries (MOH, MOE, Ministry of Youth, Culture and Sports and Ministry of Local Government), annual transaction and audit reports from CNLS, TRAC, UN agencies, the Presidential Emergency Plan for AIDS Relief (PEPFAR), the GFATM and the African Development Bank (ADB) projects. The NHA was lead by the MOH with support from the United States Agency for International Development (USAID)/ Health Systems Fifteen data collectors tracked funding flows from the financing source to the provider for HIV health and non-health components. The data collection approach used for the NHA involved the following sequence of steps: 1) Where possible, access original expenditure records from institutions (e.g. executed budgets/reports from the MOH, referral hospitals, the Genocide Survivors Fund (FARG), and the National Blood Transfusion Centre (CNTS) as well as those listed above as collected by the NASA team), 2) Examine other secondary (already available) data, including the Health Information System, existing studies etc., 3) Use ongoing surveys (eg. PLHIV household survey as referenced above) and finally, 4) Develop and implement targeted NHA surveys for donors, NGOs, private and public employers/corporations and insurance companies. As per international NHA norms, the HIV and AIDS sub account reflects expenditures, which are monetary or in-kind transactions associated with the actual delivery of the service or product. Therefore, it differs from commitments and from disbursements, and captures in monetary terms the transactions for actual rendered services. To ensure complimentary and harmonised findings, the two teams (CNLS and MOH) worked together during the data analysis stage. A mapping of coding was undertaken to match NHA spending categories with the NASA codes, which are more disaggregated. NHA values were selected because they capture actual expenditures by provider, while NASA numbers were based on spending declarations by donor (which in some cases may reflect the disbursements rather than expenditures depending on the records kept by the donor). When there was not information collected through NHA questionnaires, for instance for income generating activities, NASA values were exploited. Since NASA considers all expenditure on condoms under HIV, while NHA makes a distinction with family planning, data from the reproductive health subaccount of NHA were also included. For trend analysis, spending data for 2005 collected according to NASA methodology were used, as reported in the UNGASS Report Unpublished results (as of November 2007) from an HIV and AIDS household survey conducted as part of a baseline evaluation of performance-based contracting in Rwanda are reported here. The household survey was conducted in 2006 by CNLS with technical support from the World Bank and the Rwandan School of Public Health 17

20 Recommendation for 2008 Conduct only one resource tracking effort for a given year, but produce two outputs, namely NHA tables and the NASA tables. Harmonisation efforts should inform the exercise from the beginning. This will help meet the needs of both health and HIV stakeholders, and will also avoid redundant and duplicative gathering of similar data. If NHA are used, ensure that non-health HIV items are also included with the NASA level of breakdown and maintain separation between donors (rather than only using an aggregate category of donors). Also, care must be taken to ensure that CNLS representatives are included in the MOH team as well as the NHA Steering Committee. Moreover, continued use should be made of existing data collection in the country, in particular the information on expenditure by stakeholders at the district level that is captured by the database CNLSnet. Findings and interpretation Part 1: Financing Sources The financing of the HIV and AIDS response in Rwanda is through government ministries and other public institutions, the private sector which includes corporations, out-of-pocket household expenditures, and international partners such as UN agencies, the ADB, the World Bank s Multi-sector AIDS Project (MAP), the Global Fund, the United States Government (USG) through PEPFAR, and other bilateral donors. The table below shows the sources of financing for HIV and AIDS in TABLE 4: Source of Financing for HIV and AIDS in Rwanda, RwF Financing Sources Amount spent 2006 Government 2,426,172,514 UN agencies 1,211,907,456 ADB 478,773,163 MAP 6,387,617,763 Global Fund 7,174,979,556 USG-PEPFAR 15,914,838,678 Other donors (bilateral donors, foundations) 13,429,287,334 Corporations 25,255,030 Out-of- pocket 1,953,813,665 All other private 216,302,449 Total 48,340,589,281 Exchange rate 2006: 1$ = RwF Total HIV spending in 2006 is Rwandan Francs (RwF) 48.3 billion (United States Dollars (USD) 87.6 million). When comparing with previous years we note an increasing trend in expenditures. Declared expenditure in 2005 was USD 81.4 million, in 2004 USD million and in 2003 USD 9.6 million. It should be borne in mind that data for 2005 and previous years refer to declared expenditure by donors while data for 2006 reflect actual expenditure by providers. Therefore, these figures may in fact underestimate the increase that happened in Since the amounts reported track expenditure by implementing partners for a particular service/product, some funds disbursed by donors may not have been spent in their entirety in 2006 for a number of reasons; for example, the disbursement was made late in 2006 or the disbursement was intended for use over multiple years. Consequently, in these cases, actual spending is only a fraction of what donors report to have disbursed. The total amount of spending for 2006 represents 3.3% of the GDP in Rwanda. 92% of the HIV and AIDS spending is incurred by donors. However, we note that Government contributions increased by about 767 million in real 2006 RwF (USD 1.4 m) since 2005 (UNGASS Report, 2006). 5 Based on NHA/NASA findings as of January 28,

21 Private AIDS expenditure is largely based on analysis of PLHIV out of pocket (OOP) spending on health care (note this amount does not include non-health OOP spending on HIV). OOP spending by PLHIV is 1.2 times more than the general population. This represents a decrease from 2.99 times more in 2002 (NHA records). Expenditure from private sources, including out-of pocket spending by PLHIV, represents only 2.7% of the total. The figure below shows the percentage contribution to the total by each financing source. Figure 2: Expenditure per Financing Source, 2006 Part 2: Financing by HIV Programme Intervention Table 5 presents a breakdown per AIDS spending category in 2005 and To facilitate comparison between years, all the 2005 estimates have been adjusted to 2006 real RwF, accounting for inflation. Table 5: Breakdown by spending category in 2005 and 2006 Spending category Indicative Expenditures 2005 Adjusted to constant 2006 RwF Amount spent 2006 Prevention programmes 10,831,999,496 11,519,430,542 Treatment and care components 17,421,116,845 14,975,375,517 Programme management and administration strengthening Incentives for human resources 10,948,334,363 14,250,590,951 Social protection and social services excluding Not available 2,532,628, ,596,813 OVC Orphans and vulnerable children 3,129,429,767 3,108,734,148 Enabling environment and community 3,812,717,238 (including FARG) 3,880,904,328 development 62,483, ,173,109 HIV- and AIDS-related research (excluding operations research) 2,562,567 (Updated value: 1,137,763,548) 267,783,872 Total 44,928,555,072 48,340,589,281 Exchange rate 2005: 1$ = 550 Rwf, Exchange rate 2006: 1$ = RwF Adjustment of 2005 data to 2006 constant Rwandan francs was made using International Monetary Fund, World Economic Outlook Database, September 2005 Source for 2005: UNGASS report 2006, Expenditure records e.g. Ministry of Finance execution report, CEPEX, annual and audit reports from CNLS,TRAC, GF, PEPFAR, WB/MAP project and NHA data. 19

22 HIV prevention programme expenditure increased from 10.8 to 11.5 RwF billions. This is attributable to the commitment of Government and donors with regard to HIV prevention programmes as a means to reduce HIV infection rates. Government funds are spent mainly on programmes covering blood safety, community mobilisation, school HIV prevention programmes, and programmes for vulnerable populations. Of all USG-PEPFAR funds that could be disaggregated, 38% were used for prevention, mainly voluntary counselling and testing (VCT), mass media, management of STIs and prevention of mother-to-child transmission (PMTCT). There is a decline in spending for care and treatment programmes by RWF 2.5 billion. Although the number of patients increased by more than 12,000 from 2005 to 2006, we report a significant reduction in the prices for ARVs (by about 30% for the most-used drugs, such as Efavirenz and Lamivudine) and for some tests (by 30% for CD4 fascount and more than 60% for the Tri test CD3/CD4/CD45). This reduction in prices more than compensated the increase in quantities and balanced the overall increased costs for opportunistic infections (OIs) and other tests (including rapid HIV tests). Therefore, from 2005 to 2006 the overall cost of treatment remained almost stable in Rwanda (Central Purchasing of Essential Medicines in Rwanda (CAMERWA)). The decrease we observe in NHA/NASA values may be due to the change in methodology as already explained above (declared expenditure in 2005 versus real expenditure in 2006). HIV health-related expenditure as a percentage of the total spending on HIV is 84.3%. Overall, HIV and AIDS health care spending accounts for 24% of all health care spending in This represents an increase from 15% in 2005, according to NHA records. Funding for orphans and other vulnerable children. The government amounts include an estimated proportion (20%) of the Genocide Survivals Fund (FARG) to support education for OVC in the country. This proportion relates to the percentage of OVC infected or affected by HIV. Much of this amount goes for OVC education in terms of school fees. MAP, with 1.3 billion (2.4 million) was the second large contributor for OVC in Programme management and administration strengthening. The management and administrative costs of HIV programmes have also increased by more than 40%. According to expenditure records, USG-PEPFAR, followed by MAP, spent more than any other donor in programme management and upgrading laboratory infrastructure. Social protection. According to NASA-NHA data, there has been an increase in social protection interventions, excluding OVC, from RwF 2.5 billion (USD 4.6 million) in 2005 to RwF 3.1 billion (USD 5.7 million) in This is attributable to a large increase in funding for income-generating activities for PLHIV. HIV- and AIDS-Related Research (excluding operations research). It is difficult to make a comparison with 2005 data as reported in the UNGASS 2006 Report, since the value did not take into account the spending for two big studies, the RDHS 2005 and the PLACE study. If we were to take into account an amount of about 2 million USD, the funds spend for research diminished in

23 The figure below plots expenditure by spending categories in 2006, highlighting the percentage contributions by financing source. GFATM finances the largest share of treatment and care while USG finances the largest share of prevention programmes. Figure 3: Expenditure per Category and Financing Source,

24 22 The table below presents how much was spent on rendered HIV services/products in the country in 2006 (RwF). These amounts are in some cases different from disbursed amounts by donors. Table 6: National AIDS Spending Assessment Financing sources Private Sources Public sources All other private Out-ofpocket Corporations Private Sub- Total UN Agencies Global Fund MAP Project ADB PEPFAR Other donors International sub-total All Other Public Central / National Public sub- Total TOTAL 48,340,589,281 RwF 2,426,172,514 2, ,015 1,141,499 44,597,403,950 1,211,907,456 7,174,979,556 6,387,617, ,773,163 15,914,838,678 13,429,287,334 1,328,127,598 25,255,030 1,953,813, ,302,449 AIDS Spending Categories 1. Prevention (sub-total) 342,554, ,360, ,268 11,051,647, ,347, ,541, ,378, ,787,038,599 4,106,341, ,228, ,228, Mass media *** 3,370,300 3,395 17,006,672 1,283,490, ,396, Community mobilization 104,423, ,456, , Voluntary counseling and testing 246,126, ,889 15,300,771 1,454,249, ,973, Condom social marketing 217,299, Public and commercial sector condom provision 1,237,214 1,246 4,043,149 81,318,814 58,735, ,033, Improving management of STIs 6,058,498 1,024,846, ,792, Prevention of mother-to-child transmission 16,083,783 16, ,824, ,476, Blood safety 175,969, ,013, Others / Not-elsewhere classified 75,542,041 69,538 76,938, ,541,208 ** 886,378,702 ** 754,915, ,197, ,673, ,579,581 93,555 13,933,647, ,712,263 6,303,433,816 1,600,187, ,470,811,661 2,629,502, ,054,574 25,255, ,358,328 2,441, Care and treatment (subtotal) 2.1 Outpatient care 108,913,761 76, ,712, ,836,146 ** 654,327,514 ** 485,340, ,415,573 19,012, ,942,595 2,061, Antiretroviral therapy 1,482,044,977 1,387,599, ,833, Psychological care 187,292, ,855, Palliative care 2.11 Additional/informal providers 94,023, Hospital care 26,665,820 16, ,349, ,860, ,771,380 6,242, ,472, , Opportunistic infection (OI) treatment 410,579, ,626, Others / Not-elsewhere classified 3,171,203, ,919,378 1,325,396,756 1,325,396, ,555,507, ,318,535, ,236,971, Orphans and other vulnerable children 3.1 Education 1,325,396,756 1,318,535, Community support 1,236,971, ,349, ,561, ,067 13,408,512, ,998, ,313,955 2,511,482, ,773,163 7,476,696,603 2,099,247, ,729, ,868, ,861, Program management and administration strengthening

25 Financing sources Private Sources Public sources All other private Out-ofpocket Corporations Private Sub- Total UN Agencies Global Fund MAP Project ADB PEPFAR Other donors International sub-total All Other Public Central / National Public sub- Total TOTAL 48,340,589,281 RwF 2,426,172,514 2, ,015 1,141,499 44,597,403,950 1,211,907,456 7,174,979,556 6,387,617, ,773,163 15,914,838,678 13,429,287,334 1,328,127,598 25,255,030 1,953,813, ,302,449 AIDS Spending Categories 4.1 Program management 244,702, , ,468, ,313,955 1,744,764, ,834,211 5,044,273,421 1,194,551, Planning and coordination 288,080, , ,134, ,861, Sero-surveillance 7,883,513 7, , ,830,411 32,392, Upgrading laboratory infrastructure 14,896,072 15,003 1,211, ,717,662 2,275,592, ,533, Others / Not-elsewhere classified 43,672, ,938, ,635,486 71,868,647 26,694,046 26,667,187 26, ,902, ,690,576 71,033, ,804,706 67,374, Incentives for human resources 5.4 Formative education and build-up of an AIDS workforce 11,134,927 11,215 36,690,576 5,517,400 36,863, Training 15,532,260 15,644 65,516,008 27,804,706 30,510, ,108,734, ,108,734, Social protection and social services excluding orphans and other vulnerable children (sub-total) 6.1 Monetary benefits 25,054, Social services 510,395, Income generation 2,573,284, ,173, ,173, Enabling environment and community development 7.1 Advocacy and strategic communication 7,228, Human rights 100,944,896 39,505,050 39,465,300 39, ,278,822 2,849, ,487,110 72,942, Research excluding operations research which is included under (sub-total) Calendar year 2006 (January- December) Average exchange rate for 2006: 1$= Rw ** Amounts under others may relate to different categories under the same section; however, information was not available at the time of the report to further disaggregate the amounts. Also, portion of spending on antiretroviral (ARV) drugs may be embedded in a category for outpatient care if more specific/disaggregated information was not available from implementers. 23

26 3.1.2 POLICY/STRATEGY DEVELOPMENT AND IMPLEMENTATION The first key document articulating Rwanda s development priorities is the Government s Vision 2020, which includes the six pillars describing strategies for achieving the country s long-term development objectives. The second key document is the Economic Development and Poverty Reduction Strategy (EDPRS) , in which HIV and AIDS actions are integrated into all sectors. Rwanda fully adheres to the Three Ones principles: the existence of one national coordinating body, one strategic national plan of action and one sole monitoring and evaluation framework. Overall coordination is the function of CNLS in collaboration with its decentralised structures at the district level through the CDLS. CNLS mandate is to ensure multi-sector coordination through the implementation of the National Multisector HIV and AIDS Policy and its reinforcing Strategic Plan ( ). The Strategic Plan encompasses Government s support of decentralisation, which offers enhanced opportunities for involving community-level actors and CSOs in national development priorities. The decentralised HIV response is designed as each district elaborates its annual work plan, following local priorities. Thereafter, the 30 district plans are synthesised into the CNLS national action plan. In addition to the National Strategic Plan, Rwanda has endorsed a number of policy documents and strategy papers that support the country s HIV response; notably, the 2005 Health Sector Policy (HSP), the Health Sector Strategic Plan (HSSP) , the HIV Treatment and Care Plan ( ), the National HIV/AIDS Monitoring and Evaluation Plan ( ), the National Reproductive Health Policy of 2003, and the Policy Statement on TB/HIV Collaborative Activities. A national policy on gender-based violence is currently being developed. The 2003 National Policy for Orphans and Other Vulnerable Children and the recent National Plan of Action for OVC have ensured that the national OVC response is focused and placed within the context of national and international law, and human rights. The National Reproductive Health Policy, the National Policy on Condoms and the Family Planning Strategy institutionalise important links between HIV and AIDS and comprehensive reproductive health services and condom programming by defining priority areas for expanded services. These priorities are based on the context of Rwanda s extremely high maternal and infant mortality rates and high fertility rate, together with low contraceptive use. The National Reproductive Health Policy provides the framework for an integrated response that is likewise multi-sectoral. Within its organisational, institutional and policy framework, the national response covers many sectors: Public sector. All stakeholders (also refer to NCPI Part B) recognise the strong existing leadership and highlevel political support to the HIV response by the Government, including the MOH/TRAC and the public non-health sector: the Ministry of Finance and Economic Planning (MINECOFIN), the Ministry of Education (MOE), the Ministry of Foreign Affairs (MINAFET), the Ministry of Youth, Sports, and Culture (MIJESPOC), the Ministry of Gender and Family Promotion (MIGEPROF), the Ministry of Local Government, Community Development and Social Affairs (MINALOC), the Ministry of Public Sector and Labour (MIFOTRA) and others. Civil society and private sector. Civil society is organised into several umbrellas for specific sectors: RRP+, National Women s Council, National Youth Council, Umbrella of People living with a Handicap, Coalition against AIDS for the private sector, Umbrella of Transporters, NGO Forum and the Inter-denominational Faith- Based Organisation for AIDS. Community-level initiatives are too numerous to mention; but they are primarily focused on sensitising community members and delivering Information Education Communication (IEC) training. FBOs are increasingly providing funds for support to PLHIV and affected family members. Most national NGOs have integrated HIV IEC within their programmes as a matter of course. In 2005, there were 600 PLHIV association members of the Rwandan Network of PLHIV (RRP+). By 2007, this number had risen. The network actually brings together more than 24

27 1,000 associations at the national level. Also, a significant number of enterprises have developed HIV prevention workplace programmes and taken charge of the medical costs for HIV-infected staff. Development partners. Development partners are organised around an HIV Cluster lead by the CNLS. 3.2 Programme Implementation Prevention, Care, Treatment, and Support As a part of the overall national response, concerted efforts aimed at prevention, care, treatment, and support are being carried out across Rwanda. UNGASS indicators to assess programme implementation in each area are included here. a. Blood safety (Ref. indicator 3) The National Centre for Blood Transfusion is in charge of the country s blood security. Although there are currently three branches (Huye, Kigali and Musanze), the MOH plans to open two new branches in In 2006, efforts went into the modernisation of infrastructure and equipment with the support of the American Association of Blood Banks. The number of blood units collected has risen from around 29,000 in 2004, to 38,539 in 2006, of which 1.7% tested positive for HIV. 100% of blood units come from volunteer donors, 55% in rural zones and 40% in schools. Of the 38,539 units of blood donated in 2006, 100% were screened for HIV in a quality-assurance manner following a documented standard operating procedure and participation in an external quality assurance scheme. It should be noted that all transfused blood was also screened for HIV in 2005 (National Centre for blood transfusion, 2007). b. Other prevention issues Information Education Communication and Behaviour Change Communication One priority of the Multi-sector HIV Strategic Plan is the strengthening of HIV prevention measures. Rwanda has adopted an expanded ABC (Abstinence, Be faithful, use a Condom) approach to include Education, so that it is now known as EABC. Primary HIV prevention is based on the promotion of later debut of first sexual activity, avoidance of high-risk sex, and condom use. Information on HIV is disseminated through all the various media channels in Rwanda. In 2006, prevention messages reached 463,950 persons; and another 3,123 persons were trained to sensitise communities on abstinence or fidelity with one sexual partner as a means of prevention of HIV infection (CNLS Report, 2006). By the end of 2007, efforts will be made to expand the Abstinence Programme in secondary schools and through peer communication while encouraging the dialogue between parents and their children, with the support of FBOs 4. In support of this educational approach, the First Lady of Rwanda started a nationwide campaign to improve communication on sexuality between parents and children in Condom Use Rwanda has a National Condom Policy with the aim to increase the availability and accessibility of condoms to different target groups. The main organisations concerned with condom distribution are CAMERWA, the GFATM, MAP, PSI and the United Nations Population Fund (UNFPA). In 2006, PSI sold 10 million condoms, an increase of 11% from An increase in demand was also noted by businesses and the private sector. PSI has also strengthened its distribution of condoms to members of the armed forces, to young people through youth associations,, as well as to discordant couples visiting VCT sites. PEPFAR Country Programme for Rwanda,

28 In 2005, the MOH distributed 648,240 male condoms and 1,619 female condoms. In 2006, this number rose to 833,863 male and 2,441 female condoms. According to TRAC data, 19,759 condoms were distributed to VCT clients in health centres and hospitals from January to October In October 2005, PSI undertook a national survey on the availability and accessibility of the male condom in Rwanda. The results showed that theoretical knowledge about condoms was very high, with more than 80% of Rwandans having seen a condom, heard about condoms, and being aware of the fact that it was a method of HIV prevention. The most popular channel for obtaining this information was the radio. However, the survey shows that the availability of condoms is uneven, with some regions having greater availability than others. In urban areas, points of distribution can be found in 93.2% of small administrative areas (cellules), compared to only 55.6 % in rural areas. Moreover, more than half of users say condom breakage is one of the biggest challenges in condom use, implying lack of information on how to use a condom properly. However, in spite of this, overall perceptions about condoms are positive. Women still experience stigma when attempting to buy condoms. Among the reasons given for not using condoms, trust in a person s partner is the highest at 56.5%. Reportedly, price is not a great obstacle to use. Scaling-up of efforts require not only an extension of points of sale and distribution but also an expansion of information on the location of points of access. It is also essential to ensure that all vulnerable groups and mostat-risk populations are made aware of the fact that a condom is only effective as a method of protection if it is used correctly and consistently. Management of Sexually Transmitted Infections STIs are addressed in conjunction with HIV. STI diagnosis is based on clinical observation in accordance with the syndromic management approach; however, if syphilis is suspected, the patient is sent to a laboratory for a diagnostic test. Treatment of partners of those infected has still not reached 100%. As reported in the previous UNGASS Report, the percentage of women and men with STIs appropriately diagnosed, treated and counselled at health facilities were 27% and 36%, respectively, according to the RDHS These percentages rose to 49% and 52% in the RDHS CNLS, National HIV Prevention Plan

29 c. HIV Treatment: Antiretroviral Therapy (Ref. indicator 4) Since 2002, the number of antiretroviral therapy (ART) centres in Rwanda has increased nearly 40-fold from four to 150 sites as of June The number of people being reached with ART has increased 50-fold since At that time, there were 870 people on ART and, as of September 2007, there are 44,395 people receiving treatment. The map depicted below in Figure 4 shows health facilities in Rwanda offering ART as of July 2007, and is followed by Figure 5, which provides information on numbers of sites and number of adults and children receiving ARVs. Figure 4: Health Facilities Offering ART, July 2007 Figure 5: Number of Sites and Number of Adults and Children Receiving ARVs: Number of Sites and Number of Adults and Children Receiving ARVs Source: TRAC Report

30 Efforts have been made to ensure access to ART in all districts. However, as the map above indicates, some districts still have only one site at which ART is available. Plans to expand coverage are underway. In just one year, between December 2005 and December 2006, the number of people on treatment increased from 19,058 to 34,136. Treatment programmes were initiated with at least 1,000 new adults each month (TRAC Report, 2006). The number of children enrolled each month ranged from 94 to 166. Since July 2006, measures have been put in place to scale up paediatric care and treatment. The number of people on first line treatment has steadily risen throughout 2006 from 19,676 to 33,748. The number of people on second line treatment rose from 326 to 388. At present, nearly half of all adults and children on treatment are already in WHO clinical stage 3, a clear indication that treatment needs to start much earlier (TRAC Report, 2006). A person is considered lost to follow-up if they have not attended an appointment for more than three months. While the number of people on treatment increased dramatically between January and December in 2006, the number of persons lost to follow-up during this period has varied, but is rising. An effective means of maintaining contact with patients needs to be established (TRAC Report, 2006). While the scale-up of ART coverage is a major success for the country, a gap in coverage remains. Based on Spectrum estimates, in 2006 there were 59,354 adults (15+) and 6,736 children aged 0-14 in Rwanda in need of ART. Thus, at the end of 2006, 53% of adults and 41% of children in need of ART were receiving treatment. Figure 6: Proportion of Adults and Children on ARVs by Sex, June % 4% 33% A dult m en A dult w om en G irl c hildren B oy c hildren Number of Women 59% Approximately 59% of adults receiving treatment are women. This corresponds with the ratio by sex for HIV prevalence in Rwanda. 28

31 d. Prevention of Mother-to-Child Transmission (Ref. Indicator 5 and 25) During the course of 2006, 6,611 HIV-positive pregnant women received ARVs to reduce the risk of mother-to-child transmission (MTCT). According to Spectrum estimates, there were 10,932 HIV-positive pregnant women in need of ARVs for PMTCT in 2006, revealing an estimated coverage of 61%. The number of PMTCT sites increased from 11 in 2001, to 33 in 2002, 56 in 2003, 120 in 2004, 209 in 2005, 234 in 2006 and 285 in The number of pregnant women being tested for HIV as a part of PMTCT services has also steadily increased since As a part of PMTCT services, 219,507 pregnant women were tested for HIV in 2006 and 212,501 up to November 2007 (TRAC, 2007). Figure 7: Number of Pregnant Women Tested for HIV as Part of PMTCT Services: Number of pregnant women tested for HIV as part of PMTCT services: Number of women Period nov-07 Source: TRAC, 2007 Ideally, PMTCT services are integrated into ANC, maternal and child health services and family planning. By December 2006, 234 out of 424 health facilities had integrated PMTCT. Of women attending ANC, 93.9% were tested for HIV and knew their results in With slightly over half of all facilities (55.19%) offering integrated PMTCT services, there is a need to complete the process of integration and to begin to focus on the quality of PMTCT services and quality assurance monitoring (ibid). Unfortunately, among the women who are tested for HIV and receive positive results (9,583 in 2006), about 30% still do not receive ARVs for PMTCT. 29

32 Number of Women Figure 8: Pregnant Women Who Tested Positive for HIV and Receiving ARVs for PMTCT Pregnant Women Who Tested Positive for HIV and Pregnant Women Receiving ARVs for PMTCT Pregnant Women Who Tested Positive for HIV Year Pregnant Women Receiving ARVs for PMTCT Source: TRAC In Rwanda, great efforts are made to encourage the partners of pregnant women to be tested for HIV. Among pregnant women who have tested for HIV in 2007, an average of 62.5% of their partners agree to have a test (TRAC, 2007). In a report by Ngendahimana et al 6, male participation in health facility PMTCT has increased from 9% in 2003, to 74% at end Many sites routinely have over 90% of male partners attending services. One of the challenges of providing PMTCT services is that not all women give birth in health facilities. Among pregnant women identified as HIV-positive, it is estimated that 26% of births occur at home and 16% of women are lost to follow-up (TRAC Report, 2006). The number of infants receiving Nevirapine at birth has increased steadily from 215 in 2001, to 4,274 in As an illustration, 9,583 pregnant women tested positive for HIV in 2006, and only 4,274 infants were administered Nevirapine (44.5%). Follow-up of infants is improving, with 2,942 infants tested for HIV in 2006 (ibid). Figure 9: PMTCT Interventions for Children Number of children Year Infants who rec eived A RT Infants tes ted Infants H IV + Source: TRAC Report 2006 The percentage of known HIV-positive children born to known HIV-positive mothers peaked in 2003 at 23.4%. In 2005, this percentage dropped to 11.9% (TRAC Report, 2006). Ngendahimana G et al. (2007). Involving Men in Prevention of Mother-to-Child Transmission of HIV Programs in Rwanda. Rwanda Third Annual Research on HIV Conference. Abstract I-C-6. Kigali. March

33 Of additional concern is the fact that many pregnant women who are eligible for treatment are not receiving it, as attention is given primarily to the need for a prophylactic regimen to reduce the risk of transmission of the virus to the child. e. Co-management of Tuberculosis and HIV Treatment (ref. indicator 6) The treatment success rate for TB has been improving, rising from 76.5% in 2004, to 83.4% in However, the detection rate for TB is still low. Efforts are being made to improve detection through case tracking and directly observed therapy short-course, otherwise known as DOTS (Integrated National Program of Fight against Leprosy and Tuberculosis (PNILT) Report 2006). The DOTS strategy currently being implemented is anticipated to be in effect in all health districts prior to The notification rate of TB cases has steadily increased over the past four years, from 73.2% in 2003 to 94.3% in 2006 (Rwanda MDG Report). A joint office for TB and HIV has been in operation since August Since the office s inception, health facilities have adopted a policy of systematic screening for HIV among all TB patients (TRAC Report). HIV testing is now routinely offered at the time of TB diagnosis for most patients. However, only three-quarters of centres for the detection and treatment of TB are able to carry out HIV testing (PNILT Report). Training for medical professionals in TB-HIV co-infection has been carried out. In addition, a chart for TB screening has been introduced in the management of PLHIV (TRAC Report, 2006). In 2005, among all registered TB patients in Rwanda, 69.3% were screened for HIV and 45.5% were found to be HIV-positive. Of these patients 12.8% were recorded as having received ARVs. By comparison, in 2006, 76.1% of all registered TB patients were screened for HIV and 40.7% were found to be HIV-positive. Of these patients, 30.8% were recorded as having received ARVs (PNILT Report). According to TRAC data, in 2006, 2,201 ART patients were initiated on TB treatment. In contrast, during the year 2007 (through September), 3,283 ART patients were initiated on TB treatment. A study conducted by the National Reference Laboratory on the sensitivity of Koch s Bacillus to tuberculosis drugs in 2005 showed that 3.9% of new cases versus 9.4% of previously treated cases were resistant to first line TB treatment. Resistance to second line drugs was minimal. Second line TB treatment was introduced in July In 2005, 35 patients received second line treatment and in 2006, 50 patients received second line treatment. Currently, there are more than 120 patients under second line treatment for tuberculosis. f. HIV Testing and Counselling in the General Population (Ref. Indicator 7) Among women surveyed in the RDHS, 76% had ever been tested for HIV. Of all women surveyed, 11.6% had been tested in the past 12 months and received their results. Among men surveyed, 78% had ever been tested for HIV and 11% had been tested in the past 12 months and received their results (RDHS 2005). Women and men in urban areas with secondary-level education or higher and with greater wealth are much more likely to have had a test in the last 12 months and received the results (RDHS, 2005). Among youth respondents, in 2000, only 0.8% of girls and 0.9% of boys aged had been tested for HIV and received the result; whereas, in 2006, 12.6% of girls and 11.3% of boys had done so, revealing significant behaviour change in the six-year period (BSS, 2006). The number of sites (FOSA and mobile VCT) providing VCT increased considerably between 2003 and In 2003, there were only 44 sites offering VCT. By 2004, 129 sites were open and in 2005, 229 testing sites were available. By 2006, a total of 256 VCT sites were functioning. The number of tests conducted at VCT sites has also risen during this four-year period. In 2006, 472,194 tests were conducted. For 96.7% of the tests, the person received their results (TRAC Report, op. cit.). 31

34 Figure 10: Cumulative Number of Tests Conducted at VCT Sites (FOSA and mobile VCT): Number of people tested Year M en W om en Total Source: TRAC Report, 2006 g. HIV Testing and prevention programmes in Most-at-risk populations (Ref. indicators 8 and 9) Recent data regarding HIV testing for selected most-at-risk populations is available through the BSS conducted in Data were collected for sex workers and truck drivers. No systematic research has been done for men who have sex with men, prisoners or injecting drug users. In 2000, 35.9% of the sex workers in the sample responded that they had ever received an HIV test and knew their results, as compared to 65.3% in After controlling for differences in sampling between 2000 and 2006, sex workers were 3.3 times more likely to have received a test and results in 2006 than in Illiterate sex workers were 56% less likely to have gone for a test and received the results (BSS, 2006). Among truck drivers surveyed in 2000, 26.8% had ever been tested for HIV and received the results. In comparison, in 2006, 55.6% of the truck drivers surveyed had ever been tested for HIV and received the results. Truck drivers were 3.2 times more likely in 2006 than in 2000 to have been tested for HIV and received the results (ibid). There are little data available to convey a clear sense of the reach of HIV prevention programmes with regard to most-at-risk populations. Nevertheless, the CNLS is actively involving vulnerable groups in HIV programmes. This includes programmes aimed at the social reintegration of sex workers on a voluntary basis (through income generating activities) and a programme of VCT (and related HIV care and treatment) for prisoners. District programmes focussing on providing assistance to sex workers have emphasised marriage as an important step in re-integration and to ensure legal protection to children. Prisoners have the same right to access VCT, care and treatment as any other person in Rwanda. The emphasis on provision of services in prisons has recently been strengthened with the training of 300 peer educators in three main prisons in Condoms are not available in prisons. In 2006, the USAID-funded most-at-risk populations programme expanded VCT service delivery and continued Behavioural Change Communication (BCC) activities among most-at-risk populations, notably prisoners, female sex workers, truckers and high-risk youth. A total of 22,498 individuals were counselled and tested for HIV through static and mobile VCT sites, and all HIV-positive clients were referred to clinical sites for follow up care and treatment. The programme also provided peer education training, formative supervision and interpersonal 32

35 communication activities for policemen, local defence forces and female sex workers associations in hot spot zones. The PEPFAR-supported military BCC programme continued training, peer education activities, shows and support to Anti-Aids Clubs. A total of 7,084 individuals received mobile VCT services in 2006, and HIV-positive clients were referred to military hospitals or mobile clinics. In collaboration with the National Prisoners Steering Committee and the CNLS, PSI/Rwanda provided VCT services in Butare, Gisenyi, Gitarama and Kigali Prisons to a total of 7,685 prisoners. In 2006, a pilot programme to provide ART in three prisons was initiated. As a result of this, 300 peer educators have been trained, information has been distributed, and VCT and ART services are being established (PSI). The national HIV policy serves all people living within the nation s borders, including refugees, asylum seekers and internally displaced persons. Refugees fall under the category of most at-risk populations, as they are mobile and interact closely with the host population. Today Rwanda has over 50,000 refugees. Thanks to the support from partners such as UNHCR, GLIA (Great Lakes Initiative on AIDS), PEPFAR and OPEC, all four refugee camps in Rwanda benefit from HIV services. For instance, in 2007 at the camps in Kiziba and Gihembe, more than 3,000 refugees received VCT services, while PMTCT services were provided to all pregnant women in need. HIV activities in the refugee camps also focus on HIV prevention through anti-aids clubs, youth associations, peer educators and religious leaders. ART has been provided through the referral system to district hospitals; however, there is a plan to extend treatment sites in two of the refugee camps. h. Support for Children affected by HIV and AIDS and school attendance of orphans (Ref. Indicators 12 and 10) The vulnerability of orphans in the education system was well illustrated by the 2005 RDHS, which highlighted the inability of households with orphans to meet the costs of schooling. Children living in child-headed households were experiencing the greatest difficulties. While 91% of children aged whose parents are both alive and who are living with one of their parents attend school, just 75% of children who have lost both parents attend school (RDHS, 2005). A 2006 study followed 692 young heads of household and noted, among other issues, their difficult living conditions, the problems in accessing education, and the psychological distress suffered by many OVC 7. As the responsibility for caring for OVC is often absorbed by families and communities, it is essential that these households are supported in their efforts to look after these children. Nonetheless, according to RDHS data, the households of 12.6% of OVC aged 0-17 received free basic external support in caring for the child or children, while less than 1% of households receive all three types of recommended support. Out of all households caring for OVC, 87% receive no external support (DHS, 2005). Through the Strategic Plan for OVC adopted in May 2007, Rwanda has established a specific political body for the protection of orphans, with the aim of defining the areas for intervention of public services and NGOs, and orienting these services to their needs. A minimum package for OVC support has been defined and intervention practices among partners harmonised. The package covers elements of health (including PMTCT, HIV prevention services and VCT), nutrition, formal and non-formal education, protection, psychosocial and socioeconomic support. The decentralisation process in Rwanda is contributing to the implementation of a rigorous follow up strategy for OVC at the peripheral level. In 2006, 292,609 OVC had access to at least one of the components of the minimum package of assistance (CDLS Reports, 2006) By the end of 2006, a total of 258,934 OVC had been assisted in attending school through the payment of their school fees and the provision of necessary educational materials. Other mechanisms for support included Programme Evaluation Report on Case Management of Care in Rwanda;

36 the membership subscriptions to community-level health insurance schemes, professional training and the implementation of HIV prevention activities (CNLS Report, 2006). i. Life Skills-based HIV Education in Schools (Ref. Indicator 11) The percentage of schools providing life skills-based HIV education in the last academic year is not available in Rwanda (United Nations Children s Fund (UNICEF)). However, life skills-based education is one of the components of the Child-friendly Schools. At present, there are 54 such schools in Rwanda and plans are underway to extend these Child-friendly components to cluster schools, or the 2-4 schools surrounding each of the model schools. The model schools will each contain a teacher resource centre for in-service trainings to build the capacity of teachers in the life skills-based curriculum and the child-centred approach. Life skills enhancement activities in Child-friendly schools include school sports activities and facilities, children s clubs for life skills enhancement, relevant learning experiences for life skills promotion, and adolescent peer support and leadership mechanisms. Among others, PSI in collaboration with MIJESPOC, MINEDUC and CNLS implements a youth programme targeting students, their parents and teachers in 30 secondary schools in six districts through training and technical guidance to secondary school Anti-AIDS Clubs in life skills and peer education techniques HIV KNOWLEDGE AND BEHAVIOUR General Population (Ref. indicators 13, 15, 16, 17) As a part of the DHS in 2005, young women and men aged were asked a series of five questions to test their knowledge of HIV. 45.3% of women aged and 57.3% of women aged had a fairly comprehensive knowledge about HIV, as did 49.0% of men aged and 49.9% of men aged (RDHS, 2005). The BSS includes information on the percentage of young people who correctly identify both ways of preventing the sexual transmission of HIV and who reject major misconceptions about HIV transmission. In 2000, young men and women had very similar percentages of comprehensive HIV knowledge, at 9.7% and 9.1% respectively. By 2006 knowledge had improved, but the gap between women and men had widened considerably to 12.9% for women and 16.8% for men. Multivariate analysis revealed that lower education level alone could decrease a woman s chances of having comprehensive knowledge by as much as 70%. Among men and women without education, among those from a rural setting, and among those from the poorest quintile, the proportion of those with correct information is much lower than among the remainder of the population (BSS, 2006). One of the principal HIV prevention strategies used with young people is that of abstinence and delaying age at first sexual encounter. Two nationally representative RDHS surveys have documented a relatively late sexual debut (at 20 years) and infrequency of multiple sex partners. According to the RDHS 2005, 5.2% of girls aged and 2.6% of women aged had had sexual intercourse before the age of 15. Among men, the figure is much higher; 15.3% aged and 10.8% aged According to the BSS data, the proportion of young people who had their first sexual debut later than age 15 has remained stable at 11% between 2000 and In 2005, 0.6% of women and 5.1% of men who had sex in the last 12 months had sex with more than one partner during that time. 19.7% of women and 40.9% of men reported using a condom the last time they had higher-risk intercourse (RDHS, op. cit.). Most-at risk Populations (Ref. indicators 14,18) The percentage of sex workers with a comprehensive knowledge of HIV has shifted from 26% in 2000 to 36.2% in Illiterate sex workers have a 81.5% less chance of having comprehensive knowledge than those who have at least secondary education (BSS, 2006). In 2000, 32.0% of truck drivers had a comprehensive knowledge of HIV and AIDS. By 2006, this percentage had 34

37 risen to 39.1%. Multivariate analysis reveals that truck drivers in 2000 were disadvantaged with regard to a key variable, that of education. A person s level of education plays a critical role, as illiterate truckers are 60% less likely to have a comprehensive knowledge of HIV (ibid). The BSS showed a slight increase from 2000 in use of condoms with the most recent client in the last 12 months. In 2000, the percentage was 81.8%, whereas it had increased to 86.6% in Only female sex workers were included in the sample (ibid). There is no information available on behaviours for men who have sex with men and injecting drug users (Ref. indicators 19, 20, 21) IMPACT ALLEVIATION For available information on HIV prevalence trends per age and sex in the general population and across most-atrisk populations, refer to Section 2 (Overview of the Epidemic). HIV Treatment: Survival rate on ART (Ref. indicator 24) ART has the potential to increase dramatically the survival and quality of life for PLHIV. A study carried out by TRAC over the years 2004 and 2005 found that 91% of adults and children with HIV were alive and on treatment 12 months after initiation of ART 8. Although more work needs to be done to ensure support for and follow-up of persons on ART, the survival rate is very encouraging. Improving uptake of HIV testing and doubling efforts in the continued roll-out of ART is critical, as there were still more than 10,800 AIDS-related deaths in 2006 alone (Spectrum estimates). Care and Socio-economic Support to PLHIV Support to PLHIV is delivered through programmes set up by persons who are themselves affected by and/or infected with HIV. Such programmes include income-generating activities supported by community organisations (CNLS, op, cit.) With the contribution of its partners, CNLS has helped PLHIV associations and other vulnerable groups consisting largely of women. In total, 150 associations throughout the country were financed in 2006 through ADB, CARE International, MAP, RRP+ and UNDP. Improvement of access to health care is essentially dealt with in the same way as for OVC: payment of treatment costs for ARVs and opportunistic infections through community-level health insurance. Membership of PLHIV associations and micro-credit schemes has enabled PLHIV to feel less isolated and has helped reduce the effects of stigma and discrimination. 8 TRAC Report on the evaluation of clinical and immunologic outcomes from the national antiretroviral treatment program in Rwanda, (November 2007) 35

38 4 BEST PRACTICES CNLSnet and TRACnet Rwanda is among one of the most advanced African countries in information technology. This capacity is being utilised to make the country s monitoring and evaluation system function more efficiently. In 2005 through 2006, CNLS designed and developed a system for e-management (planning and reporting) of the response to HIV and AIDS. The system is now fully operational. An HIV and AIDS web access database (CNLSnet) tracks service providers, their action plans, beneficiaries, and budget at the district levels. The system also monitors implementation progress. Districts are equipped with a generator and basic information technology material. The CDLS compile data from all stakeholders operating in their areas and transmit these to the national database through the Internet. For this purpose, the CNLS has developed a harmonised and codified list of activities. Implementing partners compile their action plans by choosing within this list. To simplify reporting, the planning template is linked, in the same database, to a quarterly reporting form that has an additional three columns showing the number of beneficiaries reached, the activity s progress and the budget spent. Each stakeholder is identified by the same agreement number assigned by the government when giving the authorisation for operating in the country. The database is widely accessible for consultation but only authorised institutions can make changes to data. The advantages of the system are: It is easily accessible to all authorised partners through the CNLS web page Data submitted by the districts are accessible to users instantly. It provides a common, simple and standardised planning and reporting electronic format that facilitates analysis of data and reports. As a locally developed system, it is sustainable and can be easily revised without the need to import external technical assistance. Work is ongoing to improve the database to make its interface more user-friendly and to include a component to make the reports more instructive in terms of geographical distribution of activities. TRAC (Treatment and Research AIDS Center) houses TRACnet, an example of innovative ART information management. As CNLSnet, TRACnet provides real-time access to vital HIV and AIDS information nationwide. TRACnet was developed in 2003 and was up and running by the beginning of The system is currently fully functional. It is used by 100% of health facilities providing ART, including the ones located in remote rural areas, and it covers all patients. It can be viewed at Figure 11: TRACnet - National Data Dashboard TRACnet has the capacity to collect, store, retrieve, display, and disseminate critical programme, drug distribution, and patient information for HIV care and treatment (clinical and laboratory data) and has greatly assisted in the scale up of HIV clinical services. All data related to the patients are now available from one common source. TRACnet not only improves the efficiency of programme management, but also has the potential to increase the quality of patient care. A web-based Geographic Information System (GIS) interface displays health facilities and ARV drug stock levels, providing rapid alert for 36

39 shortages and/or stock-outs. TRACnet leverages existing structures by drawing on mobile telephone networks, computers, and paper record systems. Most users access the system via the toll-free mobile phones charged on solar energy. Over 400 users have been trained and are using the system to submit monthly programme indicator reports and weekly consumables (drug) reports. Health facilities personnel owning a phone and accustomed to using text messaging features, has shown ease of use after only minutes of training. However, although the information technology used for TRACnet is efficient and robust, there are concerns regarding sustainability due to cost. CNLSnet, locally conceived and reasonably priced, has the advantage to be more sustainable. Both CNLSnet and TRACnet give decision-makers the ability to view all HIV/AIDS information centrally in real-time and to analyse data immediately for fast action. These piloting experiences will serve the progressive introduction of e-management within the entire health sector. In fact, due to the success of TRACnet and CNLSnet, the Government plans to implement HEALTHnet to monitor all health care indicators. UMUGANDA All Rwandans talk openly about HIV for one day Umuganda is an initiative that aims at bringing together communities living in the same sector or administrative areas to meet for community work of public interest and discussions on relevant issues. Through this event, all Rwandans are invited to meet in a prescribed location to carry out whatever type of community service has been determined; for example, picking up rubbish, planting trees or rehabilitating roads. The Umuganda service takes place on the last Saturday of every month. No one is exempt from this community service. Picture 1. Community Discussions during HIV Umuganda, 2007 In the last three years, Rwanda has been adapting the international theme for the World AIDS campaign to national needs and priorities and the Umuganda of the last Saturday of November is taken as the National AIDS day. This strategy has proven successful to channel the dialogue and discussions around the national World AIDS Day campaign theme. For instance, in 2007 the theme was Family responsibility vis-à-vis the children. The Umuganda dedicated to HIV involves high level leaders, ministries, senators and parliamentarians, and developments partners (including Heads of UN agencies). These key national decision-makers and authorities join local leaders and community activists at the district level to carry out specific community activity. In all Umuganda sites, after the community service, an open in-depth dialogue session for about two hours focuses on mobilising authorities, communities and families to maintain HIV high in the agenda. HIV Umuganda is preceded by a mobilisation campaign (family days and media campaign) lasting two months and engaging all partners and all sectors of the country and covering all districts. HIV Umuganda is a massive day of mobilisation and achieves the highest possible country coverage contributing to the intensification of HIV prevention. All Rwandans, all leaders and all partners at all levels participate to this day. Moreover, the campaign has the advantage of not being expensive since it fits into an ongoing country initiative. 37