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					        REPUBLIQUE DU RWANDA
      COMMISSION NATIONALE DE LUTTE
             CONTRE LE SIDA




LA TROISIEME CONFERENCE ANNUELLE D’ECHANGE
     ET DE RECHERCHE SUR LE VIH et le SIDA


          KIGALI, 29-30 MARS 2007



          LIVRE DES ABSTRACTS
                                      PREFACE



La Commission Nationale de Lutte contre le SIDA (CNLS), en collaboration avec
l’ensemble de ses partenaires, organise depuis trois ans, une Conférence annuelle de
recherche et d’échanges sur le VIH et le SIDA. Cette conférence se veut être un cadre
de dissémination des recherches réalisées sur le VIH et le SIDA, de partage et
d’échanges d’expériences entre intervenants dans la lutte contre le VIH et le SIDA au
Rwanda.


La 3ème Conférence qui se tiendra à Kigali du 29 au 30 mars 2007, vient après celles
menées successivement en 2005 et 2006 et s’intègre dans un vaste programme non
seulement de renforcement de l’interaction entre chercheurs, décideurs et praticiens
mais aussi de renforcement des capacités et de la qualité des recherches.


L’ambition, lors du lancement de la 1ère Conférence, était que celle-ci aille au-delà des
frontières nationales. L’année 2007 est spéciale car, elle va permettre de faire un pas
dans la réalisation de cette ambition. En effet, en plus des catégories traditionnelles de
recherches pour les deux précédentes conférences, la principale innovation de la 3ème
Conférence est l’intégration d’une nouvelle catégorie qui englobe les recherches
Multi-pays, ce qui donne une dimension internationale à la dite conférence. Elle
donne ainsi à tous les intervenants au Rwanda, la possibilité d’échanger sur les
recherches et programmes qui transcendent les frontières.
De surcroît, la diffusion de l’information scientifique et technique comme facteur de
développement est devenue la substance même de ce lieu d’expression de la
communauté scientifique.


Ce livre d’abstract contient non seulement les travaux de recherche et interventions
qui ont été approuvés par le comité de sélection pour présentation orale, mais aussi
l’ensemble des travaux soumis par les chercheurs et intervenants et qui nécessitent
une amélioration en vue de leur publication dans la bibliothèque virtuelle de la CNLS.
La publication de l’ensemble des abstracts soumis dans le présent livre a été guidée
par le souci de permettre aux participants à la conférence d’être informés sur
l’ensemble des recherches et interventions en cours dans le pays, et non seulement
celles qui feront l’objet de présentation orale.
Ce livre n’aurait pas été conçu sans la contribution de plusieurs auteurs affiliés à
diverses organisations partenaires dans la lutte contre le VIH et SIDA. Que chaque
auteur, chaque organisation ayant contribué par voie de soumission d’un abstract ou
d’un poster trouve ici l’expression de notre gratitude.
Nos remerciements s’adressent également à tous ceux de nos partenaires qui ont pris
une part active au processus de revue et de sélection des abstracts publiés dans ce
livre.


La CNLS tient à exprimer ses remerciements à la Banque Mondiale, à l’ONUSIDA et
à Measure Evaluation pour leur assistance financière dans l’organisation de cette
conférence.


Que ces deux jours d’échanges puissent aider chaque intervenant de la lutte contre le
VIH et le SIDA au Rwanda à apprendre des expériences des autres en vue de
l’amélioration de l’efficacité de nos actions envers les personnes vulnérables au VIH
ainsi que celles qui en sont infectées ou affectées.



                               Dr Agnès BINAGWAHO
                            Secrétaire Exécutif de la CNLS




                                                                                   2
                                       PREFACE

The National AIDS Control Commission, in collaboration with all partners, has been
organizing, since three years ago, an annual research and exchange conference on
HIV and AIDS. This conference is meant to be a framework of spreading researches
carried out on HIV and AIDS, of sharing and exchanging experiences between
stakeholders in the fight against HIV and AIDS in Rwanda.


The 3rd Conference, which will take place in Kigali from 29 till 30 March 2007,
follows those held successively in 2005 and 2006 and fits in a vast programme not
only of strengthening the interaction between researchers, decision-makers and
practitioners but also building capacities and quality of researches.


The ambition, during the launching of the 1st Conference, was that this one should go
beyond national borders. 2007 is a special year because it is going to allow making a
step in the realization of this ambition. In fact, besides the traditional research
categories for the previous two conferences, the main innovation of the 3rd conference
is the integration of a new category that includes multi-country researches, which
gives an international dimension to the said conference. It therefore gives to all
stakeholders in Rwanda, the possibility of exchanging on researches and programmes
that transcend borders.
Moreover, the spreading of scientific and technical information as a development
factor has become the real substance of this place of expression of the scientific
community.


This abstract book contains not only research works and interventions that have been
approved by the selection committee for oral presentation, but also all the works
submitted by researchers and stakeholders, which require an improvement for their
publication in the digital library of CNLS.       The publication of all the abstracts
submitted herein was guided by the concern to allow to the conference delegates to be
informed on all researches and ongoing interventions in the country, and not only
those that will form the subject of oral presentation.
This book would not have been compiled without the contribution of several authors
affiliated to various organizations partner in the fight against HIV and AIDS. May


                                                                                    3
every author, every organization that has contributed by submitting an abstract or a
poster find here the expression of our gratefulness.
Gratitude is also due to all those among our partners who have played an active role in
the process of reviewing and selecting the abstracts published in this book.


CNLS wants to express its gratitude particularly to the World Bank, UNAIDS and to
Measure Evaluation for their financial assistance to the organization of this
conference.


May these two exchange days help every stakeholder in the fight against HIV and
AIDS in Rwanda learn from other people’s experiences in order to improve the
effectiveness of our actions towards people vulnerable to HIV as well as those
infected or affected by HIV.




                               Dr Agnès BINAGWAHO
                            Executive Secretary of CNLS




                                                                                     4
Table des matieres

PREFACE                                               1

TABLE DES MATIERES                                    5

SIGLES ET ABREVIATIONS                                6

LISTE DES ABSTRACTS                                   8

LISTE DES POSTERS                                     17

I- LISTE DES ABSTRACTS ACCEPTES POUR                  21

 LA PRESENTATION ORALE
I-B. RECHERCHE CLINIQUE ET PRISE EN CHARGE            22

   THEURAPEUTIQUE
I-C. EPIDEMIOLOGIE ET PREVENTION                      34
I-D. DOMAINE SOCIAL ET ECONOMIQUE                     52
I-E. POLITIQUE ET MISE EN ŒUVRE DES PROGRAMMES        64
I-F. ETUDE REGIONALE ET PROGRAMME MULTI-PAYS DE       81
   RECHERCHE SOCIALE DANS LE DOMAINE DU VIH ET SIDA
II- ABSTRACTS A PUBLIER DANS LA BIBLIOTHEQUE          99
  VIRTUELLE
II-B. RECHERCHES CLINIQUES ET PRISE EN CHARGE         100
    THEURAPEUTIQUE
II-C. EPIDEMIOLOGIE ET PREVENTION                     145
II-D. DOMAINE ECONOMIQUE ET SOCIAL                    183
II-E. POLITIQUE ET MISE EN ŒUVRE DES PROGRAMMES       214
ANNEXE                                                286




                                                            5
Sigles et Abréviations

AA          Alimentation Artificielle
AEC         Association des Epouses des Camionneurs
AIDS        Acquired Immune Deficiency Syndrome
AM          Allaitement Maternel
AMATA       Allaitement Maternel sous Trithérapie ARV
AMU         Association Mwana Ukundwa
ANC         Antinatal Clinics
APELAS      Association du Privé et Para-étatique dans la Lutte contre le Sida
ARBEF       Association Rwandaise pour le Bien être Familiale
ART         Anti Retroviral Therapy
ARVs        Antiretroviral drugs
ASP         Association des Séropositifs
AUC         Accuracy and Area Under the Curve
AVSI        The Association of Volunteers in International Service
BCC         Behavioral Change Communication
BK          Banque de Kigali
BMI         Body Mass Index
BIT         Bureau International du Travail
BNPC        Bostwana National Productivity Center
BOCAIP      Bostwana Christian Aids Intervention Program
BONASO      Bostwana Network of Aids
BSS         Behavioral Surveillance Survey
BUHFM       Butare University Hospital and Faculty of Medecine
CARES       Center for AIDS Research, Education and Services
CBO         Community – Based Organisation
CBT         Community Based Testing
CDC         Center of disease Control
CDLS        Commission de District de Lutte contre le Sida
CDV         Centre de Dépistage Volontaire
CD4         Cluster Differentiation 4
CHAMP       Community HIV/AIDS Mobilisation Program
CHF         Community Health Financing
CHHs        Child Households
CHU         Centre Hospitalier Universitaire
CHUK        Centre Hospitalier Universitaire de Kigali
CHWs        Community Health Workers
CNLS        Commission Nationale de Lutte contre le Sida
CPN         Consultation Pré-Natale
DHS         Demographic and Health Survey
DMO         District Medical Officer
DOT         Directly Observed Treatment
DPS         Dried Plasma Spot
EDS         Enquête démographique et de Santé
EGPAF       Elisabeth Glaser Pediatric AIDS Foundation
EMR         Electronic Medical Record
EOSTS       Entended on Site Technical Support
FACHR       Fédération des Associations nationales de personnes handicapées
FBOS        Faith Based Organizations


                                                                                 6
FDC       Fixed Dose Combination
FGD       Focused Group Discussion
FHI       Family Health International
FOSA      Formation Sanitaire
FVA       Faith Victory Association
HAART     Highly Active Antiretroviral Therapy
HBC       Home Based Care
HIV       Human Immunodeficiency Virus
HPV       Human Papilloma Virus
ICAP      International Center for AIDS Care and Treatment Programs
IDCC      Infectious Desease Care Clinic
IEC       Information, Education and Communication
IGAs      Income Generating activities
IMCI      Integrated Management of Childhood Illness
INSR      Institut National des Statistiques du Rwanda
IRIS      Immuno -reconstitution inflammatory Syndrome
IST       Infections Sexuellement Transmissibles
LNR       Laboratoire National de reference
MAP       Multi-Country Aids Program
MVCT      Mobile voluntary Counseling and Testing
OI        Opportunistic Infections
ONUSIDA   Programme Commun des Nations Unies sur le VIH/SIDA
OVC       Orphans and Vulnerable Children
PAMASOR   Programme d’Accompagnement aux Malades du Sida et aux Rejetés
PEPFAR    Presidents Emergency Plan for AIDS Relief
PLACE     Priorities for Local AIDS Control Efforts
PLWHA     People living with HIV/AIDS
PMTCT     Prevention of Mothers to Child Transmission
RDHS      Rwandan Demographic Health Survey
RHPIF     Rwanda HIV/AIDS Public Interest Fellowship Program
RPHIFP    Rwanda HIV/AIDS Public Interest Fellowship Program
RRP+      Rwandan Network of People Living with HIV/AIDS
SIDA      Syndrome de l’Immuno - Déficience Acquise
SW        Social Workers
SWAA      Society for Women Against HIV/AIDS
TRAC      Treatment and research on Aids Center
UNAIDS    The Joint United Nations Programme on HIV/AIDS
UNICEF    United Nations Children’s Fund
USAID     United States Agency for International development
VCT       Voluntary Counselling and Testing
VIH       Virus de l’Immuno - déficience Humaine
WE ACTx   Women’s Equity in Health Care & Treatment
ZIP       Zone d’Intervention Prioritaires




                                                                          7
LISTE DES ABSTRACTS

I- ABSTRACTS ACCEPTES POUR LA PRESENTATION ORALE

I-B.: RECHERCHE CLINIQUE ET PRISE EN CHARGE THERAPEUTIQUE

I-B-1. Secondary effects and other complications from 1st line ARVs: Observations
on 406 adverse effects necessitating drug changes in patients from two health
facilities in Rwanda. I.Turate, B. Ngirabatware, F. Shumbusho (FHI)

I-B-2. Symptomatic lactic acidaemia on stavudine-containing ART: clinical features
of 20 cases and risk factor assessment. J.V.Griensven (MSF) et Al.

I-B-3. Evaluation of a new national quality control approach, for HIV testing in
Rwanda. P. Rugimbanya (LNR) et Al

I-B-4. Validation of WHO-recommended immunological criteria for treatment failure
J.v.Griensven (MSF) et Al
Recommendation to emphasize implications for national protocol (FHI)

I-B-5. Evaluation d’une technique alternative automatisée à coût réduit pour la
mesure de la charge virale plasmatique du HIV-1 au Rwanda

I-B-6. Joint Supervision with TRAC Partners in HIV Programs: Major Findings
(TRAC)


I-C.: EPIDEMIOLOGIE ET PREVENTION

I-C-1. Changes in HIV knowledge, sexual risk, and utilization of VCT among youth
in Rwanda: Behavioral Surveillance Results from 2000 – 2006. C. Kayitesi (TRAC)
and al.

I-C-2. Contraception – an effective and underutilized approach to preventing HIV
sequelae. BN Maggwa (FHI) and al.

I-C-3. Changes in sexual risk behavior in sex workers in Rwanda: Report of findings
comparing 2000 and 2006 BSS data and review of implications for prevention
programming. A. Kabeja (TRAC) and al.

I-C-4. Bilan de la campagne de dépistage volontaire mobile au niveau de 19
entreprises privées et para-étatiques du Rwanda.
Vestine Mutarabayire (APELAS) et al.

I-C-5. Expanding HIV Care and Treatment to Rwandan Prisons: A Collaborative
approach. Ruben Sahabo (Columbia) and al.

I-C-6. Involving Men in Prevention of Mother-to-Child Transmission of HIV
Programs in Rwanda. Gerard Ngendahimana (Intrahealth) and al.


                                                                                 8
I-C-7. Mobile VCT: An Evaluation of Innovative HIV-Testing Approaches. Aimee E.
Jeffrey (CDC-Rwanda).

I-C-8. Determinants of Condom Use among high-risk youth who frequent hotspots in
high-transmission zones”. S. Leuschner (PSI-Rwanda)

I-D.: DOMAINE SOCIAL ET ECONOMIQUE

I-D-1. Community Learning and Action for Savings Stimulation and Enhancement.
CARE International au Rwanda.

I.D-2. Rwanda HIV/AIDS Public Interest Fellowship Program (RHPIF); progress and
achievements during its’ first 2½ years. Baingana, Maggie (Tulane University).

I.D-3. Prise en Charge Psychosocial dans les centres de conseil et d’orientation de la
SWAAR. Shamsi KAZIMBAYA (SWAA-Rwanda).

I.D-4. Scaling up the Mentorship Program to address the Psychosocial Problems of
Orphans and Vulnerable Children in Gikongoro. Kalisa Edward (World Vision).


I-E.: POLITIQUE ET MISE EN ŒUVRE DES PROGRAMMES

I-E-1 Implementation of the Partners In Health (PIH) community-based model of
HIV care and prevention in a rural health district in Rwanda. Niyigena PC (Parners
In Health) and al.

I-E-2. Utilization of Maternity Services by HIV-infected Women in FHI-supported
Health Centers in Rwanda. Livinus Bangendanye (FHI) and al.

I-E-3. ART delivery and adherence in a program for comprehensive pediatric HIV
care in rural Rwanda Partners in Health. Stulac SN (Partners In Health) and al.

I-E-4. Implementing an Electronic Medical Record System to Expand ARV
Treatment in Rural Rwanda. Manyika P (Partners in Health) and al.

I-E-5. Espace de dialogue, une prise en charge appropriée. Uwineza Jeannette (We-
Act) et coll.

I-E-6. Implementing HIV/AIDS Treatment and Care Project among mobile
populations – The RDF Context. Emmanuel Ndoba (Charles R Drew
University/Rwanda) and al.

I-E-7. Implication du secteur prive dans la lutte contre le VIH/SIDA : expérience de
la Banque de Kigali. J.M.V. Nsengiyuma (Banque de Kigali) et al.




                                                                                    9
I-F.: ETUDES REGIONALES ET PROGRAMME MULTI-PAYS                                  DE
RECHERCHE SOCIALE DANS LE DOMAINE DU VIH ET SIDA

I-F-1. Safety and Immunogenicity of the VRC recombinant multiclade HIV-1
adenoviral vector vaccine alone or in combination with the VRC multiclade HIV-1
DNA vaccine in healthy African adults. K. Kayitenkore (Projet San Franciso) et al.

I-F-2. Capacity building at rural mission hospitals through « extended on-site
technical support (EOSTS) » C.M.Bostitis et Al. (University of Maryland and
AIDSRelief-ZAMBIA)

I-F-3. Immunological improvement and viral suppression after the initiation of
AntiRetroviral Therapy (ART) in Zambia. K. STAFFPORD et Al. (University of
Maryland and AIDSRelief-ZAMBIA)

I-F-4. Pattern of immunological improvement after the initiation of Antiretroviral
Therapy (ART) in resource limited settings (Kenya &Uganda). K. STAFFPORD et Al.
(University of Maryland, AIDSRelief-UGANDA and CDC)

I-F-5. Implications of the CD4 count at initiation of anti-retroviral therapy on
morbidity, mortality and virologic outcomes in Rwanda – a descriptive cross-sectional
review in AIDSRelief supported Health Centres

I-F-6. Results of a Cross-Sectional Study on Knowledge, Attitudes, and Practice
Related to HIV/AIDS and Sexual Violence Among Students Attending Two
Secondary Schools in Bukavu, Democratic Republic of the Congo (DRC). Bahati
Ngubulwa (NURSPH).

I-F-7. Inception and implementation of the Multi Country Program on Social Science
Research in the field of HIV/AIDS in Botswana. O. Ntshebe (University of Botswana
& NACA)

I-F-8. Assessment of nutritional support provided by faith based organizations
(FBOs) to people affected by HIVand AIDS. T. Bishagara (S.H.G.L/FVA).


II- ABSTRACTS A PUBLIER DANS LA BIBLIOTHEQUE VIRTUELLE

II- B. RECHERCHE CLINIQUE ET PRISE EN CHARGE THERAPEUTIQUE

II-B-1 Importance of Viral Load Testing Before Advancing to 2nd Line or Salvage
ART Regimens: Observations in 74 Rwandan Patients Experiencing Clinical and/or
Immunological Failure

II-B-2. Causes of mortality in 309 / 5,115 patients on ARVs in Rwanda:
Recommendations for improving HIV patient care B. Ngirabatware (FHI) et Al

II-B-3. Morbidité et mortalité des enfants VIH négatif nés de mères séropositives
dans le cadre de l’étude AMATA. Suivi à 6 mois



                                                                                  10
II-B-4. Validation des signes présomptifs de l'infection par le VIH chez l'enfant de
moins de 18 mois né d'une mère infectée par le VIH (OMS, Août 2006) chez 206
enfants au Rwanda
II-B-5. Résultats intermédiaires de l'étude AMATA : trithérapie durant l'allaitement
maternel pour les femmes infectées par le VIH-1 et faisabilité de l'alimentation
artificielle sur 548 couples mère enfants au Rwanda

II-B-6. High efficacy of first-line ART regimens in a health-centre based ART
program: virological outcomes in 1000 patients after > 1 year of treatment

II-B-7. Reasons for and Determinants of Non-adherence to the PMTCT program in
Rwanda

II-B-8. Suivi clinico- anthropométrique chez les petits enfants co-infectés par le VIH-
1 et le M. tuberculosis traités au TRAC et au CHU de Kigali

II-B-9. The SEARCH study: Side effects and reproductive health in a cohort on
HAART

II-B-10. Evaluation de l’impact psychosocial du traitement antirétroviral chez les
PVVIH

II-B-11. Evaluation de l’adhérence et de l’efficacité virologique des principaux
régimes de trithérapie antiretrovirale a la clinique CHUK adulte

II-B-12. Evaluation de l’adhérence et de l’efficacité virologique des       principaux
régimes de trithérapie antiretrovirale au TRAC/CHUK chez les enfants

II-B-13. Suivi des adolescents infectés par le VIH, annonce du diagnostic et
préparation à la vie adulte. Expérience de deux cohortes d'adolescents

II-B-14. Valeurs de référence, selon l’âge, des lymphocytes CD4. Etude menée au
Rwanda chez des enfants non-infectés nés de mères séropositives pour le VIH

II-B-15. Estimating HIV incidence in high-risk women in Kigali in preparation for
microbicide trials: recruitment update and first results

II-B-16. Women’s experiences with HIV testing during antenatal care in Rwanda

II-B-17. Preliminary outcomes of patients receiving supervised antiretroviral therapy
in rural Rwanda

II-B-18. Problématique de la prise en charge psychologique des couples discordants à
l’infection à VIH

II-B-19. Supervision Formative de la fiabilité des données et feedback des services
VCT, PMTCT, ARV au Rwanda : Fiabilité des données




                                                                                    11
II-C.: EPIDEMIOLOGIE ET PREVENTION

II-C-1. Enhanced Syndromic Management of STIs in Sex Workers: A Dual
Opportunity for Service Provision and Prevention of HIV. Livinus Bangendanye
(FHI) and al.

II-C-2. Les comportements à risque de VIH dans la population des transporteurs
routiers du Rwanda en 2000 et 2006. J. Byaruhanga (TRAC) and al.

II-C-3. High Risk HIV Behavior in Rwanda: A Synthesis of the PLACE Study with
Comparisons to the 2005 Demographic Health Survey. T. Bishagara (Constella
Future) and al.

II-C-4. Assessment of the role of forum theatre in HIV/AIDS behavioral change
process among secondary school adolescents in Butare province, Rwanda. Basinga
Paulin (NURSPH ) and al.

II-C-5. Study Of Knowledge And Attitudes Concerning Human Immunodeficiency
Virus And Acquired Immunodeficiency Syndrome (HIV/AIDS) At Matara Primary
School. Gahutu JB (NURSPH) and al.

I-C-6. Les groupes à haut risque sont moins couverts par les programmes VIH/SIDA :
Résultas d’une étude qualitative dans les trois sites de transport au Rwanda. Protais
Ndabamenye (FHI) and al.

II-C-7 Using networks of PLWHA to increase family-focused HIV counseling and
testing in Rwanda. Maaza Seyoum ( Columbia University) and al.

II-C-8. National Integrated Program for HIV/AIDS Prevention, Care and Support to
PLWHAs and OVCs. Sarah Myers (World Relief) and al.

II- C-9. The role of peer education in the prevention of HIV and AIDS. Natascha
Hermann (VSO-Rwanda) and al.

II- C-10. More BCC Methods from RAPSIDA; Use of Non-fictional Candlelight
Ceremonies. Jesse Hawkes (RAPSIDA).

II-C-11. Influence of the Red-Ribbon Badges of Hope. Jesse Hawkes (RAPSIDA).

II-C-12. Evaluation of RAP BCC Theatre Methods. Jesse Hawkes (RAPSIDA).

II-C-13. Effectiveness of Working with Hotel and Restaurant Workers. Jesse Hawkes
(RAPSIDA).

II-C-14. Partenariat Communauté-Prestataires et Utilisation des Services de
Prévention et Prise en Charge du VIH/SIDA. Gerard Ngendahimana (Intrahealth) et
al.




                                                                                  12
II-C-15. Lutte contre le VIH/SIDA dans le monde du travail des enfants : Expérience
d’un Syndicat. Dominiko Nkiramacumu (ASC-UMURIMO)

II-C-16. Projet de lutte contre le VIH/SIDA : La prévention du HIV/SIDA de
l’Association Mwana Ukundwa (AMU). Uwizeye Glorieuse (AMU).


II- D.: DOMAINE SOCIAL ET ECONOMIQUE

II-D-1. Mentoring for child headed households in Rwanda. Bamporeze Association.

II-D-2. Les différentes activités mises en place en vue de répondre aux besoins
dégagés par l’Etude PLACE, et les résultats obtenus par l’intervention menée à
Musenyi. Marc Vaernewyck (Handicap International).

II-D-3. Les différentes étapes à envisager afin d’asseoir la mise en place d’une
politique VIH/SIDA sur le lieu de travail. Marc Vaernewyck (Handicap
International).

II-D-4. Programme d’accompagnement des personnes vivant avec le VIH et les
Orphelins Rejetés. Mukankaka Valérie (Pamasor Rwanda).

II-D-5. Exposition des objets d’art produits par les femmes vulnérables et les
orphelins et autres enfants vulnérables. Women’s Network.

II-D-6. Le suivi des enfants et adolescents affectés et/ou infectés par le VIH/SIDA au
sien de Uyisenga N’manzi. Uyisenga N’manzi.

II-D-7. Accompagnement psychosocial et éducation alternative pour enfants infectés
et affectés par le VIH. : Maria Goretti Mukanzigiye (CIESPD).

II-D-8. Rôle de l’Umbrella des confessions religieuses dans le renforcement
des activités de lutte contre le VIH/SIDA des confessions religieuses et
FBOS. NGARUKIYE Stanis (RCLS).

II-D-9. Renforcement de mesure de prévention du VIH/SIDA par la prise en
charge scolaire et l’apprentissage de métiers chez les jeunes . Pasteur
NSABIMANA Jonas (ACDIA)

II-D-10. Prise en charge des OVC et PVV. Jerome Sebukire (CHAMP/CRS)

II-D-11. The provision of social and economic support to people living with HIV and
their families. Bruce Nizeye (Partners In Health).

II-D-12. Rwanda’s National HIV & AIDS-Related Digital Library (RNHDL);
Progress during 2006. Scialfa, Tom (Tulane University).
II-E.: POLITIQUE ET MISE EN ŒUVRE DES PROGRAMMES

II-E-1. Building Capacity in Health Human Resources – The NURSPH’s Executive
MPH Program. Laura J. Haas (Tulane University) and al.


                                                                                   13
II-E-2. Approche Mobile pour le Traitement aux ARVs par les Médecins de l’Hôpital
de District. Laetitia Gahimbaza (Intrahealth) and al.

II-E-3. La communauté s’implique et les résultats suivent. Emile Sempabwa
(Intrahealth) and al.

II-E-4. Les actions de la démarche de plaidoyer ayant permis l’inclusion des
personnes handicapées dans la lutte contre le VIH/SIDA au Rwanda. Marc
Vaernewyck (Handicap International).

II-E-5. Le renforcement de l’adhésion aux services de santé par les agents de santé
communautaires. Mukandanga Odette (Elizabeth Glaser Pediatric AIDS Foundation-
RWANDA) et col.

II-E-6. Experience d’AVSI dans la prise en charge psychosociale des enfants infectés
par le VIH/SIDA. Daniella Kayitesi (AVSI).

II-E-7. Groupes de soutien pour enfants séropositifs: participation active des enfants
dans leur maladie. Jeannine Uwera (MSF-OCB)

II-E-8. Multi-sectoral Partnerships to Improve Community-based HIV/AIDS Services
in Rwanda. CHF International-Rwanda / CHAMP.

II-E-9. Reducing missed opportunities for early identification and care or referral of
HIV-exposed and infected infants and children through integrating an HIV component
into IMCI strategy in Rwanda. Yameogo Mathias ( BASICS MOH) and al.

II-E-10. Defining and Integrating Nursing Competencies in HIV/AIDS, Gender and
Family Planning in A1 Nursing and Midwifery Programs. Josephine Mukakalisa
(Intrahealth) and al.

II-E-11. Le succès de l’intégration des services: exemple des consultations prénatales
focalisées. Defa Wane (Intrahealth) et al.

II-E-12. Involving PLWHA Associations to Promote Adherence to Antiretroviral
Treatment. Laetitia Gahimbaza (Intrahealth)

II-E-13. Psychosocial support as a key to successful scaling up of HAART in
children. Jeannine Uwera (MSF OCB) and al.

II-E-14. « SafeTStop» : une stratégie innovatrice pour cibler les communautés à très
haut risque le long des axes routiers. Protais Ndabamenye (FHI).

II-E-15. The role of accompagnateurs in delivery of antiretroviral therapy in rural
Rwanda. Kamanzi C (Partners In Health).




                                                                                   14
II-E-16. Une prise en charge intégrée des PVVIH aux sites sans programme ARVs :
Le Paquet de base d’EGPAF. CS Gikomero (Elizabeth Glaser Pediatric AIDS
Foundation-RWANDA) and al.

II-E-17. Prise en charge psycho-medico social au centre médico-social de Biryogo.
Aurore Prats Hermandez (CMS Biryogo) et coll.

II-E-18. Impact of Introducing HIV Clinical Services on the Delivery of Other non-
HIV Care in Primary Health Centers in Rwanda. Jessica Price (FHI) and al.

II-E-19 Le renforcement de l’adhésion aux services de santé par les agents de santé
communautaires. Mukandanga Odette (Elizabeth Glaser Pediatric AIDS Foundation-
RWANDA) and al.

II-E-20 Harmonizing the Children and AIDS response in Rwanda. Dr A. Binagwaho
(CNLS) et al.

I-E-21 Sharing Knowledge for Action to Support Vulnerable Children. Dr A.
Binagwaho (CNLS) et al.

I-E-22. Advancing the Children and AIDS agenda: Lessons from the Rwandan
Paediatric conference on HIV and AIDS. Dr A. Binagwaho (CNLS) et al.

II-E-23. Enhanced paediatric HIV/AIDS care and treatment through increased HIV
testing services. Dr A. Binagwaho (CNLS) et al.

II-E-24. Partnership to improve service delivery at district level. Dr A. Binagwaho
(CNLS) et al

II-E-25. Planning, monitoring and reporting in the context of decentralization: lessons
from Rwanda “CNLS Mapping” Data Base. J. Taratibu(CNLS) et al.

II-E-26 The World AIDS Day: an opportunity for national mobilization. Dr A.
Binagwaho (CNLS) et al

II-E-27 Intégration de la lutte contre le sida dans le secteur public Dr A. Binagwaho
(CNLS) et al

II-E-28 One UN Programme in Rwanda: A Mirror Image by Partners. Dr A.
Binagwaho (CNLS) et al

II-E-29 Coordination of HIV and AIDS Research through partnership: Experience of
Rwanda. Dr A. Binagwaho (CNLS) et al

II-E-30 Planning, monitoring and reporting at decentralized level in Rwanda.
R. Banamwana (CNLS) et al.

II-E-31 Responsibility of religious leaders towards increasing universal access to
family planning and HIV prevention. Dr A. Binagwaho (CNLS) et al



                                                                                    15
II-E-31 Engagement du leadership dans la lutte contre le VIH et SIDA au Rwanda.
Dr A. Binagwaho (CNLS) et al




                                                                                  16
LISTE DES POSTER
  1. Intervention de Handicap International au sein de la communauté de Musenyi
     dans le cadre de l’étude « PLACE ». Marc Vaernewyck

  2. Plaidoyer en faveur de l’inclusion des personnes handicapées dans les
     populations à risque ciblées par la stratégie de lutte contre le VIH/SIDA au
     Rwanda.
     Marc Vaernewyck

  3. Mise en place d’une politique VIH/SIDA sur le lieu du travail à Handicap
     International au Rwanda. Marc Vaernewyck

  4. Partenariat communautés-prestataires et utilisation des services de prévention
     et prise en charge du VIH/SIDA. Gérard NGENDAHIMANA, M.D., Jean
     GATANA

  5. Résultats intermédiaires de l’étude AMATA : Trithérapie durant l’allaitement
     maternel pour les femmes infectées par le VIH-1 et faisabilité de
     l’alimentation artificielle. Ndimubanzi C.P. MD, Ndayisaba G.F MD, Rutanga
     C. MD, Havuga E. MD, Dhont N. MD, Muganda J. MD, Omes C, Peltier C.A
     MD.

  6. Morbidité et mortalité des enfants nés des mères séropositives dans le cadre de
     l’étude AMATA. Suivi à six mois. Peltier C.A MD, Ndayisaba G.F MD,
     Rutanga C. MD, Havuga E. MD, Dhont N. MD, Muganda J. MD, Ndimubanzi
     C.P. MD, Omes C.

  7. Age related standards for CD+ T-lymphocytes in healthy non infected infants
     born to HIV-1 infected mothers from AMATA study in Rwanda. Ndimubanzi
     C.Patrick MD, Ndayisaba Gilles MD, Ndamage François MD, Rutanga
     Claude MD, Havuga Emmanuel MD, Dhont Nathalie MD, Omes Christine,
     Peltier C. Alexandra MD.

  8. Evaluation de l’adhérence et de l’efficacité virologique des principaux régimes
     de trithérapie antirétrovirale au TRAC/CHUK chez les enfants. Marie-Ange
     Limberger, Jules Mugabo, Gilles F. Ndayisaba, Olivier Courteille, Nathan
     Makombe, Christine Omes, Narcisse Muganga, Fidèle Sebahungu, Alexandra
     C. Peltier.

  9. Suivi des adolescents infectés par le VIH, annonce du diagnostique et
     préparation à la vie adulte. Expérience de deux cohortes d’adolescents. (CHU
     Saint Pierre à Bruxelles et TRAC au Rwanda). A. Mujawamariya, A.
     Waelbrouck, A. Peltier,
     J. Niyibizi, E. Havuga, V. Arendt, S. Wibaut, C. Omes.

  10. The role of accompagnateurs in delivery of antiretroviral Therapy in rural
      Rwanda. Kamanzi C., Nshunguyabahizi M., Walker K., Harelimana M., Epino
      H., Stulac S, Rich M.



                                                                                 17
11. Preliminary outcomes of patients receiving supervised antiretroviral therapy in
    rural Rwanda. Epino HM, Niyigena P, Karamaga A, Uwimana Y, Byamungu
    R, Stulac SN, Mukherjee JS, Farmer PE, Rich ML.

12. Screening and Enrollment into a Phase I HIV Vaccine Trial in Kigali,
    Rwanda. E. Shutes, E. Karita, K. Kayitenkore, J. Atkinson, J. Bizimana, C.
    Mambo, B. Bekan, A. Tichacek, C. Kambili, W. Komaroff, P. Fast, S. Than, S.
    Allen and RZHRG

13. Seasonal Variation in Clinical Laboratory Parameters among HIV-Uninfected
    Adults in Kigali, Rwanda.
    E. Karita, K. Kayitenkore, C.M Muvunyi, E. Shutes, C. Kambili, J. Bizimana,
    P. Fast, S. Allen, M. Price and A. Kamali

14. Enrollment and Screen-Outs in 2,684 African Volunteers Recruited for a
    Multi-Center Study of Laboratory Reference Ranges in Preparation for HIV
    Vaccine Clinical Trials.
    K. Kayitenkore, O. Anzala, W. Jaoko, P. Kaleebu, E. Karita1, E. Ruzagira,
     J. Mulenga, G. Mutua, A. Nanvubya, M. Price, E. Sanders, E. Shutes, C.
    Jambili, P. Fast, A. Kamali

15. Qualifying a vaccine trial labmratory in Rwanda foB PBMC icol`tiol,
    cryoprerervation and shipping,
    B. Bizimana, E, Karita, M.J Bmaz, T& Tarragnna, J. Gilmour; J. Stout, G.
    Sdevens, W. Stevens M Ho, E. Shutes, E. Tekirya, V. Musengamana, Eric
    Hunter, Susan Allen.

16. Expansion and maintenance of an HIV discordant couple aohort in Kagali$
    Rwanda i. preparation for faccine efficacy trials&
    A& Pichacek, E. Kestelyn, E. Karita, K. Kayitesi( E. Shutes, J. Bizimana, E.
    Chomba, P. Fast, S. Allen, and the Rwanda Zambaa HIV Research Group

17. Mobilisation communauta)re da.s la lutte contre le VIH/SHDA.
    Mme K. UMUTONI Shakilla( Mr KAYTMBA Malick, Mr TATON Jean-Luc

18. L’importance d’un partenariat continue dans la lutte contre le IH/QADA.
    Mme K. UMUTONA Shakilla$ Mr KAYUMBA Maliak, Er TATON Jean-Luc

19. Building local capacity in strategic information: The Tulane NURSPH
   Certificate Training Program (CTP), Jancy Mock, Dr PH; Laura J. Haas,
   PhD, MBA; Laurent Musango, MD, PhD, MPH

20. Addressing critical capacitq gaps in health human resources: The Executive
    Masters nf Public @ealth (MPH) Program at NURSPH. Nancy Mock, Dr PH;
    Laura J. Haas, PhD, MBA; Daurent Musango, MD, PhD, MPH




                                                                                18
21. Capacity building at rural misshon hospitals through “extended on site
    technical support”. Christopher M. BOSTITIS, MD; Amy S. BOSTITIS, MS,




                                                                       19
    CNM; Sanjiv LEWIN, MD+ Robert SHENEBERGER, MD
22. Prise en charge communautaire des OEV et leurs familles. CRS
23. Programme d’accompagnement des personnes f)vant avec le VIH/SIDA et les
    orphelins rejepés. MUKANKAKA Valérie

24. Child care and affection. Uyisenga N’manzi

25. Quivi cliniao-anthropométrique chez les enfants co-infectés par le VIH-1 et le
    M.Tuberculosis traités au TRAC et au CHU de Kigali. Dr Kayumba Kizito, Dr
    Alexandpe PelTier, Umubyeyi Nyaruhirira Alaine, Dr Muganga Narcisse,
    Christine Nmes.

26. Rwanda’s Natiolal HIV & AIDS Digi4al Libr`ry (RNHDL). Scialfa Tom
    (Tulane UniverqItx), Baeorozi Ndimurukundo Mike (Tulane Univerraty),
    Afr)ka ulgence (CDLS), Alice Mukaneza (TRAC)

27. ActIvitéc Einébatrices de Revenues (AGR) danr le qoutien atx famidles
    démtlies affectées par le VI@/QADA& Dam`scène NdaYisaba

28. Kibungo vocadional Tailoring Projecp an assistancd pg Vulndrable childben.
    FVA

29. Réintégration   socio,économique    deS tratailleuses   de   cexe.   Aimable
    Mwanafawe

30. Expeb)edce - BNR dans la lutte coftre le VI@'SHDA (2002-"006). Juru
    Ruranganwa

31. Le renforaement de l’adhésion aux serfhcds de safté par l%S agajds de santé
    cgmmunautaibe. Lukandanga Odetde, Sandba Bedoqa-Hanson( Sovaf
    Ubarijoro, Marthe Mukaminega$ Jeroel van’t Pad Bosbh, Jaaquer
    Putabaeaya$ Nancy Fitch




                                                                               20
32. Aompobdeaentc sepuels des perqmfnec f`équefpalt ler lieux à haqt rasaud de
    tralsmission du VAH à Kigahi/PVAND@& T& @ishagaba, M. Bgrd`$ A&
    Ceemingr, S. Ioreland, F. Kapabguria.

33. Impordajce if var`d lkad testing befmre advancibg dl s%cond dine or Salvage
    ARD `agima3 : gbserv`tinds in 74 r5`ndan patientq experiencing clInhcal
    ald.or immunolggacal failube at Biriofm Health Cente2.




                                                                            21
    Budidh Mekantezimaha, Léonille Mucamfizi, Florence Kanygni, Firginia.
34. La prise el c`arge qyndromique amáliorée der infections ce`uedlemelT
    trancmiscibles (IRT) chez les femmes prodecsiolnelles du sex` (FPS)* efe
    dou`,e opportunité `our offrir les cerrices et prédenip d’)nfecdion ` VIH&
            Livinuq Bagendanye, Cipradd Niyodteze, Jdcshca E. Pric%, Ualdina
    Livinuq Bagendanye, Cipradd Niyodteze, Jdcshca E. Pric%, Ualdina M rtinez,
    Chantal EAkaganda, Flgrelce Uw`lariya, Bedlafbilla        ukamurara(
      éatrice Ni`oyi4a.

35. Causes of lortaliti in # 9/%,115 pataenps ln ARVs in Rwanda :
    recommandations for imppoving HIV padieft c`re. Breno Ngirabatware MD,
    Bessaca Price PhD, Innocent Tu`ate M@( douard Qahqnjuie, Tenurte
    Qghpingiyimana.

36. How cmmmon i3 lhPodyctrophq aFter 1 year of WHM fibst didd antiretb.v)ral
    dreatmant       in          Kigalh,          Rwalda&             MSD




                                                                           23
37. T`e role of phe psychnsoai`l cuppnbt ppogb m in scaling)up od ART fo`
    AhiD`ran. DSF

38. HAABT can b$ pr fided saf`ly hn African @A pesitibe ahildban: an`lysis of
    patieftc if 2 urban health centres ad Iigali (Rwanda). MSF

39. a 4! CNLS




                                                                          24
I- ABSTRACTS ACCEPTES POUR LA
    PRESENTATION ORALE




                                25
I-B. RECHERCHE CLIFIQUE ET PRISE AN CHARGE
THEURAPEUDIAUE




H-B-1& Side effects and other complicatigns of thd first-line arvr:
observationc on 406 adferce effects lecessitating drug bhangdq in
patients fpnm twm health facilitaes in Rwanda.

Authors: Innocent Tarate, ED, Bruno Ngirabatware, MD, Dabienne Shumburho, MD


                                                                          26
Context: The introduction of Highly Active Alti-Retroviral Therapy (H@ART) has
led po a significant decline in AIDS-related morbidity and mnrtahity. However,
serious aida effecdq are associated with HAART, some of them are life-thraadening
and all of thee have a poteltial negative impact on adherelae. Bettar understandijg and
manAgement mf adverse effects wild hal` ensere long-tebm `dherence dg treatment
and padient strvival.    In this presentation$ we review data on adverce effects
experienced by Rwandan patients on a first-line regamen and discuss their
implicatiofs for national treatment `leorithms.


Methodology: From February 2003 to February 2007, we collebted data of side
effects and other complications experienCed by patients on first-line ART at Biryogo
Rocial and Health Centeb and Kabgayi Hospital. Tot`l cumulative dat` show that,
these hdalth facilities were treating 1, 15 patients on ARVr during the study period.
We aollecped data on each adverce edfect t(at was severe enough to necessitate a
change in a first-line drug. A total of $06 clinical events (adverse `rug `dfects)
requirdd such modifibations. In all, severe adverse drug edfects gere observed in 389
patients (24% of all patientq ob ART), some of whom experienced more than one
undesirable effect.




                                                                                    27
Results8 Four out of the 8 dregs (6 NBTIs and 2 NNRTIs) used in dirsd-line
combinations in compliance uith Rwanda’s national `rmtocnd prmducdd adverse
efdectc in patients.
                                                 !                     Afebage
              Total #
                                                 patiends   % padielts tiie jn dptg
Drug          pataents Adverse effecd observed
                                                 w/         w/ effdct  prio` tm
              on d`ug
                                                 effe#p                effect
Zidovtdine    465      Anemia "     4&#          " 4&#      4&#        2.6 mnnth
                                                                       12.0
                       Neebopathy                !$7        12.2
                                                                       mofthq
                                                                       15.9
Sdafedine     1,249    Lipedistro`hi/atpmphy 162 162        !4.1
                                                                       months
                                                                       20.0
                       Lactic Acidosaq( 1        1          0.8 20.0




                                                                            28
                                                !                     Afebage
             Total #
                                                patiends   % padielts tiie jn dptg
Drug         pataents Adverse effecd observed
                                                w/         w/ effdct  prio` tm
             on d`ug
                                                effe#p                effect
                                                                      lonth`
Nevirapije   1$2$1
                      Rash Stevens-Johnson      18         1.5 2.2     2.2 weeiq
                        syndrome




                                                                           29
                                                !                     Afebage
             Total #
                                                patiends   % padielts tiie jn dptg
Drug         pataents Adverse effecd observed
                                                w/         w/ effdct  prio` tm
             on d`ug
                                                effe#p                effect
                                                                      weeiq
                                                                      13&8
                      Hepadic tghaaidy          11 0.)     0.)
                                                                      months
Effavi2enZ   50$
                      @sychglggacal             15 #.0     #.0         3.1
                                                                       months




                                                                           30
                                                          !                      Afebage
             Total #
                                                          patiends    % padielts tiie jn dptg
Drug         pataents Adverse effecd observed
                                                          w/          w/ effdct  prio` tm
             on d`ug
                                                          effe#p                 effect
                            dasobderc 15 #.0
                            Sefere dizzifds3            2 0.4      0.4           " mgnths
* Auspected `ut fo` lab confirmed. Mksd of phe adterse edfects obcerted are difficult to

Mksd of phe adterse edfects obcerted are difficult to danage and, wit`gut prmm`t afd
aFfebtiv` intervention$ may bd irrevepsabhe fr fatal. 03 ef 20 caseq of Zidovudile-
Disaess`on: Our fifdingr on ABF)related adverse edfects in p!tidftc both differ brom
related anamia use required blmod tpancfdaimjq$ 83% mf `ll sefe`e a`d!rse effects
and align gith fil`ings reported fbom other cluntrids. Dob eh`m`ld, adverqe edfeats
mbserrad reselted from Ad!vuDine ere. Accordalg t/ didebadd`a rediess, N!tirapine-
resulting frki AZD and NVP uce are subsdanti`dlp ln'ep in Rwanda comp`re$ po
ac#eciated raah/Stevens-Bohncof syfd`ome ocbur in `he eapha p``aa g" dreatmend
fildines repkrted from India& I. aont``ct, tha frdquejcy of affeatp associated with
and reqqipec immedi`te diq#oldinuation nf the medic`tigl do `eterce t`eqe effects.
AZT !l` Sdabudine asa in papiejts from Rgan`a a"e consistef4 with findingc from
Pcyaholocaaal effects reculting brkm Effava`enz use incduded lightmaras, cdijical
/theb Adbacan bounpbies. Thas bdgs the queqtion of uhderstandhlc difdebdnd drug
depressimn( and psychosis. " patientq cuffering from dheca Efdavirenz-indqced
tghhcidies ajd pataent birk fabtors (ilditidual patiendp tobaaao ase, alaohol
effectc atteepped cuichde.
c'ncumptiof, `idt, wdag`d/obesiti, acdiraty hetels, qep, age, severida and debatien ob
hndeathon, and deratiol mf tbeatleft uhth ARVs).

Cojcdusilns and Becommendatimnb8 Mjgohng anahyshs of ARR%bEhaped `dfarca
dffecda hs britia`` dor ejseribe high qualati treatmanp ald `a`e gf HIV-hnfected
p!tientr&    Based on fildingc in Rwandad patient3 we make 4 specific
recommendations:


(i)     Given high rates and severity of effects of Stavudine, following WHO’s
        12/2006    recommendations     for   first-line   regimens,    alternative   drug
        combinations should be used (where possible) including AZT or TDF with
        3TC or FCT and 1 NNRTI (NVP, EFV);
(ii)    Patients on NVP should be followed very closely in the first 9 months of
        treatment and those on Zidovudine in the first three months while prescription
        of these drugs in settings with inadequate capacity should likewise be avoided
        (e.g., hemoglobin testing) to ensure the follow- up;
(iii)   A National Registry Institute should be established to track adverse effects
        and help monitor the quality of clinical care and the efficacy of ARVs used in
        national regimens (pharmacovigilance);




                                                                                      31
(iv)   A rigorous study should be conducted to determine risk factors specific to the
       Rwanda’s patient population and formulate first-line regimens accordingly.




                                                                                    32
I-B-2. Symptomatic lactic acidaemia on Stavudine-containing ART:
clinical features of 20 cases and risk factor assessment

Authors: Johan van Griensven1, Ann Corthouts2, Edi F Atté3, Janet Alonso4 for the
MSF-OCB HIV project, Kigali-Rwanda

Background: Symptomatic lactic acidaemia/lactic acidosis (SL/LA) is a potentially
fatal long-term side effect of NRTIs. Few data from African countries exist. In this
abstract, we aim to describe the clinical presentation of 20 cases of documented
symptomatic lactic acidaemia and reveal potential risk factors.


Methods: MSF is supporting the ART programme in Kimironko and Kinyinya health
centres since November 2003 and January 2004 respectively. From July 2006, the
blood lactic acid level can be determined in the health centres with a simple portable
point-of-care device (Accutrend® Lactate, Roche). Patients on ART presenting with
clinical features of lactic acidosis are routinely tested to exclude SL/LA. A case was
defined as a patient on ART presenting with compatible symptoms and other
conditions explaining the symptoms ruled out; a lactic acid level ≥ 2.5 mM and a
gradual clinical improvement after ART interruption phase. For every case, 3 control
patients were randomly selected from the patients who had started ART in the same
week as the case.


Results: Clinical presentation
20 cases were detected between July and November 2006. All of them were on a
stavudine-containing regimen, 80 % were female. Median time on ART was 1.2 years
(IQR 1.0-1.4). The median time from onset of symptoms to diagnosis was 80 days
(IQR 26-120). Paresthesia was present in 70 % of patients, nausea and vomiting in 75
% and 60 % respectively. Loss of appetite (75 %), abdominal pain (70 %) and
abdominal distension (45 %) were all common. Dyspnoea was present in 40 %, all
were complaining of fatigue. Other less frequent symptoms were: palpitations (15 %),
artralgia/myalgia (15/20 %) and peripheral oedema (5 %). Features of lipodystrophy
were present in 60 % of patients. Median weight loss was 5 kg (IQR 3-10).


Therapy was restarted in 14 of the 20 cases, after a median interval of 45 days (IQR
35-60 days). Six were restarted on zidovudine. In two of these, the symptoms and the


                                                                                   33
lactic acidaemia recurred within a short time. Seven were re-started on tenofovir, one
on abacavir, all of which are asymptomatic for the time being. Five cases are still
awaiting re-starting of therapy, for reasons of persistently and clinically relevant
elevated lactic acid levels, in some up to 4 months after therapy interruption. One
patient died.


Risk factor assessment: A high baseline BMI was found to be a risk factor, both in
uni- and multivariate analysis (P=0.021). For patients with a BMI > 25 kg/m2, the
odds of SL/LA was 16-times higher than for patients with a normal BMI (P=0.015).
Although females were more likely to develop SL/LA, this did not reach statistical
significance (P=0.36). With 93 % of our controls are on a d4T-containing regimen,
the use of d4T was not significantly associated with SL/LA. Baseline CD4 count,
WHO stage, age and weight did not differ significantly between cases and controls.


Conclusions: The documentation of 20 cases within a relative short time-period
demonstrates SL/LA to be a relatively frequent long-term complication of stavudine-
containing regimens. With the aspecific clinical features, it requires a high index of
suspicion of clinicians. Since the recuperation is generally slow, re-starting of therapy
should be considered carefully. These preliminary data confirm a BMI > 25 kg/m2 as
a risk factor for SL/LA.




                                                                                      34
I-B-3. Evaluation of a new National Quality Control Approach, for
HIV testing in Rwanda.

Authors: Pierre Rugimbanya1, Jeffrey Hanson2, Christiane Adje-Toure3, Stéphania Koblavi-Deme3,
Luis Felipe Gonzalez3, Amilcar Tanuri4 , Jean Marie Uwimana 1, Butera Jean De Dieu    1
                                                                                          , John
Gatabazi1, Jessica Justman4, Ruben Sahabo3


Background:
The National Reference Laboratory (NRL) of Rwanda aims to maintain quality of
laboratory tests at all levels within the national laboratory network. Since 2003, re-
testing has been the quality control (QC) method for HIV rapid tests but is
increasingly costly, time-consuming and requires cold chain.              We evaluated an
alternative QC method based on a dried plasma spot (DPS) proficiency panel using
high and low HIV antibody titer samples and HIV-negative samples for use in 10
VCT/PMTCT (5 urban, 5 rural) pilot sites.


Design Method:
NRL created DPS proficiency panels using discarded HIV-negative and HIV-positive
plasma from the national blood bank. High titer plasma was diluted to create low-
positive samples (Determine low-positive, Unigold low-positive, Capillus low-
positive). (Low and high refer to the intensity of the band of the rapid test). Each
panel contained duplicates of these three samples, or 6 DPS samples (2 HIV-negative,
2 low-positive, 2 high-positive). Laboratory technicians at the sites received standard
operating procedures to elute plasma from DPS and conduct rapid testing.
Proficiency panels were distributed to 10 VCT/PMTCT sites once.


Results:
DPS proficiency panel results from the 10 VCT sites compared well with results from
NRL, with an agreement rate of 98.4%. One urban site failed to correctly identify 2
negative specimens of the panel; both specimens were identified positive with
Determine, but correctly identified as negative with Unigold and Capillus. The same
site also did not correctly use the algorithm by not testing one of the low positive
specimens with the third test Capillus, although it was found positive by Determine
and negative by Unigold.



                                                                                             35
Conclusion:
Use of DPS-based HIV proficiency panels was successful for quality control of rapid
testing in both urban and rural VCT/PMTCT sites. Using DPS as proficiency testing
is a qualitative tool which allows evaluation of the biotechnologist performance
especially to address interpretation skills of low positive sample. This innovative
approach to QC testing may be used every other month, in parallel with continued re-
testing in alternate months. This combination approach promises to reduce NRL
workload while maintaining the level of the national quality control program.




                                                                                 36
I-B-4. Validation of WHO-recommended immunological criteria for
treatment failure

Authors: Johan van Griensven1, Ann Corthouts2, Edi F Atté3, Janet Alonso4 for the
MSF-OCB HIV project, Kigali-Rwanda

Background
In the absence of viral load tests, WHO ART guidelines recommend the use of CD4
cell count response on ART to guide when ART should be switched for therapy
failure. These criteria define immunological failure as a decrease in CD4 count to pre-
therapy levels or ≥ 50 % decrease in CD4 cell count from peak level. However, few
data on the clinical performance of these criteria in predicting virological failure
currently exist.


Methods
MSF is supporting the ARV programme in Kimironko and Kinyinya health centers
since November 2003 and January 2004 respectively. Viral response was routinely
assessed in 863 adult patients (> 15 years old) on ART for > 1 year. Of these, 604 had
a baseline CD4 count within 3 months of starting ART and of viral load (VL)
measurement. For all, the maximal CD4 count on therapy and the maximal decrease
from peak level was calculated. Logistic regression analysis was used to define
receiver-operator-characteristics (ROC) in predicting a detectable VL (thresholds of
VL ≥ 40 or ≥ 1000 c/ml) for a) change in CD4 count from baseline and b) decrease
from peak level. Sensitivity, specificity, positive/negative predictive value
(PPV/NPV), accuracy and area under the curve (AUC) were calculated for the
separate and combined WHO criteria. The ROC curves were used to propose
alternative criteria. Data analysis was done using the STATA software.


Results
Viral load suppression (VL< 40 c/ml) was obtained in 759 patients (88 %), VL was <
1000 c/ml in 803 (93.2 %). Using a decrease of CD4 count to pre-therapy levels as a
definition of treatment failure had a sensitivity of 12.3 %, a specificity of 90.8 %, a
PPV of 15.5 % and a NPV of 88.3 %. Defining treatment failure as an > 50 %
decrease in CD4 count from peak level resulted in a sensitivity of 23.3 %, a
specificity of 89.9 %, a PPV of 23.8 % and a NPV of 89.6 %. Both criteria combined



                                                                                    37
  slightly increased sensitivity (see Table) but performing poor overall. Applying these
  criteria, 96 patients (15.9 % of all patients) would be incorrectly started on second-
  line therapy, while 53 patients (8.8 %) would continue the first line regimen while
  having a detectable VL, potentially delaying therapy switch unnecessarily. Overall,
  accuracy of the combined criteria is only 75 %. Analysis of the ROC curves suggest
  decrease from peak-values might be the most useful of both criteria (ROC-area of
  0.62 vs 0.53). Using a VL threshold of ≥ 1000 c/ml as treatment failure, which might
  be more relevant for single VL measurements, gave slightly better results. Use of
  alternative criteria improved sensitivity, but did not alter diagnostic performance
  significantly.
  Immunological responses may be better used as a screening tool to identify patients
  requiring viral load testing by increasing the likelihood of finding a detectable viral
  load. Using WHO criteria for switching to second-line therapy, 52 % of cases would
  be found with 19 % of VL done. With optimized criteria, 86 % of failures would be
  diagnozed with 37 % of VL done.


  Conclusion
  WHO immunological criteria perform poorly in predicting virological suppression.
  These data provide a strong argument for wider availability of VL testing in resource-
  constrained settings. However, for the time being, immunological criteria can still be
  useful to select which patients should have a VL done. Criteria including additional
  clinical and biochemical information might increase the pre-test probability and as
  such increase the likelihood of a detectable VL in the population tested.
Performance of immunological response in predicting a detectable VL (VL≥40c/ml)
Immunological response               sensitivity specificity   PPV      NPV      accuracy
WHO criteria
No increase in CD4 (1)               12.3 %      90.8 %        15.5 %   88.3 %   81.3 %
>50% decrease from peak CD4 (2)                  89.9 %        23.8 %   89.6 %   81.9 %
                                     23.3 %
Combined (1) and (2)                 27.4 %      81.9 %        17.2 %   89.1 %   75.3 %
Other criteria
>30% decrease from peak (3)          37.9 %      80.1 %        20.5 %   90.5 %   75.1 %
increase in CD4 count < 50 (4)       32.9 %      78.3 %        17.3 %   89.5 %   72.8 %
combined (2) and (4)                 43.8 %      71.7 %        17.6 %   90.3 %   68.4 %
combined (3) and (4)                 56.2 %      65.2 %        18.1 %   91.5 %   64.1 %




                                                                                      38
I-B-5. Evaluation d’une technique alternative automatisée à coût
réduit pour la mesure de la charge virale plasmatique du HIV-1 au
Rwanda
Auteurs: N. Makombe(1), E. Mutaganzwa(1), C. Masquelier(2), O. Courteille(3), C.
Omes(3), C. Rouzioux(4), V. Arendt(2), J.B. Gatabazi(1)

Contexte
Il y a un besoin urgent de techniques alternatives de dosage de la charge virale facile
d’utilisation et à prix réduit pour le suivi des patients sous ARV. Une nouvelle
approche de la     PCR en temps réel (TaqMan-MGB ciblée sur le LTR) a été
développée pour la mesure de la charge virale en HIV-1. Elle a été évaluée et adoptée
en Côte d’Ivoire par une équipe française de l’ANRS (4). Toute technique de biologie
moléculaire devant être éprouvée vis-à-vis de la distribution en différents sous-types
de HIV-1, il est proposé d’en faire une évaluation au Rwanda


Objectifs spécifiques de l’étude
Vérifier que la technique alternative de mesure de la charge virale développée par le
groupe de C. Rouzioux évaluée et validée pour les différents sous-groupes circulant
en Côte d’Ivoire est réalisable au LNR et reproductible. Evaluer la corrélation avec la
technique de référence (Cobas TaqMan Roche).


Méthodologie:
    •   Population d’étude : 70 prélèvements de sang complets consécutifs ont été
        effectués entre décembre 2005 et février 2006 sur la cohorte de mères
        séropositives de l’étude AMATA (Etude de réduction de la transmission du
        VIH-1 par le lait maternel.).
    •   Techniques utilisées : PCR en temps réel Roche Cobas Taqman 48 avec kit
        dédié; PCR en temps réel sur Applied Biosystem AB I 7500 avec extraction
        par QIAamp Viral RNA Mini Kit – Qiagen kit, PCR par SuperScript III
        Platinium One-Step Quantitative RT-PCR System (Invitrogen), Amorces et
        sonde TaqMan « maison » NEC 131, NEC 001 et sonde MGB-FAM MLC1.
    •   Tests statistiques : Une suspension virale de concentration connue a été
        testée 4 fois dans 4 séries séparées pour estimer la reproductibilité, la « CT
        value » et la linéarité de la méthode. Le coefficient de corrélation de



                                                                                    39
        Spearman et la méthode de Bland-Altman ont servi à comparer la méthode
        alternative à la méthode de référence.


Résultats
La technique est reproductible. En prenant 400 copies/ml comme seuil de
détectabilité, le coefficient de corrélation entre les techniques était de 0,91 (p<0,001)
entre la méthode de référence de Roche et méthode maison. La différence entre la
valeur de charge virale plasmatique obtenue par une technique et celle obtenue par
l’autre était en moyenne de 0,33 log10.


Conclusion
La PCR en temps réel TaqMan ciblée sur le gène LTR (technique Rouzioux-ANRS)
est une alternative intéressante à la technique commerciale Cobas TaqMan Roche.
Elle fait appel à une technologie comparable, présente des performances analytiques
similaires, revient moins cher et permet de traiter un plus grand nombre d’échantillons
(42 tests par série pour la méthode Roche contre 88 pour la méthode ANRS). D’autres
investigations sur un plus grand nombre d’échantillons sont en cours pour confirmer
qu’elle est adaptée à la distribution des sous-types circulant au Rwanda.




                                                                                      40
I-C.: EPIDEMIOLOGIE ET PREVENTION




                                    41
I-C-1. Changes in HIV knowledge, sexual risk, and utilization of
VCT among youth in Rwanda: behavioral surveillance results from
2000 – 2006.
Authors: C. Kayitesi1, JP Tchupo2, A. Assimwe1, E. Kayirangwa3, A. Kabeja1, J.
Byaruhanga1, J. Price2, T.Cote3, V. Nizeyimana1
1
  TRAC, 2FHI, 3CDC
Context: To monitor and evaluate the combined efforts of various actors and partners
implementing HIV prevention and care activities in Rwanda, the Government of
Rwanda, with support from USAID, has conducted two consecutive Behavioral
Surveillance Surveys (BSS). Typically, BSS surveys are repeated every 3 to 6 years.
They are designed to track changes in HIV-related knowledge and behaviors in select
segments of the population. BSS findings complement epidemiological surveillance
of HIV prevalence rates and help decisions makers to better plan and respond to
specific informational needs. In this presentation, we review BSS findings from 2000
and 2006 on HIV knowledge levels, sexual risk behaviors, and utilization of voluntary
counseling and testing (VCT) services among Rwandan youth.


Methods: Unmarried youth between the age of 15 and 19 years old (BSS 2000:
4,929 females and 3,326 males; BSS 2006: 2,281 females and 2,128 males) were
selected using a probability sampling approach to ensure a national representative
sample.   Interviews were conducted by trained interviewers and took place in
participants’ households. To ascertain trends in knowledge and sexual risk behavior
over time, X2 tests of significance were performed on key variables comparing BSS
2000 and 2006 results. Logistic regression analysis was performed to control for
important socio-demographic in the sample population.


Results: STI Knowledge: Based on an index score of STI symptoms (in females and
males) free-listed by respondents, a significant (p<0.01) improvement in STI
symptoms recognition was found in youth interviewed in 2006 compared to 2000.
Significant increases were found among both female and male respondents.
HIV Knowledge: HIV knowledge level in youth increased considerably between 2000
and 2006. More youths knew at least one HIV prevention method (p<0.01) or had
extensive HIV knowledge, as measured through a composite indicator used by
UNAIDS and PEPFAR (p<0.01).           Although the mean number of known HIV



                                                                                  42
prevention methods increased significantly (p<0.05) between the two years of the
BSS, the proportion of youth who also cited one or more incorrect means of
prevention also increased significantly (p<0.05).
Sexual risk behavior: In male respondents, significant (p<0.01) declines in premarital
sex were reported in 2006 compared to 2000, however no significant changes were
observed among female respondents.        For sexually active males and females, a
significant (p<0.05) decline was observed in the number of sexual partners reported in
2006 compared to 2000.         Also among sexually active youth, significantly more
females (p<0.05) and males (p<0.01) reported condom use at last sex encounter.
Nevertheless, no change was observed in systematic and consistent condom use
between the two periods of the survey. Males respondents that were older (Odds
Ratio: 1.882) and had a higher education level (Odds Ratio:1.91) reported a
significant increase in condom use at last sex. The declared prevalence of STIs
dropped considerably both among females and males (p<0.01). STI treatment seeking
at professional health services increased moderately among female respondents
(p<0.10).
Utilization of VCT: The proportion of youth who knew where to receive HIV testing
in 2006 was significantly higher (p<0.01) compared to 2000. Also compared to 2000
findings, significantly (p<0.01) more youth reported having sought an HIV test and
returning for their results.     Older age and education level predicted (p<0.01)
utilization of VCT services as did proximity with the disease, i.e. knowing someone
with HIV infection (p<0.01).


Conclusions: Findings from 2000 youth BSS compared to 2006 showed
improvements in knowledge levels, decreases in sexual risk behaviors, and increases
in utilization of VCT. This latter finding reflects the tremendous scale-up of VCT in
Rwanda in the last five years as well as effective promotion of these services. These
BSS findings are consistent with results from HIV seroprevalence surveys, which
show declining HIV prevalence levels in Rwanda during the 2000s. These combined
results are encouraging and clearly suggest that efforts to prevent and control HIV in
Rwanda are yielding fruits. We recommend examining BSS results in closer detail to
identify where the best results were obtained in this youth population and promote
successful interventions linked to these best results nationwide.



                                                                                   43
I-C-2. Contraception –an effective and underutilized approach to
preventing HIV sequelae.

Authors:
BN Maggwa, Director of Research, Family Health International, Kenya
HW Reynolds, Scientist I, Family Health International, USA
R Wilcher, Senior Program Officer, Family Health International, USA
W Cates Jr., President of Research, Family Health International, USA

Institution responsible: Family Health International

Context : With women of childbearing age accounting for nearly half of those
infected with HIV, use of contraception to prevent unintended pregnancies in HIV
infected-women can significantly reduce mother-to-child transmission of HIV and the
number of AIDS orphans. Yet, contraception for HIV prevention has been an
underutilized intervention, despite mounting evidence of its effectiveness.


Objectives: The objective of this analysis is to demonstrate the level-1 evidence that
preventing unintended pregnancies in HIV-infected women who do not wish to
become pregnant is an effective and cost-effective strategy for reducing mother-to-
child transmission of HIV.


Methodology: Data for this presentation come from the existing literature and extant
information bases.    We review the three different published models that have
demonstrated the potential impact of family planning services on preventing HIV
sequelae. We then use Demographic and Health Survey (DHS) data to estimate the
number of infant HIV infections currently averted by contraceptive use in Rwanda.
We also estimate the annual proportion of unintended pregnancies (i.e., pregnancy not
wanted or wanted later) to women living with HIV in Rwanda as a measure of unmet
need for family planning services. Finally, we estimate the additional cost to the
President’s Emergency Plan for AIDS Relief (PEPFAR) to avert unwanted
pregnancies (i.e., pregnancies not wanted) in HIV-infected women, relative to current
levels of PEPFAR expenditures.


Results: Current contraceptive use in Rwanda averts over 1,500 unintended births to
HIV+ women each year, despite an extremely low contraceptive prevalence rate of
7.4%. This means that almost 500 HIV infections in infants are prevented each year


                                                                                   44
by contraceptive use. However, an estimated 4,615 unintended births still occur to
HIV+ women in Rwanda (35% of all births), resulting in almost 1,400 unintended
HIV+ births annually.     Averting HIV+ births via contraceptive use to prevent
unintended pregnancies rather than PMTCT programs would be at an annual cost
saving of almost US$270,000. Preventing just the unwanted pregnancies (i.e., to those
women who wanted no more children) via contraceptive use would be at a cost saving
of more than US$94,000 per year.


Conclusion: Prevention of unintended pregnancies not only extends multiple health
benefits to HIV-infected women and their families, but also is a cost-effective way to
prevent new HIV infections and their sequelae. However, contraception will continue
to be an underutilized intervention unless strategic and financial commitment to
increasing access to contraceptive services for women who want to limit or space
pregnancies is met.




                                                                                   45
I-C.3. changes in sexual risk behavior in sex workers in Rwanda:
report of findings comparing 2000 and 2006 BSS data and review of
implications for prevention programming.

Authors: A. Kabeja1, JP Tchupo2, E. Kayirangwa3, A. Assimwe1, J. Price2, C.
Kayitesi1, V. Nizeyimana1, J. Byaruhanga1

1
    TRAC, 2FHI, 3CDC


Context: In HIV epidemics where transmission is spread predominantly through
heterosexual intercourse, female sex workers constitute an epidemiologically
important population to the general spread of HIV infection. It is thus critical to track
sexual risk behaviors in this group, specifically with a view to developing effective
prevention programs and services for sex workers. The Behaviorial Surveillance
Survey (BSS) for sex workers is specifically designed for this purpose. In this
presentation we report on findings from the BSS in sex workers in Rwanda,
conducted in 2000 and repeated in 2006.


Methodology:
Study participants were selected using a sampling frame designed specifically for
research in hard-to-reach sex worker populations. To ensure the most representative
sample possible, a preliminary nationwide mapping was conducted in all known
major sites where commercial sexual transactions occur.           On the days of the
interviews, 100% of sex workers present at each site and who agreed to participate in
the study were included in the sample.           Interviews were conducted at their
workplaces. In the BSS 2000, 699 sex workers were interviewed while 1,041 sex
workers were interviewed in 2006. To ascertain trends in knowledge and sexual risk
behavior over time, X2 tests of significance were performed on key variables
comparing BSS 2000 and 2006 results. Logistic regression analysis was performed to
control for important socio-demographic in the sample population.


Results:
STI and HIV knowledge: Based on an index score of STI symptoms (in females and
males) free-listed by respondents, a significant (p<0.01) improvement in STI
symptoms recognition was found in sex workers interviewed in 2006 compared to



                                                                                      46
2000. Similary, HIV knowledge index scores were significantly higher (p<0.01) in
sex workers interviewed in 2006 compared to 2000.


Sexual risk behaviors: The median age of sex work debut reported in the BSS 2000
sample was 18 years compared to 19 years in the BSS 2006 sample. Condom use
during the last sexual intercourse was significantly greater in 2006 compared to 2000
findings, with both paying clients (p<0.05) and with non-paying sex partners
(p<0.01). Also, the proportion of sex workers interviewed who had a condom with
them at the time of the interview was significantly greater (p<0.05) in 2006 compared
to 2000. However, on the indicator of systematic and consistent condom use with all
sex partners, 2006 findings showed a significant decline (p<0.05) compared to the
year 2000 reports. The declared prevalence of STIs was significantly lower (p<0.01)
in the 2006 sample compared to the first BSS.


Utilization of Voluntary Counseling and Testing (VCT): The proportion of sex
workers who knew where to receive HIV testing in 2006 was significantly higher
(p<0.01) compared to 2000. Twice as many sex workers interviewed in 2006 had
sought an HIV test and received their results compared to the 2000 sample.


Conclusion: Multiple sexual partnering that comes with the sex trade is inherently
risky.   Nonetheless, it is possible to substantially reduce risk of HIV and STI
transmission in commercial sex transactions, namely through consistent condom use,
knowledge about and prompt treatment seeking for curable STIs, and knowing one’s
HIV status. The importance of consistent condom use in high risk sexual encounters
cannot be over stated. Findings from other studies on high risk sexual encounters
show that no statistically significant difference in HIV seroconversion rates exists
when comparing populations reporting inconsistent use with those reporting no
condom use. In light of this evidence, the decline in reported rates of consistent
condom use in Rwandan sex workers is highly troubling and demands immediate and
concerted programming attention.




                                                                                  47
I-C-4. Bilan de la campagne de dépistage volontaire mobile au niveau
de 19 entreprises privées et para-étatiques du Rwanda.

Auteurs : Vestine Mutarabiyire, Jacqueline Mukakazenga et Dr Juru Ruranganwa


Institution responsable : Association du Secteur Privé et Para-Etatique pour la lutte
contre le SIDA (APELAS)


Contexte
Le dépistage volontaire reste une stratégie clé de lutte contre le VIH/SIDA. Pour
permettre la connaissance du statut sérologique, le Rwanda a mis en place des centres
de dépistage volontaire dans la plupart des districts sanitaires du pays. Ces services
sont malheureusement très peu utilisés par les travailleurs tant des entreprises privées
que para-étatiques, notamment celles qui ne disposent pas de centres médico-socials
avec le service de conseil et dépistage volontaire. Pour faciliter l’accès à ce service
essentiel pour la prise des mesures de prévention ou l’amorce d’une prise en charge
précoce, l’APELAS a organisé au cours de la période de 2004-2006, une campagne
de dépistage volontaire mobile dans les entreprises privées et para-étatiques.


Objectifs spécifiques de l’étude
   •   Faciliter aux travailleurs des entreprises du secteur privé et para-étatique
       l’accès aux services de conseil et dépistage volontaire ;
   •   Disposer des données sur la proportion des travailleurs de chaque entreprise
       atteints du VIH en vue du plaidoyer pour la mise en place ou le renforcement
       des politiques et programmes de lutte contre le SIDA sur le lieu de travail.


Méthodologie
La campagne a été organisée au sein des entreprises privées et para-étatiques
membres de l’APELAS qui en ont exprimé la demande. Les activités de dépistage ont
été organisées pendant une ou deux journées selon la taille de chaque entreprise. Des
salles de counselling garantissant la confidentialité ont été rendues disponibles dans
chaque entreprise.
Les counselling pré et post-test ont été assurés par les conseilleurs formés par le
TRAC. Les tests de dépistage ont été pratiqués par les techniciens laboratins formés



                                                                                      48
par le Laboratoire National de Référence en suivant le protocole national en vigueur.
Le contrôle de qualité aussi a été assuré par le Laboratoire National de Référence.
Les travailleurs de chaque entreprise ont été invités à faire la démarche de dépistage
volontaire par un communiqué signé du Point focal VIH/SIDA de l’entreprise,
précisant le caractère non obligatoire et strictement volontaire de l’opération. Les
personnes dépistées séropositives ont été orientées vers les centres de prise en charge
des personnes vivant avec le VIH. Les résultats individuels des tests restent
personnels et n’ont pas été communiqués à l’employeur.


Principaux résultats :
La campagne de dépistage volontaire mobile fut menée au niveau de 26 entreprises.
Toute fois les données de sept (7) entreprises ont été exclues de l’étude en raison de la
participation des familles et des communautés environnantes.
Le nombre total des travailleurs au niveau des 19 entreprises étudiées a été de 15.490,
soit une moyenne de 815 travailleurs par entreprise, avec des extrêmes allant de 18 à
4.137
Le nombre de travailleurs ayant effectué la démarche de dépistage volontaire a été de
10.659, soit 68,8 % du total des travailleurs. Le nombre de travailleurs dépistés
séropositifs au VIH a été de 758 (soit 7,1 % en moyenne)


Conclusion
Les campagnes de dépistage mobile sur le lieu de travail permettent d’une part l’accès
des travailleurs aux services de dépistage volontaire, et d’autre part de fournir aux
entreprises des informations sur la situation de l’épidémie du VIH en leur sein. Les
résultats des campagnes de dépistage volontaire mobiles peuvent servir de base au
plaidoyer envers les responsables des entreprises en vue de la mise en place de
politiques et programmes de lutte contre le VIH et le SIDA sur le lieu du travail,
autofinancés et autogérés par les entreprises elles-mêmes.




                                                                                      49
I-C-5. Expanding HIV care and treatment to Rwandan prisons: a
Collaborative Approach.

Authors: Ruben Sahabo, Veronicah Mugisha, François Ndamage, Agnes Binagwaho


Location of project team: Kigali, Rwanda
Key words: ART, prisons, partnership


Context: The Rwandan prison population increased from 12,800 to 35,000 across 12
prisons after the 1994 genocide. Many prisoners are HIV-infected or at high risk of
infection. During the genocide, rape was common, leading to increased HIV
transmission among victims as well as perpetrators, many of whom are in prison.
While sexual activity in prison is banned, outbreaks of STIs and anecdotal evidence
suggest that unprotected same-sex sexual activity does occur. 38% and 19% of
prisoners accessing VCT in Ruhengeri and Gisenyi Prisons respectively, are infected
and HIV prevalence for all prisons (8%) is more than twice the national average (3%).
AIDS is the leading cause of death in prisoners, accounting for 30% of all deaths.


Approach: In 2003, the Government of Rwanda established a steering committee to
assess HIV care and treatment needs of prisoners and capacity of prison health clinics
to provide such services. A national plan to integrate services into prisons was
developed, including ICAP support at 2 prisons—Gisenyi and Kigali Central Prisons
beginning in early 2007. ICAP supported the Treatment and Research AIDS Center
(TRAC) to adapt HIV protocols and tools for the prisons, train prison providers,
strengthen links between prison clinics and district hospital laboratories, and establish
effective referral systems for prisoners on ART upon release.


Outcomes and challenges: By January 31, 2007, 44 providers from 12 prisons were
trained in HIV care and treatment. Services are provided at Gisenyi and Kigali Central
Prisons by multidisciplinary teams, including social workers/nurses from the clinics
and doctors who rotate in twice weekly. In Kigali Central Prison, about 9 % of
patients have a CD4+ of <100cells/ml, 14% have CD4+ between 100-200 cells/ml,
22.4% have CD4+ between 200-350 cells/ml, whereas 50.4% have CD4+ > 350. The
prison HIV-infected population has a higher proportion of patients eligible for ART



                                                                                      50
compared to the expected in the general population. More than 45% of HIV-infected
patients in the prison are ART eligible. Clinics and on-site laboratories are being
renovated. Ongoing clinical mentoring is provided by TRAC and ICAP. Key
challenges include space limitations, involuntary disclosure of prisoners taking ART,
and assuring continuation of care for patients upon release from prison. Relative to
non-prison patient populations, adherence to care and treatment is high.


Key recommendations: Initial results are promising. Prisoners are motivated to use
VCT and access ART. Prison programs need to carefully plan for the special needs of
prisoners such as confidentiality and continuity of care within and outside prisons.




                                                                                       51
I-C-6. Involving men in prevention of mother-to-child transmission
of HIV programs in Rwanda.

Authors: Gerard Ngendahimana, Jean Gatana, Stéphanie Marion-Landais

Institution responsible: The Capacity Project, Kigali, Rwanda

Geographic location of the project: Rulindo, Gicumbi, Nyagatare, Gatsibo,
Kayonza and Rwamagana Districts

Context/Problem statement: While necessary to encourage disclosure of results
within couples and support HIV+ women to prevent HIV transmission to their infants
during and after birth, involving men in PMTCT and other HIV prevention services
has been a challenge in Rwanda.


Project/Intervention goal (s) /Objectives: During the PMTCT sessions both partners
receive HIV counseling and testing and develop a risk reduction plan with a trained
counselor.
Project/Intervention description and characteristics of beneficiaries: IntraHealth
International/The Capacity Project supports PMTCT services at 21 rural health
facilities in Rwanda. In December 2002, IntraHealth began sending letters home with
women who attended prenatal consultations requesting that their male partner
accompany them on their next visit for HIV counseling and testing. Men are also
encouraged to attend prenatal services with their partners through messages routinely
disseminated by community health volunteers.


Implementation/Progress (of activities): The invitation letters and community
outreach appear to have contributed to the impressive numbers of men attending
PMTCT services. Since the launch of the male involvement program in 2002, male
partners have received counseling and testing within health center PMTCT programs.
The rate of male participation, initially only 9%, has increased significantly in all 21
facilities, with an average of 74% of male partners attending PMTCT services in
December 2006. Many sites routinely have over 90% of male partners attending
services, with Kajevuba and Ntoma rural health centers reporting 100% and 97%
respectively, in December 2006. Male involvement in PMTCT services at these sites
has become routine, with the majority of women’s husbands or partners coming with
them to services without the need for prompting through an invitation letter.


                                                                                     52
Strategies from IntraHealth/Capacity Project Rwanda’s programs to involve male
partners in PMTCT services may offer valuable models for replication in other
PMTCT and reproductive health programs.




                                                                           53
I-C-7. Mobile VCT: an Evaluation of Innovative HIV-testing
approaches.

Author: Aimee E. Jeffrey MS, RN
Author’s title and address: Program Officer, CDC/Rwanda, Blvd de la Revolution,
P.O.Box 28, Kigali, Rwanda

Geographic location of the project: Multiple locations in Kigali, Rwanda including
Kagarama High School, CS Nyacyonga, and Kibagabaga Hospital

Context/Problem statement: The current VCT policy in Rwanda specifies that blood
is drawn by venipuncture and that the HIV test is performed by a laboratory
technician. This process is time-consuming, creates additional medical waste, requires
a larger blood quantity than is necessary for a simple rapid test, and utilizes trained
laboratory technicians to run these tests rather than perform higher level duties. There
is also a risk of mixing samples during analysis and having decreased client
confidence in results due to the fact that the blood specimen is taken from the
counselling room for analysis. Wait times can exceed 4-6 hours and the process does
not guarantee that 100% of clients receive their results.


Project objectives: The new approaches to VCT are intended to simplify the VCT
process, reduce wait times, reduce medical waste, reduce error, and increase client
confidence while maintaining high quality standards. Our model includes the use of
non-nurses as counsellors, pre-test counselling in group, finger prick for specimen
collection, parallel testing algorithm, and single session CT whereby the rapid test is
done by the counsellor and results are interpreted with the client. 10% of all client
samples are collected for quality control and sent to the NRL. A laboratory technician
is on-site to supervise lab activities, ensure adherence to protocol, and resolve
problems that arise. HIV-positive clients are referred to care sites and follow-up is
done at the health centres to see how many clients arrived at the sites for care.


Project Description and characteristics of beneficiaries: Based on Kenya’s
successful model of Mobile VCT, CDC implemented a similar program in Rwanda in
2006. The goal was to demonstrate innovative approaches to VCT and evaluate the
quality of test results as well as the effect on waiting time, client satisfaction, follow-




                                                                                        54
up for HIV-positive clients, and feasibility in this setting. This is an ongoing activity
for 2007, the first phase of which was recently completed.
Achievements/realizations: Between October 2, 2006 and January 31, 2007 over
2564 clients were tested using the new approach. 100% of clients received their
results. NRL quality control testing data show 100% concordance with the MVCT
results reported to clients. 89% of clients with previous venipuncture experience
reported preference for finger prick and 97% of clients reported that they believed
their results. The average duration of the individual testing session was 26 minutes.
Total average wait time including IEC = 262 minutes, ranging from 79 minutes to 467
minutes. We were therefore successful at reducing wait times for some clients (those
during the first half of the day) but not all. 53% of HIV-positive clients were
confirmed to arrive at a health center for follow-up care.


Conclusion/Lessons learned: MVCT can be an effective tool to provide HIV testing
outside of fixed care centers, especially for hard-to-reach groups. 100% concordance
of quality control data reflects the high quality of testing that was maintained in the
field. Client satisfaction with finger prick is high and single session counseling can
achieve high client confidence in results. In order to reduce wait times for all clients,
having multiple group IEC sessions during the day is necessary. By doing so, half the
clients can receive IEC and be tested in the morning and the other half will receive
IEC and be tested in the afternoon. Counseling for referral of positive clients remains
a challenge and new methods to ensure follow-up should be developed.




                                                                                      55
I-C-8. Determinants of Condom Use among high-risk youth who
frequent hotspots in high-transmission zones”. PSI-Rwanda.

Author: PSI
Principle Researchers: PSI/Rwanda and CNLS, with technical support from the
National Statistics Office

Background and objectives: 2005 DHS results indicate a national HIV prevalence
among general population at 3%, 7% among urban populations and 2% among rural
populations. Sexually active youth represent a high risk target group that requires
targeted prevention interventions to reduce the incidence of new HIV infections.
Several recent studies (2005 DHS, 2005 Condom Accessibility Study, 2005 PLACE
study) show that despite significant increases in condom sales over 10 years of social
marketing in Rwanda, condom use remains low. While these studies provide solid
baseline indicators of condom use, access and availability, they do not explore factors
associated with use, in terms of the Ability, Opportunity and Motivation of youth in
Rwanda to use condoms correctly and consistently. Under the leadership and support
of the CNLS and District Mayors, PSI/Rwanda conducted a quantitative study in
August of 2006 that was intended to build upon the lessons learned in the 2005
PLACE study. The PLACE study examined sexual behavior, condom access and
availability at “hot spots” in high transmission zones. This study intended to identify
the determinants of condom use among young people who frequent hot spots in high
transmission zones. In addition, this study measured the impact of communications
activities on these key factors, to assess the ability of prevention communications to
affect behavior, and the determinants of behavior. The findings of this study will
inform targeted condom communications and distribution programs, to prioritize
messaging on the most important factors influencing use, and to guide sales and
distribution agents to improve condom access and availability.


Methods: Sampling was based on target group population sampling and replicated
the methodology use in the 2005 PLACE study. The study was fielded in three area of
Rwanda; Kigali Ville, Gisenyi and Byumba. Gisenyi was selected to represent a
border semi-urban population, while Kigali Ville was selected to represent an urban
population and Byumba representing a rural population.     Interviews were conducted




                                                                                    56
between 6:00 p.m. and 11:00 p.m. in local bars. Youth aged 15-29 were asked to
complete the survey and the end sample was 2,961.


Results: Youth who reported having a regular, casual or paid partner within the last
12 months were included in the analysis. A total of 839 cases were analyzed using
multivariate logistical regression in SPSS. Condom use at last sex act was reported at
65%, however consistent condom use fell dramatically to 26%. Eight indicators were
found to be significant among condom users. Condom users
   Were less likely to agree that girls and young people feel pressure to have sex, or
   to be forced to have sex (Opportunity: social norms)
   Were more likely to have condoms on them, or be able to find them, when they
   wanted or needed them (Opportunity: “easy” access)
   Felt more comfortable speaking with their partners about condoms, or convincing
   their partners to use without losing their trust (Ability: self-efficacy)
   Felt more encouraged and supported by their partner and friends to use condoms
   (Ability: social support for negotiating use)
   Were able to speak more openly with their partner and friends about condoms
   (Ability: social support)
   Showed a greater ability to demonstrate the 5 steps of correct condom use
   (Ability: self efficacy)
   Had less confidence in their partner’s sexual behavior (Motivation: trust/stigma)
   Were less likely to think that condom use would negatively impact relationship
   trust (Motivation: trust/stigma)


An impact table shows that youth who were highly exposed to any HIV/AIDS
intervention campaign could demonstrate the 5 steps of correct condom use more than
those less exposed, reported higher levels of partner social support about condom
discussions, higher levels of knowledge about HIV/AIDS prevention methods and
stronger beliefs about the efficacy of condoms.


Recommendations: Results show that while knowledge about HIV/AIDS and modes
of transmission is high among sexually active youth, non-users lack the confidence
and self-efficacy to use condoms consistently. If social marketing programs are to
impact correct and consistent condom use among youth, program development should


                                                                                   57
engage local sexually active youth within the community to develop communications
activities that focus on increasing social support for young people to speak about, and
negotiate, condom use, by increasing parent-child, child-child, and partner
communications about sex and condom use. Messages should reinforce positive
health behaviors such consistent condom use regardless of partner type, voluntary
counseling and testing for sexually active youth including people who are in stable
and ‘trusting’ relationships.


Interpersonal communications campaigns should include condom demonstrations to
increase self-efficacy, or the ability of a young person to use the condom correctly.


Distribution programs should focus on increasing availability and visibility in after-
hours kiosks nears bars and other hot spots, to make it easier for potential users to find
condoms when and where they want them.


Media and message placement planning should focus on increasing frequency and
weight of exposure to program messages.




                                                                                        58
I-D. DOMAINE SOCIAL ET ECONOMIQUE




                                    59
I-D-1. Community learning and action for savings stimulation and
enhancement (CLASSE INTAMBWE)

Author : D. Pinault
        CARE International in Rwanda
       OVC & HIV/AIDS Advisor, E-mail: delphinep@care.org.rw

Project location: 20 districts : Nyamasheke, Rusizi, Nyamagabe, Nyaruguru, Huye,
Gisagara, Nyanza, Rugango, Muhanga, Kamonyi, Ngororero, Nyabihu, Karongi,
Rutsiro, Rubavu, Nyagatare, Gatsibo et Kayonza, Rulindo, Gicumbi.


Context
CARE has moved beyond an HIV/AIDS – nutrition discussion to consider food and
livelihood security more generally. CARE’s experience working with vulnerable
groups has demonstrated that people who do not have access to adequate food and
economic means are more likely to contract HIV by adopting risky behaviors. In
addition, lack of food is the main cause of non-adherence to ARV regimens. In
Rwanda, 64% of the population lives with less than $1 a day. With such rampant
poverty, women and young girls are increasingly engaging in high-risk behaviors for
survival, exposing themselves to HIV, STIs and all forms of abuse and exploitation.
Free food distribution helps but also creates dependency if not accompanied by
longer-term strategies. Traditional Income Generating Activities have not yielded the
anticipated results in terms of building the longer-term food and livelihood security of
PLWHAs. Lastly, promoting home gardening and agricultural projects is becoming
increasingly challenging because of land scarcity. Confronted with this need to find
innovative longer-term solutions to the food and livelihood security of PLWHAs,
CARE decided to integrate its CLASSE (Community Learning and Action for
Savings Stimulation and Enhancement) “Intambwe1” model, which consists in
organizing vulnerable community members in Voluntary Savings and Loan (VSL)
groups, into its HIV&AIDS program.


Project/Intervention goal/objectives
The integration of an economic and food security component in CARE’s HIV &
AIDS program aims at strengthening the longer term livelihood and food security of
HIV-infected households and those most at risk of being infected with AIDS. Specific

1
    Means “step by step” in Kinyarwanda.


                                                                                     60
objectives include: 1. To mitigate the impact of HIV-AIDS on infected/affected
households; 2. To reduce vulnerability to HIV-AIDS of most at risk households.


Project/Intervention description and beneficiaries characteristics
CARE Rwanda assists the most vulnerable (vulnerable women, Orphans and
Vulnerable Children, PLWHAs, the elderly, marginalized groups, etc) in forming
VSL groups of 15 to 30 people who pool their savings together into a fund from
which members can borrow. The money is paid back with interests causing the fund
to grow. A VSL may decide to create a “social fund” to provide grants or interest free
loans to members, usually used to cover funeral costs or emergency health costs.
After having saved a minimum capital and gained sufficient experience with small
loans, VSL groups are linked to Banque Populaire (BP) through a MOU between
CARE and BP. The local BP branch opens a term deposit account for each linked
VSL group, which deposits their savings in the bank. CARE opens a credit line at BP
from which BP can issue loans to VSL groups. Sometimes, groups are organized into
one umbrella organization called “Inter-grouping”. Functioning as a liaison between
VSL groups and BP, inter-groupings process the project and loan applications drawn-
up by VSL groups and ensure the recovery of loans. In order to meet the immediate
food needs of VSL group members, free food (thanks to a MOU with WFP) is
distributed while groups are organized and trained in the VSL CLASSE Intambwe
methodology.


Achievements/realizations
Tangibly speaking, the results of nearly six years of implementing CLASSE
Intambwe across most of the country speak for themselves.


                   CLASSE Intambwe – Cumulative Results since 2000‐2005 
                
                   •   Number of participants                  22,992
                   •   % of women                              60.0
                   •   Number of SL groups                     1295
                   •   Average individual weekly savings       $0.16
                   •   Total value of all SLG savings          $149,732
                   •   Total value of all SLG loans            $190,896
                   •   Reimbursement rate                      93%
                




                                                                                   61
Conclusion/Lessons learned:
CARE’s CLASSE-Intambwe methodology has proven an effective strategy to
improve PLWHAs longer term livelihood and food security in Rwanda. The approach
has also given most at risk groups of contracting HIV livelihood alternatives that help
reduce their exposure to the virus. The creation of VSL groups of infected and non-
infected individuals has reduced stigma and discrimination against PLWHAs. Some
PLWHA associations with advanced VSL groups have started to use their incomes to
renew consumables from volunteers Home-Based CARE kits and are also buying
food and other necessities for those in need.


However the integration of CLASSE Intambwe in the HIV&AIDS program also met
challenges. While the “traditional” CLASSE methodology is usually not injecting
external funds until the credit line is open at the bank, CARE noticed that PLWHAs’
savings capacity is often lower than that of most other vulnerable groups practicing
the methodology. PLWHAs have usually spent all their money and sold their assets to
respond to the virus. PLWHAs who can only save very limited amounts tend to get
discouraged and could leave the VSL group. CARE responded with various strategies.
In some cases, groups’ savings were matched by CARE. With some groups, IGAs
were funded with the agreement that incomes would be injected in the VSL groups.
Food distribution was also used as an effective strategy to stimulate PLWHAs’
savings capacity. Food assistance proved not only to improve the nutritional status
and health condition of PLWHA and to reduce exposure to HIV-AIDS of at risk
groups, it also allowed VSL group members to save on food and inject their savings in
the VSL group. However, experience has demonstrated that 6 months distribution is
too short a period to elevate affected households to a self-sufficient level, without
risks of falling back. Often infected people need a few weeks to recover and gain
physical strengths that will allow them to fully take part in IGAs of the VSL Groups.
On an average, a VSL group member needs two years to increase its household
incomes and assets base by 35%, up to a level that will allow him/her to meet basic
needs, including food, health care (paying a health insurance) and school fees. Ideally,
however, more savings and/or assets should be built to face potential future financial
shocks; otherwise, the household might fall back in a precarious situation very easily.




                                                                                     62
I.D-2. Rwanda HIV/AIDS Public Interest Fellowship Program
(RHPIF); progress and achievements during its’ first 2½ years.

Authors: Baingana, Maggie, (Technical Advisor; Tulane University); Kinani Peace,
(Program Coordinator; NUR/SPH), Scialfa, Thomas (Director; Tulane University),
Mishram, Mahita (Program Officer; CDC).
Email: Office@tulane-rwanda.com


Geographic location of program: Fellows in the RHPIF are placed in not-for–profit
organization in the cities of Kigali, Butare and Kabuga. The NGOs in which the
fellows are placed have activities throughout the country.


Problem statement: In Rwanda, trained human resources - particularly that of trained
managers - are scarcer than in any other African country due to (a) the lingering
demographic impact of the genocide and (b) employee loss and absenteeism due to
HIV & AIDS. Dependency on new university graduates is high yet these graduates
find it difficult to obtain employment because: 1) they have no professional
experience and 2) training at the universities is still largely theoretical. Employers
want people with practical skills and experience so that they are immediately
productive within the organization. HIV & AIDS is still largely addressed as a health
problem; it must be integrated more effectively into other sectors to begin reducing
HIV transmission.


Program objectives: The goal of the RHPIFP is to reinforce the GoR’s objective to
build sustainable human resources in management              and leadership while
simultaneously reinforcing their capacity to fight HIV & AIDS right now. The
objectives of the RHPIFP are:       1) to provide Rwandan (non-health) university
graduates with practical skills and experience in multi-sector HIV & AIDS program
design, implementation, management and evaluation 2) to provide fellows - and their
supervisors – with the knowledge & tools needed to better integrate HIV & AIDS and
to improve the overall management capacity of the host organizations 3) to increase
the capacity of Rwanda’s (297) HIV & AIDS focal points to fulfill their role and
mandate within the public and private institutions in which they work 4) to build the




                                                                                   63
capacity of the NUR/SPH to effectively implement a program of this size with little or
no external assistance.
Description of intervention: Rwanda’s School of Public Health (NUR/SPH)
implements the RHPIFP with technical assistance provided by Tulane University.
Funding is provided by PEPFAR through CDC. This program recruits and trains
young Rwandan graduates from all disciplines (except health). It also recruits the not-
for-profit organizations that wish to host the fellows for two years. The NUR/SPH
must select and match fellows with host agencies based on objective criteria and
procedures.       During the course of the two-year fellowship, practical training is
provide to fellows and supervisors prior to fellow placement and then at their 6 & 12
months post-placement.          Training covers necessary skills in (1) planning,
management & fund raising (2) monitoring, evaluation & reporting (3) stigma
reduction through ethics, gender and cross-cultural communication & BCC (4) HIV &
AIDS epidemiology, prevention and care (5) sustainable development. At 18 months,
fellows begin a 2-month, 9-credit NUR/SPH certificate course which focuses on
analytic skills for evidence-based programming. Facilitation (supervision) visits to
fellows and supervisors in their workplace are conducted every 3 months. Tulane
partners with NUR/SPH during RPHIFP implementation and transfers the tools &
skills needed for the NUR/SPH to do this on their own.


Achievements: From its inception (9/2004) to-date (12/2006), the fellowship has:
developed the program and its tools, curriculum and procedures for training,
recruitment and matching fellows to host agencies. The 1st cohort (10 fellows) was
placed in 4/2005 and the 2nd cohort (15) was placed in 04/2006. Two (1st cohort)
fellows have already been permanently hired by their host agencies. A university
recognized certificate course and MPH credits has been integrated into the RHPIFP.
50/297 focal points have already been trained.              RHPIFP implementation
responsibilities have been transferred from Tulane to NUR (NUR at 5 % during year 1
to approx. 80% by end of year 2). Through supervision we find that most fellows are
working in good conditions and have expressed satisfaction with the program as do
their supervisors. MIFOTRA (Ministry of Public Service and Labor) adopted the
RHPIFP model and is now working with NUR/SPH to expand this program to the
national level.



                                                                                    64
Lessons learned and next steps: It is difficult to place fellows in organizations
outside Kigali though most fellows are involved in projects implemented throughout
Rwanda. The RHPIFP is well known to all Rwandan graduates (330 applications in
2006). Sustainability through developing an alumni network and marketing the
fellowship to potential donors and employers is a priority in 2007 as is recruiting the
3rd cohort and preparing for the 1st cohort’s graduation.




                                                                                    65
I.D-3. Prise en charge psychosociale dans les centres de conseil et
d’orientation de la SWAAR

Auteur : Shamsi Kazimbaya

Fonction et adresse de l’auteur : Secrétaire Exécutif de la SWAA ; BP 5.196
Kigali ; Tél : 08301299 ; Email : shamsi_2409@yahoo.fr


Localisation géographique du projet: Kigali (District de Gasabo), Povince du Sud
(District de Muhanga), Province de l’Est (District de Ngoma)

Description de l’intervention

Les centres de conseil et d’orientation de SWAAR fournissent des services de
counselling et de soutien aux personnes vivant avec le VIH et à leurs familles au
niveau de chacune des trois Provinces. En 2006, les activités de ces trois centres ont
été financées par CHF/CHAMP.


Contexte
La prise en charge globale des personnes vivant avec le VIH exige de répondre à
l’ensemble des besoins de ces personnes, qui sont d’ordre médical, psychologique,
social, économique, nutritionnel et juridique. A partir de l’année 2002, le
Gouvernement du Rwanda, à travers le TRAC a accéléré le processus d’intégration
des services de prise en charge des personnes vivant avec le VIH dans les activités des
formations sanitaires. Les services mis en place au niveau des formations sanitaires se
sont très vite heurtés à une forte demande, au point de nécessiter une collaboration
avec les communautés, particulièrement dans la prise en charge psychosociale des
personnes infectées et affectées par le VIH. Les centres de conseil et d’orientation de
SWAAR ont été créés dans le but de relayer les formations sanitaires en offrant aux
personnes vivant avec le VIH et à leurs familles des opportunités de formation, de
conseils, d’ éducation, de soutien et de suivi.


Objectifs de l’intervention


Les centres de conseil et d’orientation de SWAAR poursuivent les objectifs suivants :




                                                                                    66
   •   Mettre à la disposition de la population des services de counselling et
       d’information accessibles à tous, avant et après les services de dépistage, mais
       aussi à tout autre moment que le besoin se fait sentir ;
   •   Promouvoir les attitudes positives envers les personnes infectées et affectées
       par le VIH ;
   •   Orienter ou référer les clients vers des services ou organismes qui peuvent
       répondre à leurs besoins ;
   •   Contribuer à la réduction de l’impact socio-économique du VIH sur la vie des
       personnes vivant avec le VIH.


Réalisations:
Au cours de l’année 2006, les centres de SWAAR ont fourni les services suivants :
   •   Counselling d’accompagnement des personnes vivant avec le VIH ;
   •   Causeries éducatives et projection de films pendant que les clients attendent
       d’être reçus par les conseillères ;
   •   Paiement des frais et matériel scolaires pour les OVC ;
   •   Appui aux activités génératrices de revenus par le biais de micro-projets aux
       ménages de personnes vivant avec le VIH regroupées en association.


Au total 13496 clients ont été reçus en counselling dont 4.602 (34,1%) au niveau de
Kigali, 5.257 (39,0%) au niveau de la Province du Sud et 3.637 (26,9%) au niveau de
la Province de l’Est. Les femmes représentaient 81,9% des clients des centres (n=
11.047)
Les motifs de consultation des conseillers par les clients étaient les suivants :
demande de conseil pour faire face à un problème lié au VIH (5.016 clients, soit
37,2%) ; demande d’assistance matérielle (8.249 clients, soit 61,1%) ; demande de
dépistage volontaire (108 clients, soit 0,8%) ; autres motifs (123 clients, soit 0,9%).
Les clients qui ont sollicité les centres pour un dépistage volontaire ont été orientés,
après le counselling, au niveau du Centre de We-Act et des FOSA pour Kigali, des
FOSA pour les deux autres centres. Les demandes d’assistance matérielle ont été en
rapport avec : assistance alimentaire (75 %), scolaire (2 %), mutuelle de santé
(12.4%),
Autres (10.6 %).



                                                                                     67
Au total, 377 orphelins ou enfants des clients des centres ont bénéficié d’un appui à la
scolarité (paiement des frais scolaires, dotation en matériels scolaires). Les mutuelles
de santé ont été payées à 2.284 ménages. Le nombre de clients ayant bénéficié de
visites à domicile ou à l’hôpital a été de 3.511 dont 1.099 à Kigali (soit 31,3%), 891 à
Muhanga (25,4%), 1521 à Ngoma (43,3%). Les femmes représentaient 79,8% des
clients visités (n=2.802 Vs 20,2% d’hommes (n=709). Les centres ont accordé des
micro-projets à 20 associations de personnes vivant avec le VIH fréquentant les
centres (9 à Kigali, 5 à Muhanga, 6 à Ngoma) pour un total de bénéficiaires de 154
(51 à Kigali, 58 à Muhanga, 45 à Ngoma). Le montant total de crédits alloués a été de
8.106.350 Frw. Le taux de remboursement a été de 53% et le montant total épargné,
de 736.887 Frw (soit 9% du montant épargné).


Conclusion:
Les centres de conseil et d’orientation de SWAAR ont apporté une contribution
significative à la prise en charge globale des personnes vivant avec le VIH en leur
offrant un espace d’écoute et en apportant des solutions aux problèmes auxquels elles
sont confrontés sur le plan sociale et économique. La prédominance des demandes
d’assistance matérielle parmi les motifs de recours au counselling montre la nécessité
d’une collaboration et une complémentarité des différents intervenants du secteur
communautaire dans la réponse aux différents besoins des personnes vivant avec le
VIH et de leur famille.
Il a été constaté que les services offerts par SWAAR aux PVVIH leur donnent l’espoir
de vivre et améliorent leur situation sanitaire et financière.
Un partenariat entre les formations sanitaires et les intervenants du niveau
communautaire pour répondre à l’ensemble des besoins des personnes vivant avec le
VIH devra être renforcé. La diversité des besoins explique certainement le faible taux
de remboursement des microcrédits accordés aux clients des centres.




                                                                                     68
I.D-4. Scaling up the mentorship program to address the
psychosocial problems of orphans and vulnerable children in
Gikongoro.

Author: Kalisa Edward
Email: ekalisa@wvi.org, Telephone: (250) 08304357
Director for Technical Services, World Vision Rwanda

Geographic location of the project: The project is implemented in the Southern
Province in Nyaruguru and Nyamagabe districts.

Context/problem statement: In December 2001, with assistance from WVR, the
community members identified 2,098 of the ‘most vulnerable’ youth living in 723
households. As of March 2003, this number had increased to 886 child-headed
households due to HIV/AIDS with a total of 2,658 youth. Without parental love, care,
and guidance, orphans experience traumatic problems in their lives. In a post-
genocide society like Rwanda with persisting mistrust and suspicion, innovative ways
of caring for children need to augment the traditional methods of community
mobilization towards care for OVC.


Project/intervention goal and objectives: The goal is to improve the overall well-
being of OVC.

Specific Objectives
   1. To enhance the general and psychological health of OVC through
       implementation of psychosocial support to complement basic needs services.
   2. To improve the ability of eldest child of CHHs to cope with the challenges of
       caring for themselves and younger siblings.
   3. To improve social networks for CHHs through adult mentorship, peer support
       activities, and community awareness raising and mobilization.
   4. To reduce the impacts of stigma and discrimination on OVC.
   5. To improve child safety and protection in local communities thereby
       facilitating their access to available resources.


Project description and characteristics of the beneficiaries: Mentorship program is
a beneficiary-sensitive home visitation program utilizing trained adults to provide


                                                                                 69
psychosocial support to child-headed households. The program adds psychosocial
support to a basic need package focusing on adult guidance, supervision, emotional,
and social support while striving to promote a sense of community responsibility for
OVC.


Achievements: 177 mentors were recruited and trained but 156 mentors started
visiting 442 Child-headed households (CHHs) in October 2004 and 17,532 visits to
OVC households had been made until end of 2005 with an average of 3 to 4 visits a
month per household.
.Mentors have been grouped regionally into five “volunteer committees” of about 35
members each with each committee meeting monthly with a WVR Mentor Facilitator
for supervision and planning of upcoming events. The attendance at the monthly
meetings is 95.4% and the overall retention rate of volunteers 97.7%.
Follow-up focus group discussions with youth revealed the following benefits
accruing from the mentorship program: significant improvement in parenting skills of
head of CHH; 90% of the youth said that they feel valued when they are with their
mentor; 92% feel happy when they are with their mentor; 82% say that their mentors
understand their feelings; 87% said their mentor helped them to feel more confident
of their future, 71% of the youth agreed that their mentor helps protect them; and 83%
of youth agreed that mentors have helped them to establish better relationships with
other community members.


Conclusion/lessons learned: The lack of parental care and guidance caused multiple
emotional problems in the lives of orphans. Overall, mentors have indicated that
youth, after initial stages of apprehension, have become very responsive and
welcoming of them. The mentors have also been enthusiastic and active, with only
two mentors ceasing program involvement. Due to its impact in the last few years of
its existence, the mentorship program is being replicated in all other WVR operational
areas to benefit more orphans.




                                                                                   70
I-E. POLITIQUE ET MISE EN OEUVRE DES
PROGRAMMES




                                       71
I-E-1. Implementation of the Partners In Health (PIH) community-
based model of HIV care and prevention in a rural health district in
Rwanda.
Authors : Niyigena PC1, Nsabimana S1, Murihano JD1, Walker K1, Nizeye B1, Epino
H1, Stulac S1, Gillooly M1, Rich M1,2,3

Authors’title and adress: 1) HIV/TB Program Coordinator, Partners in Health
2) Rwinkwavu Hospital 3) Kayonza District

Geographic location: Rwinkwavu, Mulindi, Nyarubuye, Nyamugali, Kirehe and
Rukira Health Centers, Eastern Province, Rwanda

Program Description
Between May 2005 and December 2006, PIH and Rwanda’s Ministry of Health
implemented a community-based HIV prevention and care program while
reinvigorating health services for a catchment area of 340,000 people. Necessary
elements of the project were identified through review of existing data, participant
observation and key informant interviews.
The following elements were included:
   1) rehabilitation and augmentation of services at six health centers and one
       district hospital;
   2) recruitment and training of 187 care providers and 758 community health
       workers (CHWs);
   3) reinforcement of existing systems for VCT; maternal and child health; and
       diagnosis and treatment of tuberculosis, opportunistic infections, and sexually
       transmitted infections
   4) provision of social, economic, and nutritional support to people affected by
       HIV and other chronic diseases


Context
Worldwide, 42 million people are living with HIV infection; an estimated 6.5 million
need antiretroviral therapy (ART). Methods of rapid enrollment and rigorous follow-
up must be established, often in regions bereft of basic health services. We describe
the initiation of a project to provide comprehensive health services through public
institutions in an HIV-affected region of rural southeastern Rwanda.
Program objectives:




                                                                                   72
The overarching goal of the PIH model implemented in Rwanda is the rapid scale-up
of HIV prevention and care while strengthening the infrastructure and services of the
public health care system.


Achievements:
Rapid scale-up of HIV care has occurred in facilities previously limited by lack of
supplies, electricity, water, and trained personnel. Between June 2005 and December
2006; 67,137 HIV tests were performed including 9,306 for pregnant women; ART
was initiated in 1,938; ongoing nutritional and CHW support was provided to all
patients on ART; 897 infants born to HIV-infected mothers were enrolled in a
formula-feeding program; school fees were paid for 412 students while over 2000
children received uniforms and school supplies; ambulatory visits increased four-fold.
Houses were built for 55 families and over 300 homes were renovated. Income
generation project financing was provided to 36 HIV associations.


Conclusion/Lesson learned:
HIV prevention and treatment programs can be scaled-up rapidly, strengthen primary
health services, and be linked to broader poverty reduction efforts.




                                                                                   73
I-E-2. Utilization of Maternity Services by HIV-infected Women in
FHI-supported Health Centers in Rwanda.

Authors: Livinus Bangendanye ; Jessica E. Price ; Mathias Murekezi ; Cyprien
Niyonteze ; Evode Micomyiza (FHI).

Geographic location of the activity: All PMTCT sites supported by FHI in 2006
including at FOSAs in Southern, Northern and Western Provinces and Kigali City.


Context/Background: In contexts where women tend to give birth outside of clinical
settings, ensuring safe birthing practices and providing ARVs to HIV-positive women
and their children poses a significant challenge. The two most recent Demographic
and Health Surveys for Rwanda show that 70% or more women in the country give
birth at home.    Confronted with this reality, an important aspect of PMTCT
(prevention of mother-to-child transmission) programming in Rwanda necessarily
includes the promotion of maternity services for HIV-infected women.         In this
presentation, we review process indicators for PMTCT services supported by FHI in
Rwanda. We also describe the content of FHI’s support to health facilities (FOSAs)
for PMTCT generally and as it relates specifically to improvements in the maternity
services.


Project objective:
To increase the utilization of maternity services by HIV-infected women: experiences
in FHI-supported Health Centers in Rwanda.


Project Description and Results
Form January to December 2006, FHI supported 39 FOSAs to provide PMTCT
services in Rwanda (of which 12 were transferred to other technical assistance
partners during the year).   At these FOSAs, 34,130 women came for antenatal
consultation (ANC); of these, 33,147 (97%) accepted to be tested for HIV, of whom
99.8% received their results. 1,287 (3.9%) of women tested were HIV-infected.
19,321 (58%) of the women’s male partners were tested, of whom 885 (4.3%) tested
positive. Of 966 HIV-infected women who gave birth during the year, 92% of them
took ARVs for PMTCT during delivery. Of 1,038 infants born to HIV-positive
mothers and, following Rwandan national protocol, to HIV-negative mothers whose
partners are HIV-positive, 968 (93%) received prophylactic treatment with ARVs.


                                                                                  74
Compared to the national rate of approximately 30% of pregnant women delivering at
health facilities, 80% of HIV-positive women served in the PMTCT program gave
birth at the FOSA. A number of factors explain this substantially higher utilization of
maternity services among HIV-infected women: (i) upgrading and equipping ANC
and maternity services render them more inviting and increase clients’ (HIV-positive
and HIV-negative clients) confidence in the FOSA; (ii) improving health provider
knowledge of safe birthing practices for HIV-positive women prepares them to better
educate patients about the benefits of PMTCT and the importance of delivering at the
FOSA; (iii) in routine encounters and through special sessions, providing
comprehensive education to HIV-positive women about PMTCT interventions, the
support they can expect from the FOSA, and the importance of provider-assisted
deliveries improves patients’ understanding and motivation to come back to the
FOSA for delivery; and (iv) assisting women to overcome the structural barriers to
care – through payment of family mutuelle (primary health insurance) and health
facility maternity fees – enables many women to return to the FOSA for delivery.
Further, maternity utilization data from all FHI-supported PMTCT sites are
distributed to all FOSA partners with the intent of encouraging the lower-performing
ones to redouble their efforts and increase utilization rates of maternity services.


Conclusions/Lessons learned
HIV-positive women delivering in FOSAs facilitates prophylactic treatment with
ARVs for PMTCT and, through safe birthing practices, also reduces the risk of infant
infection during birth. Increasing utilization of maternity services in HIV-positive
women is thus an important strategy for averting neonatal infections.            In FHI’s
support to FOSAs for PMTCT, we have found that educating HIV-infected women
about the importance of provider-assisted deliveries, improving the quality of
maternity services offered at FOSAs, and assisting women in need with health care
fees have proven effective in this regard. However, important maternal and child
health benefits of provider-assisted deliveries at health facilities apply to all
pregnancies, regardless of the HIV status of the mother. We propose therefore that
similar activities and levels of efforts go to increasing utilization of maternity services
beyond the context of PMTCT and to the benefit of all women and infants in Rwanda.




                                                                                        75
I-E-3. ART delivery and adherence in a program for comprehensive
pediatric HIV care in rural Rwanda Partners in Health.

Authors: Stulac SN1, Lewey J1, Bucyibaruta B1, Iyamungu G1, Kayirangwa A1,
Mahoro V1, Manzi A1, Epino HM1, Farmer PE1, 2,3, Rich ML1, 2 3, Mukherjee JS1, 2, 3
Authors’ Title and Adress :
    1. Partners In Health, Boston, MA, USA, and Inshuti Mu Buzima, Rwinkwavu,
          Rwanda.
    2. Department of Social Medicine, Harvard Medical School, Boston, MA, USA.
    3. Division of Social Medicine and Health Inequalities, Brigham and Women's
          Hospital, Boston, MA, USA.


Geographic location of the Project: Rwinkwavu Hospital, Kirehe Health Center,
Rukira Health Center, Mulindi Health Center, Nyarubuye Health Center, and Rusumo
Health Center, in Kayonza and Kirehe Districts, Rwanda


Context/Background: The Rwandan government has encouraged the enrollment of
children on ART, setting the target that 10% of all patients receiving ART should be
children under the age of 15. Close follow-up including correct medication
administration and adherence monitoring are essential. Children face lifelong therapy,
have complex regimens, and may have vulnerable social situations. Their complex
social,    psychological,   and   economic   challenges   require   integrated     global
interventions.


Project objectives: The pediatric care team is comprised of doctors, nurses, social
workers, and accompagnateurs (community health workers). Children, parents, and
accompagnateurs together receive education and are responsible for daily medication
delivery. Children on ART receive a comprehensive care package, including:
•   daily directly observed therapy (DOT) at the patient’s home, administered by their
    accompagnateur;
•   monthly clinical visits to the health center, along with the accompagnateur;
•   a monthly food package;
•   monthly group counseling for children 6 or above and their parents;
•   home visits to assess and address social needs;



                                                                                      76
•   assistance with school materials and fees if needed.
Accompagnateurs receive a monthly stipend, and administer DOT at patients’ homes,
attend monthly clinic visits with patients, receive monthly ongoing group education,
and act as liaisons between the patient and the medical team. The monthly stipend is
well justified by avoiding costly second-line regimens, as well as the human and
financial cost of treatment failure.


Project description: The US-based NGO Partners In Health (PIH), in partnership
with the Rwandan Ministry of Health, launched an integrated HIV and primary care
program in two rural health districts. Between June 2005 and February 2007, 165 out
of 1938 (8.5%) of patients enrolled on ART (anti-retroviral therapy) were children
under 15. A total of 496 children with HIV are being followed. Fifty-one percent are
age five or younger. Sixty percent of the children on ART (antiretroviral therapy) are
orphans or at least one parent, and 31% are orphans of both parents.


Achievements: The comprehensive care package based on daily visits by community
health workers has multiple benefits. Most notably, adherence to medications is close
to 100%. None of the 165 patients on ART has been lost to follow-up. Two children
have required regimen changes for ARV toxicity. In addition to the 165 children on
ART, 5 children have died, and 4 transferred out of the program. There has been no
need for second-line regimens, and no treatment failure.


All children were clinically improved after 6 months and one year. All children
gained weight at six months and one year. Average weight gain was 2.5 kg after 6
months, and 4.4 kg after one year. For 47 children over age five, average CD4
increased from 419 at baseline to 733 at six months. Of 19 children over age 5 who
reached one year of treatment, average CD4 increased from 326 at baseline to 622 at
six months, and 852 at one year. For 62 children under age five, average CD4 at
baseline was 629, and at 6 months was 1092. For 27 children under five who reached
one year of treatment, average CD4 was 422 at baseline, 973 at six months, and 837 at
one year. A formal evaluation of other outcome measures and of adherence is
underway.




                                                                                   77
Conclusions/Lessons learned: Based on the success of this program in Rwanda and
other countries, we advocate for a comprehensive care package, using community
health workers as the backbone of HIV care delivery. In addition to excellent
adherence and good clinical outcomes, collateral benefits include providing income to
community members and involving people in a collective improvement of their
community’s health. Rapid and large scale-up delivery models based on community
health workers and comprehensive packages will require international advocacy and
mobilization of resources.




                                                                                  78
I-E-4. Implementing an Electronic Medical Record System to
Expand ARV Treatment in Rural Rwanda.

Authors: Manyika P.1, Lesh, N.1, J,azayeri D.2, Rich M.1, Fraser H.3, Allen C.1
Institute(s): 1 Partners In Health, Rwinkwavu, Rwanda, 2 Partners In Health, Boston,
United States, 3 Brigham and Womens Hospital, Division of Social Medicine and
Health Inequalities, Boston, United States/

Author’s title and address: Data Manager, Rwinkwavu Hospital, Rwanda

Geographic location of the Project: Rwinkwavu Hospital, Kirehe Health Center,
Rukira Health Center, Mulindi Health Center, Nyarubuye Health Center, Rusumo
Health Center

Context/Background: Effective medical data management is important in scaling up
ARV therapy. Patients on ARV therapy require consistent follow-up over a long
period of time, with close attention paid to many clinical indicators. Many projects in
resource poor areas are struggling to create effective systems for this scale of data
management.


Project objectives: The goal of the Electronic Medical Record (EMR) system is to
provide support for patient monitoring, program monitoring, and research. Patient
monitoring includes information for care of individuals, such as historical medical
summaries and alerts, e.g., if an ARV dosage is not correct for a patient’s weight.
Program monitoring involves aggregate information, such as the percentage of
patients on whom alerts fire, trends of clinical indicators such as weight and CD4
count, and trends in enrollment. The EMR will also help to fulfill internal and national
reporting requirements. Finally, the EMR will contain data for observational research
and studies.


Project description: Inshuti Mu Buzima used an implementation of the OpenMRS
(Open Source Medical Record System) to aid its rapid HIV treatment scale-up in the
Eastern Province of Rwanda. The goal of the system was to help provide better
treatment for its many Adult and Pediatric HIV and TB patients, as well as its
PMTCT patients.




                                                                                     79
Achievements: Currently, the EMR contains data for Adult and Pediatric HIV and
TB patients, as well as for PMTCT patients. Between August 2005 and December
2006, there were 1,938 patients enrolled on antiretroviral treatment in the EMR. In
that time, there are also 1,300 patients entered for follow-up, although not on
treatment. The data entry team has scaled up gradually to its current 9 person staff.
On a daily basis, several reports are generated for general administration and
monitoring of programs. In addition, reports are generated for clinical monitoring of
patient status. The EMR helps to generate consult sheets for clinical staff to refer to
as they are seeing patients, to give a brief clinical history for each patient that is
expected for that days consultations. For certain cases, it is also possible to produce a
much more detailed patient summary, in the event that more historical data is needed.
Lastly, reports are generated on a routine basis to alert clinical staff of patients with
alerted statuses, such as declining weight or CD4, no recent CD4 count, or regimens
that do not match other clinical indicators. We are in the process of adding indicators
and reports from the nutritional program as well as other programs, which will be
available soon alongside clinical data.


Conclusion/Lessons learned: We have found that incremental paper forms, i.e.
where information is accumulated over time, is much less conducive to accurate data
collection than are encounter paper forms, in which a new form is filled out on each
patient visit. It is hard for us to imagine deploying this system without a programmer
on site to discover and adapt to the evolving needs of the clinicians. Customization to
local work patterns is very important to any system’s usability. Well-trained data
entry persons are required to maintain an EMR; we found more than 4 months of on-
the-job-training was needed. Data entry persons must have the ability to problem
solve and follow up ambiguous or suspect data, and IT support persons must be
available. Electricity and at least some Internet connectivity are required, but offline
and offsite data entry can accommodate clinics that do not have electricity.




                                                                                      80
I-E-5. Espace de dialogue, une prise en charge appropriée

Auteurs : Uwineza Jeannette, Mardge Cohen, Mari Fabri Mulinda Shambo Bertin,
Zaninyana Irène, Henriette Mukanyonga, Nyiraneza Flauride, Werabe Evode.

Contact : Uwineza Jeannette
          We-Actx- Psychologue clinicienne
          Family program coordinator
          08 30 18 14

Contexte
Depuis des années, le Rwanda a connu pas mal de problèmes d’ordre écononomique,
social et politique. L’épidémie du VIH/SIDA s’est ajoutée à la pauvreté extrême des
personnes vivant avec le VIH. Pour faire face aux nombreux défis engendrés par le
VIH/SIDA, le gouvernement du Rwanda et ses partenaires aussi bien nationaux
qu’internationaux font de leurs mieux pour conjuguer leurs efforts afin d’endiguer la
pandémie.
Parmi ces partenaires, Women’s Equit in Access to Care and Treatment (WE ACTx)
a mis en place un programme pédiatrique qui prend en charge les enfants séropositifs
selon le modèle bio psycho sociale. Cela se fait dans les cliniques Icyuzuzo, et bientôt
à Nyacyonga.
Signalons que la majorité de la population rwandaise est constituée d’enfants (52%) à
cause de la guerre et du génocide de 1994. 30% des enfants sont orphelins et 16.8%
sont orphelins du SIDA.


Objectifs
L’objectif primordial du programme familial au sein de WE ACTx est de promouvoir
une prise en charge bio psycho sociale des enfants séropositifs ainsi que leur famille
afin de restaurer le sens à la vie et de les aider à se construire un avenir meilleur.
Cet objectif     ne peut pas être atteint si We-Act ne travaille pas dans la
multidisciplinarité : le programme est coordonné par un psychologue clinicienne
travaillant étroitement avec les médecins, dont un pédiatre et les infirmiers. Les
traumas consellors font partie de l’équipe, pour briser le mur du silence quant au
VIH/SIDA et créer un espace de dialogue dans la famille, à la clinique et au niveau de
la communauté par le biais des associations des personnes vivant avec le VIH.


Réalisations et résultats
A part les soins médicaux, nous avons instauré les groupes de support pour les enfants
infectés et affectés par le VIH/SIDA. Le nombre varie entre 150 -175. Ils se



                                                                                         81
rencontrent chaque dimanche, jouent ensemble, reçoivent une psychoéducation sur les
sujets divers y compris le VIH/SIDA ainsi que le cours d’anglais pour les adolescents.
Chaque séance est clôturée par le partage d’une boisson.
Les parents et les tuteurs sont aussi réunis dans différents groupes au niveau des
associations et ils sont informés des méthodes de l’annonce de l’état sérologique de
l’enfant. Les sites sont au nombre de six, couvrant les différents coins de la ville de
Kigali cela dans l’objectif de décentraliser les soins jusqu’au niveau de la
communauté. Parmi 67 cas qui ont consulté pour les thérapies individuelles 16 cas
présentent des symptômes de dépression, 16 consultent pour la violence
intrafamiliale, 15 cas pour trauma, 8 cas ont connu la violence sexuelle, 6 cas sont des
couples discordants, 6 cas consultent pour le chagrin profond, 4 cas connaissent les
problème de frais de scolarisation et 2 cas ont été abusés sexuellement.
Les visites à domicile ont été faites. Parmi 309 familles visitées entre juillet et octobre
2006, 107 soit 34.6% des enfants sont orphelins de père ou de mère par le SIDA, 128
(41.4%) sont orphelins de deux parents, 52 (16.8%), sont des enfants chefs de
ménages. 145 familles vivent dans une même maison dont                 les membres sont
comptées entre 7 et 15 et ne mangent pas assez. 90% nous confirment qu’ils ne
mangent qu’une fois par jour. Des counselling individuels sont aussi dispensés dans
les six sites submentionés.
Cette procédure nous a facilité la gestion des conflits intrafamiliaux surtout entre les
parents et les enfants quant à leur état sérologique gardé pendant longtemps comme
secret. Beaucoup d’enfants témoignent avoir intégré leur statut sérologique et sont
devenus capables de continuer la vie scolaire sans peur ni honte d’être stigmatisés.


Conclusion
Faire face à la pandemie du VIH/SIDA nécessite la conjugaison des efforts de tous.
Aucun enfant ne doit mourir pour avoir manqué de soins, chaque enfant a droit à la
scolarité et à l’épanouissement au sein de son cercle familial. Une assistance sociale
capable de répondre à ses besoins primaires est nécessaire et pour une prise en charge
intégrant toutes les dimensions de la vie humaine.




                                                                                        82
I-E-6. IMPLEMENTING HIV/AIDS TREATMENT AND CARE
PROJECT AMONG MOBILE POPULATIONS – THE RDF
CONTEXT.

Author: Mr. Emmanuel Ndoba
Title and address of the author: Country Director, Charles R. Drew
University/Rwanda Program, Chadel Building, Rue de Nyarugenge. Tel : 504459
Fax : 504454, Cell : (250) 08307954, Email : endoba@drewcares.org.rw,
endoba.drew@yahoo.com

Geographical localisation of the project: The RDF HIV/AIDS Treatment and Care
project provides technical and material support to Kanombe military Hospital in
Kigali City, Kaduha Military Hospital in Nyamagabe District and Ngarama Military
Hospital in Gatsibo District.

Context/issues of the project: The RDF has an organized structure which enables
soldiers to have access to free basic needs including health care. In this context, the
need to implement a high quality HIV treatment and care program as a continuum of
health care services is evident. Moreover, PSI carries out mobile VCT services in
addition to the stand-alone site at KMH. Though the RDF is known to care for her
members, there is still a need to implement a desirable and sustainable HIV treatment
and care program with the ability to identify new HIV cases, link the identified HIV
cases to treatment engagement sites and ensure adherence to treatment as well as
follow-up on patient’s progress. To do this, the RDF has benefited from the support of
donors and partners such as DoD and Drew with experience implementing similar
programs in military settings.


The project objectives: The overall goal of the RDF HIV treatment and care project
is to improve the quality of life of HIV+ individuals receiving healthcare services at
health RDF settings. Specific objectives include but are not limited to:

•   Improve treatment of Opportunistic Infections, STIs, TB and improve support for
    treatment adherence and HIV-related emotional problems among those receiving
    care through the RDF;
•   Increase the number of RDF providers trained to initiate and monitor ART &
    improve quality of ART care;
•   Improve laboratory infrastructure to treat OI and monitor response to ART;




                                                                                    83
•   Develop and implement infrastructure for data entry and monitoring of clinical
    and surveillance at hospital and brigade clinic levels;

Description of the project and characteristics of the target beneficiaries: The HIV
treatment and care project is a partnership between the United States Department of
Defense (DoD), the Rwandan Defense Forces (RDF) and Charles R. Drew University
of Science and Medicine, through the center for AIDS research, education and
services (CARES). This project complements existing partnerships between the US
DoD and the RDF. Specifically, Charles R. Drew University benefits from the DOD-
PEPFAR funding mechanism, a subset of USG (DoS, USAID, CDC and DOD), to
enhance the quality of HIV treatment and care among members of RDF, their
spouses, their families and communities around RDF health settings. The RDF is a
highly mobile population, whose close to 70% of members are below 35 years, they
are geographically separated from their families for a relatively long time, and they
have a stable income and are respected members of the community.


Achievements: During its eight (8) months of existence in Rwanda, the DoD-RDF-
Drew project has witnessed achievements that include but not limited to the
following:

•   Drew continues to play to link RDF’s formerly fragmented HIV/AIDS treatment
    and care program with TRAC and NRL;
•   Drew in collaboration with TRAC has trained 42 RDF providers to improve
    treatment of Opportunistic Infections, STIs, TB and 26 social workers to improve
    support for treatment adherence and HIV-related emotional problems among those
    receiving care through the RDF. 42 nurses have been trained to provide
    VCT/PMTCT services. A support group of HIV+ individuals (both civilians and
    soldiers) has been formed with nearly 100 members;
•   In collaboration with TRAC and RDF, 42 RDF providers trained to initiate and
    monitor ART & improve quality of ART care and to date, over 1,300 have been
    enrolled on treatment and care program at Kanombe military hospital alone;
•   Laboratory at KMH improved and equipped with fully automated machines with
    the capacity to conduct multiple clinical tests including but not limited to: CD4
    counts, biochemistry, hematology tests and basic laboratory tests. The lab at KMH


                                                                                  84
    is a model of integrating HIV into overall health care system, because it serves all
    patients irrespective of the HIV status;
•   A patient flow protocol has been developed to ensure that data is collected, stored
    and reported at each level in a confidential manner. The linkage between brigades
    and clinical sites remain critical elements of an effective data flow within the
    context of RDF’s health information system.

Conclusion/Learned lessons:

•   Collaboration, linkages and referrals are a key to project success;
•   Intensive awareness raising programs are equally important in ART service
    delivery;
•   Without a clear patient flow protocol, it’s impossible to implement successful
    health information systems;
•   Treatment adherence is tantamount to improved quality of life of HIV+
    individuals, the more time spent on this training the more success stories will be
    recorded;
•   Confidentiality, efficiency and willingness of providers builds the trust of patients
    in the quality of services we provide;




                                                                                      85
I-E-7. Implication du secteur privé dans la lutte contre le VIH/SIDA :
expérience de la Banque de Kigali.
J.M.V. Nsengiyumva1, L. Rugerinyange2, J. Gatera3.
1
 Chef du Service Médico-social de la Banque de Kigali, et Conseiller Médico-Social
de l’APELAS; 2Directeur Administratif da la Banque de Kigali; 3Directeur Général
de la Banque de Kigali.
E-mail : njemav@yahoo.fr
Tel: 593100 / 593144 / 08303275

Introduction
Identifié au Rwanda depuis 1983, l’épidémie du VIH/SIDA est un fléau mondial qui
gagne de plus en plus du terrain en décimant les populations actives, et laissant
derrière de nombreux orphelins. En attaquant la population active (15-49 ans), il rend
incertain l’avenir socio-économique du pays. La Banque de Kigali, l’une des plus
importantes institutions du pays n’a pas été épargnée. Au cours des 2 décennies
écoulées, la BK a enregistré pas mal de personnes infectées ainsi que des pertes en
vies humaines à cause de ce fléau. Ceci menace la stabilité de la main d’œuvre (perte
des employés expérimentés) et occasionne la diminution du rendement par le taux
élevé d’absentéisme (hospitalisation prolongée et repos médicaux). Ainsi, les autorités
administratives de la BK, conscientes de la problématique du VIH/SIDA en général,
et en particulier au sein de la population BK, ont décidé d’instaurer un programme de
lutte contre la VIH/SIDA au sein de l’entreprise et d’accorder des ARVs aux agents
BK atteints par cette maladie et leurs ayants droits.


Objectif général : Améliorer la santé des agents BK afin d’avoir un personnel
capable de contribuer au développement de l’institution et du pays en général.
Objectifs spécifiques : 1) Réduire le taux de morbidité et de mortalité dû au
VIH/SIDA, ainsi que le taux d’absentéisme. 2) Prévenir la transmission du VIH de la
mére à l’enfant.


Activités
-Sensibilisation du personnel sur le VIH/SIDA et sur le changement de comportement
-Volontary Counseilling and Testing (VCT)
-Distribution des condoms sur le lieu de travail




                                                                                    86
-Prise en charge des PVVIH : Prévention et traitement des infections opportunistes, et
traitement aux ARVs


Résultats : Depuis la prise en charge des PVVIH par ARVs en 2002 nous avons
enregistré des résultats suivants:

       Diminution du taux d’absentéisme (le taux d’absentéisme a diminué
       progressivement à partir de 2002. Il était aux environs de 3% en 2002, à la fin
       de l’année 2003, il est tombé à 1,6% (diminué presque de moitié).
       Actuellement, il est de 1, 23%).
       Diminution de délais et de cas d’hospitalisation.
       Diminution du taux de mortalité et de morbidité.
       Diminution progressive des coûts alloués aux soins médicaux et aux frais
       pharmaceutiques.


Leçons apprises et conclusion
La prise en charge des PVVIH par l’employeur précisément en leur octroyant des
ARVs est l’un des moyens efficaces pour limiter les dépenses, contribuer à
l’amélioration du rendement par diminution de la morbidité et du taux d’absentéisme,
ainsi que la conservation de la main d’œuvre qualifiée.




                                                                                   87
I-F.: ETUDES REGIONALES ET PROGRAMME MULTI-
PAYS DE RECHERCHE SOCIALE DANS LE DOMAINE
DU VIH ET SIDA




                                          88
I-F-1. Safety and immunogenicity of the VRC recombinant
multiclade HIV-1 adenoviral vector vaccine alone or in combination
with the VRC multiclade HIV-1 DNA plasmid vaccine in healthy
African adults.

Authors:   K Kayitenkore, CM Muvunyi, M Mukankuku, R Mukasahaha, J
Muziranenge, R Bayingana, E Karita

Background: Phase I studies in the US suggest that the VRC multiclade HIV-1 DNA
vaccine (clade B Gag, Pol, and Nef, and Env from clades A, B, and C) followed by
the VRC multiclade HIV-1 recombinant serotype 5 adenoviral vector vaccine (four
vectors encoding a clade B Gag/Pol fusion and clades A, B, and C Env) is well
tolerated and immunogenic. This randomized, double-blind, placebo-controlled study
is evaluating the safety and immunogenicity of this regimen and the VRC multiclade
HIV-1 recombinant adenoviral vector vaccine alone in African adults.

Methods: Healthy adults aged 18-50 in Kigali, Rwanda and Nairobi, Kenya were
randomized to receive a single intramuscular injection of 1 x 1010 or 1 x 1011 particle
units of the VRC multiclade HIV-1 recombinant adenoviral vector vaccine (rAd5) at
week 0, or the VRC multiclade HIV-1 DNA vaccine (DNA) 4mg dose at weeks 0, 4
and 8 followed by rAd5 at 1 x 1010 or 1 x 1011 doses at week 24, or placebo, in a 3:1
vaccine:placebo ratio for each group. Volunteers were followed for one year. Safety
and tolerability were assessed clinically and by routine lab tests. Immunogenicity was
evaluated by the IFN-γ ELISPOT assay.

Results: We randomized 35 people to receive rAd5 alone or placebo, and 79 people
to receive DNA prime-rAd5 boost regimen or placebo. The study is ongoing;
preliminary blinded safety and unblinded immunogenicity data are presented. The
vaccines were generally well tolerated in all groups. Injection site reactions were
common after both DNA/placebo and rAd5/placebo, with most rated as mild. After
rAd5 alone or placebo, 18/35 of systemic reactions were mild, 7/35 were moderate
and none were severe. After DNA prime-rAd5 boost or placebo, 20/42 were mild,
7/42 were moderate and 2/42 were severe (1 headache, 1 malaise). Systemic reactions
were all self-limited and not more common or severe after rAd5 compared to after
DNA. There was 1 serious adverse event, partial, subjective, bilateral hearing loss,
which was assessed as possibly vaccine-related. Overall, 6/12 volunteers in the rAd5



                                                                                    89
1010 group, 6/12 in the rAd5 1011 group, and 0/11 in the placebo group had positive
ELISPOT responses. ELISPOT responses in volunteers receiving rAd after DNA
priming have not yet been measured.

Conclusions: Preliminary safety data suggest the VRC multiclade HIV-1 DNA and
recombinant multiclade HIV-1 adenoviral vector vaccines were generally safe and
well tolerated at all doses studied. Both rAd5 doses levels were immunogenic.




                                                                                90
I-F-2. Capacity building at rural mission hospitals through
       « extended on-site technical support (EOSTS) »

Authors: Christopher M. BOSTITIS, MD, Amy S. BOSTITIS, MS, CNM, Sanjiv
LEWIN, MD and Robert SHENEBERGER, MD, AIDSRelief Zambia, Institute of
Human Virology, University of Maryland, USA.
bositis@umbi.umd.edu


Context: Most models of technical support rely on short and centralized trainings
where health care providers (HCPs) are taken out of their practice context and taught
by experts with limited field experience in resource limited settings. On-site technical
visits can be perceived by local staff as burdensome and impractical, while support
teams often leave frustrated by a perceived slowness of change.
In order to better understand the clinical and programmatic needs at our local partner
treatment facilities (LPTFs), a two-member technical team spent 6-8 weeks each at
select rural LPTFs. Key targets were ART team members (ARTTMs) and general
hospital staff. The goal was to equip and encourage ARTTMs to provide quality and
family-centered ART care through on-site trainings and interventions tailored to their
particular needs.


Approach:      CMB and ASB lived for an extended period at the LPTF. The first 1-2
weeks were spent working alongside HCPs in various clinical settings, building
relationships and integrating into the general life of the LPTF. Specific learning
needs could thus be assessed, and other issues that were impacting the quality of
clinical care identified.   The remaining time was spent providing trainings and
implementing clinical and programmatic interventions. Regular meetings were held
to review issues, set goals and determine priorities. At the end of each stay, additional
recommendations to improve the quality of clinical care were made. Shorter follow-
up visits were scheduled to occur within 6 months of the initial visit.


Outcomes and challenges: EOSTS was provided for 4 sites in 9 months. Their
learning and programmatic needs varied widely. At one, a clinical officer with no
prior ART experience was mentored and trained; she is now their primary ART HCP
and has begun basic ART training for nurses. At another, midwives that initially
refused to offer VCT to laboring women began offering it routinely. Additional



                                                                                      91
interventions included leadership restructuring, integrating inpatient/outpatient care,
linking ART/PMTCT programs, developing clinical resources, and launching satellite
clinics.
Feedback from the sites indicates that this model has been well-received, and
preliminary chart reviews suggest that quality of care – based on observed clinical
decision-making – has improved.
Because this model has only recently been implemented, a quantitative analysis of its
impact on quality of care – e.g., as assessed by treatment failure rates – has not yet
been performed.
Difficulty reproducing the model and the challenge of evaluating quality of care are
key limitations.


Key Recommendations: Specific learning needs and challenges to quality clinical
care vary at each LPTF, and a standardized approach may be inadequate to address
them all. Spending an extended period of time on site, learning its culture and
building relationships can increase the likelihood that such needs will be met,
appropriate interventions implemented, and quality care delivered.




                                                                                    92
I-F-3. Immunological improvement and viral suppression after the
initiation of AntiRetroviral Therapy (ART) in Zambia. K.
STAFFPORD et Al. (University of Maryland and AIDSRelief-
ZAMBIA)
Authors: Kristen STAFFPORD,MPH, Martine ETIENNE, Sanjiv LEWIN, MD,
Christopher BOSITIS, MD, Amy BOSITIS, MS, CNM, Anne DOHERTY, NP, Anthony
AMOROSO, MD, Robert SHENEBERGER, MD, AIDSRelief Zambia, Institute of
Human Virology, Univeristy of Maryland, USA.
stafford@umbi.umd.edu


Context: CD4 count change is used to gauge response to ART in current programs.
However the medical evidence suggests that CD4 gain is not reliably indicative of
viral suppression.


Methodology: AIDSRelief’s quality assurance program, performs annual reviews on
random samples of patients who have initiated ART >9 months ago. De-identified
patient information is collected through chart abstraction and analyzed to determine
the quality of outcomes. 5 local partner treatment facilities in Zambia participated in
this voluntary process, 1 in Lusaka and 4 rural. Both covariate and multivariate
analysis were performed to determine relationships between viral suppression and
CD4 outcomes. Viral loads were performed using the Elisa-based Cavidi Exavir
assay and QC’d using Roche Amplicor PCR.


Results: 248 patient charts were abstracted and 213 viral loads were analyzed. 195
active patients who received a viral load also had baseline and repeat CD4 counts
documented. This represented 10% of patients eligible for review. 56% were female.
Median age was 38 years. The median baseline CD4 count was 151 cells/μL. 52% of
patients who had a viral load below the lower limit of detection had a median CD4
count of 121 cells/μL at 6 months and 35% of patients had a median count of 177
cells/μL at 12 months. 46% of patients with viral failure had a median CD4 count of
72 cells/μL at 6 months and 35% of patients had a median of 196 cells/μL at 12
months.


Conclusions: While patients who did not achieve viral suppression after a median of
14 months on therapy did have lower CD4 cell counts after the first six months of



                                                                                    93
therapy, comparison of the 12 months counts indicates no significant difference in
immunologic improvement, and a statistically significant correlation was not found
between cell gain and viral suppression. The use of CD4 cell gain to measure program
success may need to be evaluated and viral loads for cross-sectional evaluation may
need to be considered for true program evaluation.




                                                                                 94
I-F-4. Pattern of immunological improvement after the initiation of
Antiretroviral Therapy (ART) in resource-limited settings (Kenya
&Uganda). K. STAFFPORD et Al. (University of Maryland,
AIDSRelief-UGANDA and CDC)

Authors: Kristen STAFFORD1, OLUMUYIWA Aina1, Martine ETIENNE1,
OLUROTIMI Mesubi1, Fred CHANDI2, Henry SERUYANGE2, XXXXX3, Anthony
AMOROSO1
1
  Institute of Human Virology, University of Maryland School of Medicine
2
  Catholic Relief Services/AIDSRelief, Uganda
3
  Centers for Disease Control and Prevention
stafford@umbi.umd.edu


Context: CD4 gain occurs in a non-linear fashion as most of the immunologic
improvement is seen in the first several months after ART initiation followed by
modest gains and long term plateau. CD4 count change is used to gauge response to
ART in current programs.            However the expected long-term immunologic
improvement after initiating ART, particularly in patients with CD4 < 200 c/mm2 is
ill defined in resource limited-settings.


Methodology: AIDSRelief’s quality assurance program performs annual reviews on
random samples of patients who have initiated ART >9 months ago. De-identified
patient information is collected through chart abstraction and analyzed to determine
the quality of outcomes. 8 of 10 clinics in Kenya and 5 of 5 in Uganda chose to
participate in the program. University of Maryland IRB approval was obtained for
retrospective analysis.    Patients were classified as having poor (<50 cells/μL),
moderate (50-149 cells/μL), and good (>150 cells/μL) immunologic improvement
from baseline.


Results: 1,140 patients were included, 525 in Kenya and 615 in Uganda. 65.6% were
female and median age was 38 years. The median baseline CD4 count was 93 in
Uganda and 128 in Kenya. Patients experienced a rapid cell gain in the first 6 months
of ART, followed by more gradual increases from 6 to 12 months. The median CD4
cell increase in the first 12 months of ART was 152 (IQR, 71-258) cells, with a mean
increase from baseline of 153 at 6 months and 189 at 12 months. 18.9% of patients
achieved poor, 29.6% moderate and 51.4% good immunologic responses. Patients
with baseline CD4 counts of < 50 cells/μL had similar immunologic response as


                                                                                  95
patients with higher baseline CD4 in the first 6 months, and then experienced a higher
increase in the second 6 months of ART compared to patients with higher baseline
counts. However, these patients did not plateau to the same level as patients with
higher baseline counts after 12 months.


Conclusions: Patients with CD4 counts <50 at ART initiation do experience good
immunologic response but      plateau at a lower CD4 count compared to patients
starting ART at higher baseline CD4 counts, maintaining an inferior immune function
after the first year of therapy, often not achieving CD4 counts >200. Additionally, as
most of the immunologic response appears to occur in the first 6 months of ART, the
utility of repeat CD4 testing for programmatic evaluation after the first 12 months of
ART may be limited.




                                                                                   96
I-F-5. Implications of the CD4 count at initiation of anti-retroviral
therapy on morbidity, mortality and virologic outcomes in Rwanda –
a descriptive cross-sectional review in AIDSRelief supported Health
Centres
Authors: Ruth M GOEHLE, Alfonse KAYIRANGA, Catholic Relief
Services/AIDSRelief Rwanda,
Kristen STAFFORD, Anthony AMOROSO, AIDSRelief, Institute of Human Virology,
University of Maryland, USA.
Parfait RABEZANAHARY, Constella Futures, Washington, DC, AIDSRelief Rwanda

E-mail for correspondence: rgoehle@crs.org
Telephone Contact: 250 - 08303191
Keywords: CD4, immunologic improvement, ART


Context: Initiation of Highly Active Anti-Retroviral Therapy (HAART) in HIV-
positive patients at CD4 cell counts of 201-350 is now a favored approach, because
failure of therapy, opportunistic illnesses and death become more common when
therapy is started at CD4 counts of < 200. In this report, we compare opportunistic
events, mortality and virologic outcomes of HAART in the first Rwanda cohorts from
two AIDSRelief local partner treatment facilities with CD4 counts at initiation of
therapy.


Methods: In this cross-sectional retrospective review, the charts of patients who had
initiated HAART since February 2005 in 2 AIDSRelief-supported clinics in Rwanda
and who had been on HAART for > 9 month were reviewed. Because the cohort size
was small, 182, all patient charts were reviewed and efforts made to obtain blood
samples for viral load determination. Data were extracted from 200 charts of the
cohort, including CD4 at start of therapy, opportunistic illnesses, mortalities and
status as at last clinical review. These included the charts of patients who had died or
transferred from care from start of ART until chart review. Blood samples for viral
load determinations were obtained from 179 patients. Viral load analysis was
performed by the National Reference Laboratories, Kigali. No patient from this first
cohort at either health center had been lost to follow-up.


Results: Sampling and chart review were completed in October 2006. 200 patient
dossiers were reviewed and are being analyzed. Median age of the patients was 37


                                                                                     97
years; 61% were female. For viral suppression, 96% of samples had counts < 400/;
the majority, undetectable. Additional information on the CD4 values at initiation and
at time of viral sampling, opportunistic infections and viral suppression and
contributing factors to the deaths of persons who began HAART in this first cohort
will be provided.


Conclusions: Like its sister AIDSRelief programs in Kenya, Uganda, and Zambia, it
is expected that patients receiving HAART in Rwanda had more undesirable
outcomes if treatment was initiated at CD4 counts of less than 200, including
opportunistic illnesses and mortality. These can greatly increase the costs of care and
reduce program efficiency. Data from these four AIDSRelief country programs
support the recommendation that HAART should be initiated before CD4 counts have
fallen to 200 where possible.




                                                                                    98
I-F-6. Results of a Cross-Sectional Study on Knowledge, Attitudes,
and Practice Related to HIV/AIDS and Sexual Violence Among
Students Attending Two Secondary Schools in Bukavu, Democratic
Republic of the Congo (DRC).

Authors : BAHATI Ngubulwa1, Joshua Rasplica RODD2 and MUNYANSHONGORE
Cyprien3 1Health District of Bukavu, DRC, 2Payson Center for International
Development, Tulane University; 3National University of Rwanda, School of Public
Health
Institution: National University of Rwanda, School of Public Health (NURSPH)


Context: Recent studies show that in developing country contexts, approximately half
of all new cases of AIDS are diagnosed among youth aged 15 to 24 years. Given this
situation, prevention via abstinence or condom usage are the means recommended to
reduce the risk of HIV infection among youth. As such, this study seeks to evaluate
the level of knowledge and behavior of youth in an educational environment in order
to assist decision makers to better target interventions towards the reduction of HIV
incidence among secondary school students. This study focuses on secondary school
students at two schools in and around Bukavu, DRC.


Specific objectives:
1) to evaluate knowledge of HIV/AIDS among students at two secondary schools in
   Bukavu.
2) to evaluate perceptions of risk related to HIV/AIDS, STIs, and sexual behavior
   among students at two secondary schools in Bukavu.
3) to evaluate sexual behavior and risk among students of two secondary schools in
   Bukavu.


Methodology:
Study population: The study population comprises unmarried students, age 14-24,
who attend two Bukavu-area secondary schools, specifically the Athanaeum of Ibanda
and the Kamangala Institute, who were present on the day of data collection and who
agreed to participate in the study.
Tools and Time Period: Data collection took place over a period of one week in
February 2006. All interviews were conducted by the researchers; sampled students




                                                                                  99
were interviewed individually in private offices or unused classrooms made available
by the schools’ administrators.
Sampling: Researchers calculated a sample size of 768 students, drawn from two
Bukavu secondary schools. To ensure representation of both rural and urban students,
researchers stratified all secondary schools in the Bukavu area by urban or peri-
urban/rural milieu and randomly selected one school from each stratum. At each
selected school, researchers used the administrative list of all enrolled students as a
sampling frame and randomly selected a proportional number of students from each
institution. Sampling was further stratified on the basis of gender to ensure equal
representation of male and female respondents and on the basis of class to ensure
proportional representation of students from each, i.e., 1st through 6th grade.
Statistical Methods: Categorical data was cross-tabulated and tested using chi-square
tests to determine measures of association (Odds Ratios) and significance.


Results: Basic awareness of HIV among the students was relatively low, with only
50.8% (390) reporting having heard of HIV/AIDS and only 28.6% (220) able to
correctly define HIV/AIDS. Only 8.3% of sexually active respondents reported using
a condom at every sexual contact, and 82.1% reported never using condoms. Of the
two hundred, eighty students who agreed to discuss their sexual debut, over 50%
reported experiencing rape or violence during their first sexual encounter. There was
no statistically significant difference between males and females in terms of
experiencing rape or violence, nor was there a significant difference between students
reporting different ages of sexual debut. However, students under the age of 15 were
significantly more likely to have experienced violence at sexual debut (OR= 3.079;
95% CI: 1.697-5.587; p<.0001) and students who lived in urban areas were
significantly more likely to report violence at first sex encounter than respondents
from peri-urban or rural areas (OR = 1.916; 95% CI: 1.107-3.315; p=.028). Students
who reported violence at sexual debut were significantly less likely to control usage
of condoms during sexual relations (OR=0.364; 95% CI: 0.172 – 0.695; p=.005) and
were significantly more likely to report seeking sexual contact for money or
protection (OR=3.564; 95% CI: 2.144-5.924; p<.0001).


Conclusion: The findings demonstrate a disturbing lack of awareness of HIV/AIDS
and an elevated rate of high-risk sexual behavior among secondary students. The


                                                                                   100
prevalence of students reporting violence at first sex is much higher than expected;
such widespread violence may reflect larger social issues in the area and has serious
implications for planning of interventions to reduce HIV transmission among youth.




                                                                                 101
I-F-7. Inception and implementation of the Multi Country Program
on Social Science Research in the field of HIV/AIDS in Botswana.

Authors: Oleosi Ntshebe2, Kenabetsho Bainame1, Marlene Nkete2, Rolang
Majelantle1, Kwaku Osewedie1, Gobopamang Letamo1, Sadasivan Nair1 and Elah
Matshediso1

Project
Botswana became involved in the Multi country program (MCP) on Social Science
Research in the field of HIV/AIDS in 2005. The objective of the Botswana Social
Science Research & HIV/AIDS initiative is to improve the effectiveness of
HIV/AIDS interventions through the strengthening of demand-driven social science
research. Funding for the Social initiative are from the Netherlands Ministry for
Development Cooperation, the Royal Tropical Insitute (Koninklijk Instituut) and the
Dutch Aids Fonds for the MCP on Social Science Research in the field of HIV/AIDS.


Achievements
The national work plan is employed to effect the activities of the initiative. To date,
the kick off workshop, capacity needs assessment, and the proposal writing workshop
have been undertaken. Four research projects are currently being funded under the
initiative. The National AIDS Coordinating Agency (NACA) is the chair of the
initiative, and the Department of Population Studies serves as its secretariat. Other
partners represented on the national committee and/or technical group are the
Ministry of Health, Botswana Network of AIDS service organizations (BONASO),
Botswana Christian AIDS Intervention Program (BOCAIP), Botswana National
Productivity Centre (BNPC), Women Affairs Department (Ministry of Labour and
Home Affairs), Infectious Disease Care Clinic (IDCC), Departments of Social Work
and Population Studies at the University of Botswana.




1
    University of Botswana
2
    National AIDS Coordinating Agency




                                                                                   102
Challenges
The initiative has faced a number of challenges in the implementation of its activities.
Some of these hurdles relate to; 1) Sustaining commitment and dedication amongst
the researchers, advisors and the membership of the committees 2) Procedures for
ethical clearance which delayed the start of research projects by over six months, and
3) Lack of succinct relationship between the chair and the secretariat for the Initiative.


Conclusion
To improve the effectiveness and sustainability of the Botswana Social Science
research and HIV/AIDS initiative, there is need for a more active role of NACA and
involvement of all stakeholders in HIV/AIDS work.




                                                                                      103
I-F-8. Assessment of nutritional support provided by faith-based
organizations to people affected by HIV and AIDS.

Authors: T. Bishagara, S. Ngarukiye, Z. Bigirimana, J. Kayirangwa, Dr.I. Mukatete ,
Dr A.Binagwaho

Institution Responsible: Shining Hope For Great Lakes (SHGL) and Faith Victory
Association (FVA)

Background: Rwanda is located in the Great Lakes Area of East Africa. The
population is estimated at about 8.5million with a demographic density of about 310
people per km2. The HIV and AIDS problem indicated by ONUSIDA 2005 is that
250.000 adults and children lived with HIV of whom 160.000 are women and there
are 160.000 orphans. The infection ration is three times higher in urban areas than in
rural setting. Malnutrition is another big issue in Rwanda as indicated by Rwanda
EDS, 2005 where 45% of under 5 years of age children are anemic and HIV and
AIDS is one of the underlying causes. HIV and AIDS weaken the infected family
members, reducing the labour capacity and eventually food insecurity. Malnutrition
which also affects the immune system is commonly observed with families affected
by HIV and AIDS.


To overcome the problem a correlation between nutrition, malnutrition, and HIV and
AIDS is established with the intention of cutting the vicious cycle. A National Guide
for the support and food and nutritional care for PLHs in Rwanda was formulated by
Ministry of Health and the faith based organizations (FBOs) are partners in taking
care of people affected with HIV and AIDS. Distribution of foods is one of the major
intervention activities. The strategy was incorporated as an integral component of the
whole programme of the community assistance directed to alleviate the effects of HIV
and AIDS on PLHs.


Methods: SHINING HOPE for GREAT LAKES, a local NGO in RWANDA
developed a motivation to assess the care provide by the partner NGOs with focus on
the faith based ones. The broad objective was to assess the appreciation of the
nutritional assistance provided by faith based organizations. Specifically the
researchers undertook to identify the role and the responsibilities of faith based
organizations as regards the PLHs nutritional assistance, describe the real nutritional



                                                                                   104
needs of PLHs and their attitudes vis à vis this nutritional assistance, analyze the
challenges and constraints faced by faith based organizations in providing the
nutritional assistance, define an appropriate strategy to improve HIV and AIDS
infected and affected people’s accessibility to nutritional programmes and suggest
appropriate recommendations in light of the research findings.


The study has been carried out in collaboration with the network of religious bodies
committed to fight HIV and AIDS in Rwanda», with technical and financial support
from CNLS, FVA and KIT of Netherlands. The Districts Mayors helped to ensure
effective participation of the PLH who were the study target group and expected
beneficiaries of the care.


Authorization was sought and the study conducted in six districts of KICUKIRO,
NYARUGENGE and GASABO in Kigali city; and RWAMAGANA, KAYONZA
and NGOMA which are rural based. The study protocol was formulated, survey
assistants trained, data collected, and processed. The main informants were FBOs,
PLHs’ as individuals and groups, close relatives to PLHs, health care and social affair
workers of the study areas.


Results: The study revealed that FBOs mobilize and supply foodstuffs, provide
nutritional education and counseling. The food distribution was mainly on monthly
basis and more regular in rural areas. The main challenges are irregular procurement
and insufficient quantities of foodstuffs and the appreciation by the PLHs is less in
rural than in urban areas. While the majority of the PLHs receiving the assistance
know the value of proper nutrition in relation to the health status, for various reasons
the foodstuff is often exchanged for other essential commodities. PLHs and their
relatives revealed need for more and regular supplies while the government employs
propose support for economic growth especially for the PLH who are still strong.


Recommandations: The researchers’ recommendations include capacity-building for
FBOs, especially in areas of planning, coordination, and focus on educational and
other developmental projects in addition to increased strategies for resource
mobilization.



                                                                                    105
II- ABSTRACTS A PUBLIER DANS LA
     BIBLIOTHEQUE VIRTUELLE




                                  106
II- B. RECHERCHE CLINIQUE ET PRISE EN CHARGE
THEURAPEUTIQUE




                                           107
II-B-1. Importance of Viral Load Testing Before Advancing to 2nd
Line or Salvage ART Regimens: Observations in 74 Rwandan
Patients Experiencing Clinical and/or Immunological Failure
Authors: Bruno Ngirabatware, MD, Fabienne Shumbusho, MD

Context: As an indicator of viral replication, viral load (VL) is the best marker of
ART efficacy and the need to change to 2nd line or salvage regimens. Ideally, VL in
combination with CD4 exams are performed routinely to monitor patients’ response
to treatment. In Rwanda, however, only the National Research Laboratory has the
capacity to test for VL, and this at a cost of $45 (US)/test. It is thus economically and
logistically impossible to routinely test VL in all patients on ARVs in Rwanda. In the
absence of VL measures, the National Treatment and Research Center for HIV
(TRAC) has developed surrogate clinical and immunological criteria for assessing
treatment failure and for advancing patients to 2nd line or salvage treatments.
Clinical/immunological status, however, does not always accord with VL; while VL
may remain at undetectable levels, CD4 counts may decline to dangerously low
levels. In patients experiencing treatment failure but with a VL at undetectable levels,
changing ARV regimen has no clinical value.          To confirm the need to change
regimens in patients experiencing clinical and/or immunological failure, we measured
VL before advancing them to 2nd line treatment. We summarize results and review
implications for national treatment guidelines.

Methodology: Between 7/2004 and 10/2006, 74 adult (>14 yrs) patients out of 728
patients on first-line ARVs at Biryogo Social and Health Center experienced clinical
and/or immunological treatment failure according to TRAC guidelines. 14 of these
patients had signs of clinical failure (occurrence or resurgence of opportunistic
infections or other pathologies indicating clinical decline); 60 had signs of
immunological failure (decline in CD4 to below pre-ART levels or 50% decrease
from the highest CD4 level attained during treatment); 8 had signs of both clinical and
immunological failure. VL was tested in all 75 of these patients before changing
regimens. In 2 patients with detectable but low (≥400 and <10,000 RNA/ml) viral
levels, repeat VL testing was performed.

Results: On average, patients had been on ART for 20 months at the time viral load
measures were requested.



                                                                                     108
1. Clinical profile of patients in treatment failure
                                     CD4 increases over time in patients               with
                                     immunological failure
WHO Stage when VL tested                         % patients with CD4 increases
                                     M=month
      F      M      Total            CD4 tested N No             1-50 51-100         >100
I     3      4      7                                  increase
II    4      7      22               M6-M0       60 30          25     20            25
III   41     12     53               M12-M6      59 46          36     7             12
IV    4      0      4                M18-M12 47 57              15     13            15
Total 52     23     75               M24-M18 46 35              22     17            26
2. Viral load results
RNA/ml                           N              %
<400 (undetectable)              68             92     Change in regimen of no value
≥400 and <10,000 (detectable but 2              2.6    Repeated VL testing at 3 mo
low)
≥10,000 (detectable)             4              5.5    Advanced      to    second-line
                                                       regimen
Total                                   74      100

Of 74 patients experiencing clinical or immunological failure, only 6 had detectable
levels of virus. Of these, 2 fell into the detectable but low level category. Repeat VL
measures were taken in both of these patients after 3 months; viral load remained
detectable in 1 patient who subsequently was advanced to 2nd line therapy. 4 of the
patients had RNA levels ≥10,000/ml; all of these patients were advanced to second-
line regimen. VL analyses indicated need for regimen change in only 5 out of 74
patients.
Conclusions and Recommendations: second-line ART is more costly, more difficult
to administer and produces more adverse affects compared to first-line ART. Patients
should be advanced to second-line treatment, therefore, only when necessary.
Whereas 74 patients under study would have been advanced to second-line ART
according to current treatment and care guidelines, VL results suggest that very few of
these patients would benefit from such a regimen change. We assume that VL
findings are accurate and that testing procedures meet quality assurance/quality
control standards. In light of these findings, we recommend: (i) conducting a similar
evaluation nationally to verify these findings; (ii) considering a modification to
national guidelines to include viral load testing before advancing to second-line or
salvage treatment; (iii) clinicians attending closely and carefully to adherence and
management of opportunistic infections in patients with clinical and or immunological
failure but with a low viral load.


                                                                                   109
II-B-2 Causes of mortality in 309 / 5,115 patients on arvs in Rwanda:
recommendations for improving hiv patient care

Authors: Bruno Ngirabatware, MD, Fabienne Shumbusho, MD, Innocent Turate,
MD, Edouard Sahunkuye, Jessica Price, PhD

Context: HAART (Highly Active Antiretroviral Therapy) has radically transformed
the care and treatment of HIV patients and, while not a cure, has altered the
perception of HIV/AIDS from being a plague to being a manageable chronic disease.
Nevertheless, some HIV patients on HAART continue to die. Causes of mortality in
ART patients are varied. In some cases, such as HIV-related cancers, medicine can
offer little help other than providing palliative care; in other cases, however,
potentially fatal conditions can be effectively managed and cured. Understanding the
causes of mortality in ART patients is one way of assessing the quality of care being
provided to patients and points to critical service gaps and needs to improve clinician
skills. In this presentation, we review data on mortality in 309 Rwandan patients and
make recommendations to improve patient care nationally.

Methods: At FHI-supported ARV sites, data are collected on all ARV patients who
die during treatment. For each deceased patient, ARV start-up date, clinical status at
ART start-up, probable cause of mortality, place where death occurred, and treatments
provided prior to death are recorded. Out of 5,115 ARV patients followed at FHI-
supported sites, 309 (6%) cases of death were recorded between July 2003 and
December 2006. Mortality findings are presented on these 309 patients.

Principal results: 48.5% (2,484) of the patients were being treated at hospitals and
51.5% (2,631) at primary health centers. All 309 patients were under a physician’s
care at the time of death. Death rates of patients being treated at hospitals (144, 5.7%)
and health centers (165, 6.2%) did not differ substantially. 16 of deceased patients
were children (≤14 years old); 293 were adults (>14 years old); patient age data are
missing in 2 cases. Overall, clinical status in patients was more compromised at the
start of treatment in these deceased patients compared to all ARV patients at FHI-
supported sites.




                                                                                     110
1. CD4 & WHO Stages at Treatment Start-up in Patients Who Died While on
ART
Average CD4/ml at ARV start-up                    WHO stage at ARV start-up
           F       M      Total*    %                   F      M     Total        %
0-49       53      43     96        31            I     2      2     4            1
50-99      31      34     65        21            II    15     10    25           8
100-199    51      28     79        26            III   111 80       191          62
200-350    34      23     57        19            IV    48     41    89           29
>350       6       4      10        3             Total 176 133      309          100%
Total      175     132    307       100%
* CD4 data on 2 cases missing

At ART start-up, 31% (96) of deceased patients had severe immuno-suppression
indicated by CD4 levels <50/ml compared to 15% in all ART patients; 29% (89) were
in WHO clinical stage IV compared to only 10% in all ART patients. On average,
deceased patients had been on ARVs for only 4 months at the time of death. 137
(44%) of patients died at home; as many died in hospitals (141, 46%), relatively few
(30, 9.7%) at health centers, and 1 patient died at a traditional practitioner service.
29% (91) of all deaths recorded were of unknown causes. TB and non-TB confirmed
pulmonary disease together were the most frequent (83 cases or 27%) known cause of
death, followed by chronic diarrhea (38 cases or 12%).


2. Causes of Mortality in Patients Followed at Health Centers and Hospitals
                                          Hospitals      Health Centers     Total
Unknown                                   62 (43%)       29 (18%)           91 (29%)
Tuberculosis                              15 (10%)       27 (16%)           42 (14%)
Pulmonary disease (TB not confirmed)      17 (12%)       24 (15%)           41 (13%)
Chronic diarrhea                          14 (10%)       24 (15%)           38 (12%)
Other, not evidently HIV-related          10 (7%)        21 (13%)           31 (10%)
Cancer                                    4 (3%)         15 (9%)            19 (6%)
Meningitis                                9 (6%)         7 (4%)             16 (5%)
Malaria                                   8 (6%)         5 (3%)             13 (4%)
HIV-related encephalopathy                4 (3%)         9 (6%)             13 (4%)
ARV toxicity                              1 (1%)         2 (1%)             3 (1%)
Wasting syndrome                          0              2 (1%)             2 (1%)
Total                                     144            165                309

Unknown cause of death and deaths occurring at home were related. In 137 patients
who died at home, 58% (80) died of unknown causes. Of all 91 deaths with unknown
causes, 88% occurred at patients’ homes. Substantially more unknown causes of




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death were in patients being followed at hospitals compared to patients followed at
health centers.


3. Place of Death in Patients Followed at Hospitals and Health Centers
Place of death Hospital                    Health Center              Total
Health         74 (51%)                    97 (60%)                   171 (55%)
facility
               70 (49%)                    67 (41%)
               Of which, 55 (79%)          Of which, 25 (37%)
Home                                                           137 (44%)
               causes of death unknown     causes     of death
                                           unknown
Other             0                        1 (1%)              1 (1%)
Total             144 (100%)               165 (100%)          309 (100%)

Discussion: The 6% mortality rate in these ARV patients in Rwanda is similar to rates
reported in wealthier countries of North America and Europe; it is markedly lower,
however, compared to mortality rates from other countries in southern Africa (e.g.,
13% at hospitals and 17% at clinics in Eastern Cape, S.A.). While this finding is
encouraging, the high number of unknown causes of death and those that occur at
home invite further questions: Why are so many causes of death unidentifiable or
unrecorded? Why is there such a substantial difference in the number of unknown
deaths in hospital versus primary health center patients? Are these findings at FHI-
supported sites similar to sites nationally? Explore these and other questions may
point the way to improving the care and chances of survival for these patients. A
related concern is the short-time delay between ART start-up and death (4 months
average). While multiple reasons may explain patient deaths, immuno-reconstitution
inflammatory syndrome (IRIS) should be considered in patients with low CD4 counts;
yet, in only two cases did treating physicians evoke this explanation.       Such a
diagnosis is especially relevant given the high number of deaths due to non-TB
confirmed pulmonary disease. In patients suspected of IRIS with non-TB confirmed
pulmonary disease, TB BK-negative should be suspected and treated accordingly. As
relates to other causes of death, the timeliness and effectiveness of clinical
interventions should be examined.




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Conclusions and recommendations
Systematically documenting deaths in ARV patients serves many purposes: (i) Death
rates are one indicator of the quality of care provided to patients. (ii) Details on the
causes of mortality and treatments prescribed prior to death point to critical service
gaps and needs to improve clinician skills.       (iii) Documenting deaths provides
information on patients’ resort to medical services. Our first recommendation,
therefore, is to institute a system nationally to track and record ARV patient deaths.
Our second recommendation is to reinforce clinician skills to recognize and manage
IRIS. Related, because patients with severe immuno-suppression often have non-
typical forms of TB (BK-negative), following WHO recommendations we would
propose that all patients with CD4<50/ml systematically receive chest X-ray. A third
recommendation is to improve clinical capacity in early detection and management
of other pathologies (namely meningitis and chronic diarrhea) that are important
causes of death. A fourth recommendation relates to deaths due to cancers. In the
absence of effective treatment, there is a need to improve capacity in Rwanda to
provide palliative care for these patients. Ultimately, however, clinicians can only
help patients who avail themselves to professional.




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II-B-3. Morbidité et mortalité des enfants VIH négatif nés de mères
séropositives dans le cadre de l’étude AMATA. Suivi à 6 mois

Auteurs : Peltier C.A, Ndayisaba G.F, Ndimubanzi C.P, Rutanga C, Havuga E,
Dhont N, Omes C

Introduction
Le choix du mode d’allaitement des enfants de mères séropositives pose un problème
à la fois éthique et de faisabilité. L’allaitement artificiel est contesté dans les pays à
ressources limitées, alors que le lait maternel reste le moyen le plus important de
transmission du VIH de la mère à l’enfant. Cette controverse est due au fait que le lait
artificiel, très onéreux, présente selon plusieurs auteurs, un risque accru de morbidité
et de mortalité.

Objectifs

Comparer la morbidité et la mortalité des enfants non infectés selon le mode
d’allaitement (DNA PCR VIH négatifs)
Déterminer les principaux motifs de consultation et d’hospitalisation selon le mode
d’allaitement.


Méthodologie
Dans l’étude AMATA les femmes font le choix entre l’allaitement artificiel ou la
trithérapie durant les 6 mois de l’allaitement maternel exclusif. Celles qui font
l’allaitement artificiel reçoivent le lait gratuitement et des conseils d’hygiène pour la
préparation des biberons.
Des suivis réguliers des enfants sont faits à J15, J45, M3, M5, M6, M7 et M9
(contrôle DNA PCR) et tous les épisodes de maladies ainsi que les décès, sont
enregistrés.


Résultats
521 enfants VIH négatifs sont nés, 301 (57,6%) sont sous allaitement artificiel, et 220
(42,4%) sont sous allaitement maternel. On note 173 épisodes de maladies jusqu’à
l’âge de 6 mois, avec une moyenne de 1,23 épisode par enfant dans l’allaitement
artificiel et 1,21 épisode par enfant dans l’allaitement maternel (p=0,81). Les décès
sont 9 (2,9%) dans l’allaitement artificiel, contre 3 (1,3%) dans l’allaitement maternel
(p=0,12). Les principaux motifs de consultation et d’hospitalisation, dans l’ordre


                                                                                      114
décroissant, sont : les infections ORL, la gastroentérite et les broncho-pneumopathies.
Leurs fréquences ne semblent pas être liées au mode d’allaitement

Conclusion

Dans un contexte de conseils étroits et réguliers sur la préparation du lait et l’hygiène
des biberons, il ne semble y avoir aucune évidence de morbidité ni de mortalité plus
élevées chez les enfants VIH négatif nourri au lait artificiel par rapport à l’allaitement
maternel.




                                                                                      115
II-B-4. Validation des signes présomptifs de l'infection par le VIH
chez l'enfant de moins de 18 mois né d'une mère infectée par le VIH
(OMS, août 2006) chez 206 enfants au Rwanda
Auteur : Ndimubanzi C. Patrick, Ndayisaba Gilles, Kayumba Kisito, Tuyishime
Gilbert, Muganga Narcisse, Rusingiza Emmanuel, Omes Christine, Peltier C.
Alexandra


Contexte
Estimation de la sensibilité et de la spécificité du diagnostic présomptif d’infection
pour le VIH proposé par les nouvelles recommandations de l’OMS (août 2006) chez
l’enfant de moins de 18 mois né d’une mère infectée par le VIH en l’absence de PCR-
diagnostic. L’OMS propose d’accepter un diagnostic présomptif d’infection par le
VIH chez un enfant avec une sérologie + et < 18 mois (la sérologie peut être positive
à cause de la présence d’anticorps maternels jusqu’à l’âge de 18 mois) s’il présente 2
des signes cliniques suivants : septicémie, pneumopathie, candidose orale ou un signe
du stade 4. Les CD4<20% sont aussi un marqueur important.


Méthodes
La PCR a une spécificité et une sensibilité de 99% après un mois de vie et constitue
l’étalon-or. Nous avons prospectivement prélevé une PCR (DNA PCR VIH
Amplicor) en même temps que le dosage de CD4 (Cyflow puis Facs calibur) et les
signes cliniques chez 203 enfants < 18 mois (92 filles et 104 garçons, âge moyen : 9
mois) avec une sérologie + pour le VIH hospitalisés au CHU de Kigali de janvier
2005 à septembre 2006.


Résultats
104 (50,5%) des enfants avec une sérologie positive avait une infection confirmée par
PCR. 82,6% d’entre eux présentent les signes cliniques de l’OMS et 51% d’entre eux
présentaient les signes cliniques sans être infectés par le VIH, signifiant une relative
bonne sensibilité mais une très mauvaise spécificité. 62,5% (sensibilité) d’enfants
avec une PCR+ ont des CD4< 20% et 82,4% d’entre eux présentent des CD4< 20%
sans être infectés (bonne spécificité). La raison de ces résultats montrant une
sensibilité ou spécificité faible peut s’expliquer par les signes cliniques et CD4 bas
similaires de l’immuno-suppression suite à la malnutrition due au manque d’apport ou



                                                                                    116
à la présence d’une tuberculose disséminée très difficile à démonter chez le jeune
enfant. Ces enfants nés de mères séropositives sont très exposés à la tuberculose et à
la pauvreté.


Conclusion
La faible sensibilité ou spécificité des signes présomptifs proposés par l’OMS
montrent l’importance de la confirmation de l’infection par la PCR et de donner des
suppléments nutritionnels et/ou antituberculeux aux enfants avant de donner des
antirétroviraux d’une façon empirique en l’absence de PCR.




                                                                                  117
II-B-5. Résultats intermédiaires de l'étude AMATA : trithérapie
durant l'allaitement maternel pour les femmes infectées par le VIH-1
et faisabilité de l'alimentation artificielle sur 548 couples mère
enfants au Rwanda
Auteurs : P. Cyaga Ndimubanzi, G.F. Ndayisaba, C. Omes, J. Muganda, E. Havuga,
V. Arendt, C.A. Peltier


Contexte

La transmission du VIH due uniquement à l’allaitement maternel est estimée à 14 %,
la suppression virale permet de réduire drastiquement la contamination.

Méthodes

Depuis mai 2005, des femmes enceintes séropositives sont incluses dans l’étude
effectuée sur 4 sites (rural et urbain au Rwanda) et choisissent après 3 séances
d’information sur les deux modes d’alimentation : allaitement maternel (AM) avec
une trithérapie chez la mère jusqu’à l’âge de 6 mois (puis soutien nutritionnel) et
l’alimentation artificielle (AA). Les femmes éligibles aux antirétroviraux (CD4<350
ou stade 4 de l’OMS) prennent D4T+3TC+NVP à vie, ou sinon une combinaison
AZT+3TC+Efavirenz est proposée à partir de la 28ème semaine de grossesse. La
trithérapie arrêtée chez les femmes non éligibles aux antirétroviraux (après
accouchement ou allaitement) est poursuivie 7 jours par une bithérapie IRTN après
l’arrêt du IRTNN. Une DNA PCR effectuée à J0-J15-J45 (-M3)-M7 permet le
diagnostic du nourrisson et connaître le moment éventuel de la transmission
(Transmission post-natale si PCR devient + après le prélèvement de J15). Tous les
enfants bénéficient du cotrimoxazole.

Résultats

572 femmes enceintes sont à ce jour incluses dans l’étude ; respectivement 57% et
43% ont choisi l’alimentation artificielle ou maternelle avec trithérapie. 1,1% des
enfants sont contaminés in utero (PCR+ entre J0-48h) et aucun enfant n’est contaminé
par l’allaitement. 527 enfants sont nés et 397 ont déjà été suivis jusqu’à 6 mois, la
morbidité et mortalité sont similaires dans les 2 bras d’alimentation. L’évolution
psycho-motrice et staturo-pondérale sont tout à fait superposable pour tous les
enfants.


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Conclusion

Aucun enfant n’a été contaminé par le lait maternel (220 enfants), l’éviction de la
transmission du VIH en préservant les avantages de l’allaitement sans les problèmes
de la malnutrition et risques infectieux des enfants nourris artificiellement sont des
données essentielles pour les pays à ressources limitées. L’absence d’effets
secondaires à court terme pour les enfants allaités et l’absence de complications
graves des femmes exposées aux antirétroviraux sont rassurantes mais les résultats du
suivi à plus long terme sont encore attendus.




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II-B-6. High efficacy of first-line ART regimens in a health centre-
based ART program: virological outcomes in 1000 patients after > 1
year of treatment

Authors: Johan van Griensven1, Ann Corthouts2, Edi F Atté3, Janet Alonso4 for the MSF-OCB HIV
project, Kigali-Rwanda
1
  MSF-OCB, MD, responsible of documentation 2MSF-OCB, MD CS Kinyinya, 3MSF-OCB, MD CS
Kimironko,
4
  MSF-OCB, MD, medical coordinator HIV project, Kigali, Rwanda


Background: The Rwanda national ART program is currently undergoing a
successful scaling-up, mainly using generic fixed dose combination (FDC) drugs.
However, the efficacy of the current first-line ART in terms of immunological and
virological outcomes have not been systematically assessed.


Methods: MSF is supporting the ART program in Kimironko and Kinyinya health
centre since November 2003 and January 2004 respectively. For every patient on
ART for > 1 year, treatment efficiency is determined by viral load (VL) measurement.
Complete immunological data were available for 604 adult patients. Immunological
success was defined as an increase in CD4 count > 50 cells/ml from baseline after at
least 1 year of therapy. Virological success was defined as an undetectable VL (< 40
c/ml) after at least 1 year of therapy. Alternative VL thresholds used: 400 c/ml
(threshold of older tests) and 1000 c/ml (to exclude viral 'blips'). Discordant responses
were defined as opposite virological and immunological responses.


Results: VL results were obtained for 871 adult patients. The median age was 38
years, 73 % were female. The median time on ART was 17.6 ± 8 months; the median
baseline CD4 count was 142 ± 78 cells/ml. Around 90 % of these obtained an
undetectable VL (87.8 % with VL < 40cc/ml; 91.6 % VL < 400 cc/ml). A VL < 1000
cc/ml (a more clinically useful marker for single measurements) was obtained in 93
%, demonstrating that current ART first-line regimens can achieve high levels of
virological control. For children (≤ 15 years old, n=129), results were slightly inferior
with VL < 40 cc/ml in 78.3 %, < 400 cc/ml in 85.3 %.
When the adult VL results were combined with the immunological outcomes,
discordant responses were revealed to be frequent. Especially, lack of immunological
recovery despite having an undetectable VL is frequent, as seen in 19 % of patients.



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Similarly, 8 % of patients had immunological success despite detectable viral loads.
Similar data where seen with a VL <1000 cc/ml as threshold.
A detectable viral load leads to in-depth counselling sessions. Out of 23 control
samples from adults after counselling, VL was undetectable in 10 (43 %) and
decreased significantly in 1. Similarly, VL was undetectable in 4 and significantly
decreased in one child, out of seven samples.


Conclusion: Health centre-based ART programs using mainly FDC generic first-line
drugs can be highly effective, both for children and adults. Discordant immuno-
virological responses are common and as such demonstrate the importance of viral
load testing to detect treatment failure. These early data also support the use of VL
testing as an adherence marker and the efficacy of adherence interventions.

Virological-immunological outcomes in adult patients
Threshold        CV<40          CV≥40            CV<1000         CV≥1000       Total
Immunological    416 (68.9 %)   49 (8.1 %)       440 (72.9 %)     25 (4.1 %)   465
Success
Immunological    115 (19.0 %)   24 (4.0%)        122 (20.2 %)     17 (2.8 %)   139
Failure
Total            531 (87.9 %)   73 (12.1 %)      562 (93.1 %)     42 (6.9%)    604




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II-B-7. Reasons for and Determinants of Non-adherence to the
PMTCT program in Rwanda

Authors: Thérèse Delvaux, Batya Elul*, Elevanie Munyana, Felix Ndagije,
         Dominique Roberfroid, Vianney Nizeyimana, and Ruben Sahabo

Background: Until recently, HIV-infected women in Rwanda and their newborns
received single-dose nevirapine (SD-NVP) for PMTCT but in late 2006 more
complex regimens were adopted. In order to inform the roll-out of the new regimens,
we explored reasons for and determinants of non-adherence to the existing NVP
regimen among mother-infant pairs.


Design/methods: As part of a larger evaluation of the PMTCT program at 12 sites in
April-May 2006, we surveyed 111 HIV-infected women who said they and/or their
newborn had not ingested NVP at all or at the recommended time during their last
pregnancy (non-adherent) and 125 women who said they and their child ingested it as
indicated (adherent).At two other sites, in-depth interviews were conducted with 26
HIV-infected women and 11 partners.


Results: Among 111 non-adherent mother-infant pairs, 42% said that neither they nor
their child took NVP, 47% that they did but not their child, 6% that only their child
did, and 5% that they and/or their child did not take it at the recommended time. All
adherent women received NVP from a health worker during pregnancy or delivery,
but only 61% of non-adherent women did despite all consulting ANC at a PMTCT
site. Ultimately, all adherent women (per definition) ingested NVP and 85% of non-
adherent women who received it ingested it. Newborns of all adherent women took
NVP, but only 7% of infants of non-adherent women did. Even among non-adherent
women who delivered in a health facility, only 19% of infants took it. Among the
non-adherent women who delivered at home, only 15% of newborns returned to a
health facility for NVP. Gender norms contributed to men’s unwillingness to bring
newborns to the health facility for NVP when women were unable to do so.
Multivariate logistic regression found that unmarried (vs. married) women and
women with <3 years (vs. ≥3 years) of education were less likely to be adherent.
Women who made <3 ANC (vs. ≥3 visits) and who were offered HIV testing after
(vs. at) their first ANC visit were more likely to be non-adherent. Having an



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uninfected (vs. infected) partner and not disclosing (vs. disclosing) HIV status to
someone aside from a partner were also associated with non-adherence in mother-
infant pairs.


Conclusions: Service delivery factors, gender norms and a lack of social support
contributed to non-adherence to the ARV prophylaxis.




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II-B-8. Suivi clinico- anthropométrique chez les petits enfants co-
infectés par le VIH-1 et le M. tuberculosis traités au TRAC et au
CHU de Kigali
Auteurs: Dr Kayumba Kizito1, Dr Alexandra Peltier2, Umubyeyi Nyaruhirira Alaine3,
        Dr Muganga Narcisse4, Christine Omes5.
1
  Recherches Pédiatriques, Lux-Development, Kigali-Rwanda ; 2Projet ESTHER,
Lux-Development, Kigali-Rwanda ; 3Departement des Sciences et Technologie,
UNR, Butare-Rwanda ; 4Departement de Pediatrie, CHU de Kigali, Rwanda ;
5
  Conseiller Technique Principal, Lux-Development, Kigali-Rwanda.



Contexte
La prise en charge de la co-infection SIDA/Tuberculose requiert l`administration
concomitante des antiretroviraux et des antituberculeux. En pédiatrie, en particulier
chez les enfants de moins de 3 ans (ou moins de 10 kg), à part le problème
d`interaction médicamenteuse entre les ARV et la Rifampicine s`ajoute le manque de
protocole consensuel et le fait que la cinétique d`élimination de l`efavirenz chez ceux-
ci n`est pas bien connue, les études pharmacocinétiques n`ayant pas été menées par la
firme elle-même.
Le Schéma rwandais adopté en présence d`experts pédiatres lors du Symposium
international sur les maladies infectieuses tenu à l`Hôtel Intercontinental en mai
2005 préconise : 2 NRTI+2xdose de NVP. Notre étude a évalué ce schéma chez les
enfants co-infectés et sous traitement ARV et antituberculeux sur le plan clinique et
anthropométrique.


Objectifs spécifiques de l’étude :
-Suivre l`évolution clinique des enfants sous traitements ARV-Antituberculeux
-Suivre l`évolution des mesures anthropométriques (P/T, P/A,T/A)
-Participer au plaidoyer pour une meilleure prise en charge des enfants co-infectés par
le VIH et le M. tuberculosis dans les pays à ressources limitées.


Méthodologie
Il s`agit d`une étude descriptive rétrospective qui a évalué les enfants de moins de 3
ans (ou moins de 10 kg) co-infectés par le VIH-1 et le M. tuberculosis et pris en
charge en Pédiatrie au CHU de Kigali et à la clinique du TRAC. La collecte des



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données à partir des dossiers médicaux a porté sur les paramètres anthropométriques,
cliniques et para cliniques avant le début des traitements et à 1 mois, 3 mois, 6 mois et
9 mois de traitement. La classification pédiatrique clinique de l`infection à VIH a été
utilisée après le test sérologique (et PCR pour les - de 18 mois). Les effets secondaires
ainsi que les décès ont été notés.


Résultats
De janvier 2005 à avril 2006, 46 enfants (22 filles et 24 garçons) ont fait l`objet de
notre étude. 80% de nos patients avaient moins de 24 mois et l`âge moyen était de 19
mois. Au début des traitements, 67% des patients avaient un déficit pondéral grave (<
- 3 Z-Scores) et 65% avaient un déficit statural grave (< -3Z-Scores). 77,6% étaient au
stade 3 clinique VIH de l`OMS, 22,4 % étaient au stade 4. La notion de contage a été
signalée dans 61% des cas, l’Intradermoréaction à la tuberculine a été positive dans
11% des cas, la bacilloscopie positive dans 2 cas. Le type de lésion radiographique le
plus rencontré est l`adénopathie hilaire retrouvée dans 10 cas (21,7% des cas), suivie
des infiltrats diffus retrouvés dans 9 cas soit 19,6 % des cas. Tous nos patients ont
reçu   le   traitement    antituberculeux   (RHZ)    et   le   traitement   antirétroviral
(2NRTI+1NNRTI). Comme effets secondaires, nous avons noté 25 cas de
vomissement, 6 cas d`anémie, 3 cas de rash cutané qui ont nécessité l`arrêt de
Névirapine, 1 cas de pancréatite décédé (amylasémie à 1446 UI/l), aucun cas d`hépato
toxicité n`a été enregistré.
La mortalité dans notre échantillon était de 41 %, 44,4 % des décès ayant survenu
dans le premier mois de traitement. Pour les survivants, la moyenne de Z-scores a
passé de -4,28 à -0,76 après 9 mois pour le poids (p=0,000) et de -4,14 à -2,48 après
9 mois pour la taille (p=0,023).


Conclusion
Le traitement ARVs et antituberculeux ont significativement entraîné le gain pondéral
et statural chez nos patients et n’ont pas causé d’effets secondaires alarmants.
Cependant la mortalité reste élevée suite au retard de diagnostic et de début des
traitements. Le retard pondéral a pu être corrigé dans les 9 mois mais le retard statural
a été difficile à récupérer.




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II-B-9. The SEARCH study: Side effects and reproductive health in a
cohort on HAART

Authors: N. Veldhuijzen1, F. Ndamage2, J. Mugabo2, L. de Naeyer1, E. Geubbels1, 3, J.
Vyankandondera3-4, J. Mugabekazi4, J van de Wijgert1, 3, P. Reiss1.
1
     Center for Poverty-related Communicable Diseases, University of Amsterdam, The Netherlands ;
2
    Treatment and Research AIDS Center, Kigal, Rwandai; 3Projet Ubuzima, Kigal, Rwandai; 4Centre
Hospitalier Universitaire de Kigali, Rwanda.


Responsible Institution: the SEARCH study is part of the INTERACT program
(Infectious Disease Network for Treatment and Research in Africa), a collaboration
between European and African scientists for capacity-building in clinical research
related to HIV, TB and malaria in Rwanda and Uganda. In Rwanda, TRAC is hosting
the INTERACT program. The SEARCH study offers two Rwandan and one Dutch
PhD student the opportunity to obtain their doctoral degree.


Background: Access to antiretroviral therapy (ART) is increasing globally. However,
the impact of highly active antiretroviral therapy (HAART) in terms of clinical
management of the individual patient, on contraceptive behavior, on the incidence of
sexually transmitted infections (STIs) and HIV, and on the gynaecological burden of
disease remains to be evaluated. Furthermore, the incidence of (treatment-limiting)
adverse effects of HAART in both men and women, which in developed countries has
been demonstrated to be the most frequent reason for having to modify treatment, is
still largely unknown.


Objectives: To evaluate the impact of HAART on various aspects of reproductive
health in HIV infected women and men. To assess the incidence of clinically
important adverse effects of HAART in women and men.


Methodology: A prospective observational cohort study with 400 HIV-positive
persons (100 men and 300 women) will be established at the TRAC HIV clinic, and
each participant will be followed for two years. Our recruitment strategies will be
such that all men and about 100 women are eligible to start HAART at cohort
enrollment, while the remaing 200 women are not immediately eligible for HAART
(but may become eligible over time). HAART will be initiated as per the Rwanda



                                                                                            126
national HAART treatment guidelines. Reproductive health outcomes include
(baseline) prevalence and incidence of acute sexually transmitted infections (STI;
such as gonorrhea, chlamydia, syphilis and trichomoniasis), baseline prevalence and
incidence of events associated with chronic reproductive tract infections (RTI; such as
cervical dysplasia due to human papillomavirus (HPV), genital outbreaks of herpes
simplex type 2 (HSV-2), and vaginal flora disturbances), sexual and contraceptive
behavior and (un)intended pregnancies. Overall adverse effects of HAART will be
systematically assessed and the incidence, severity and possible risk factors for
anemia, peripheral neuropathy, lactic acidemia/acidosis, and changes in body fat
distribution (lipodystrophy) will be studied in greater detail.
The protocol has been approved by the National AIDS Control Committee (CNLS)
and is currently being reviewed by the Rwandan Ethics Review Committee.
Preparations are being made for purchasing equipment and for staff trainings. Data
collection is expected to start the first half of 2007.


Conclusion: We hope that this study will contribute to improvements in clinical
management of HIV infected men and women, while at the same time contributing to
increasing the clinical research capacity in Rwanda.




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II-B-10. Evaluation de l’impact                         psychosocial   du    traitement
antirétroviral chez les PVVIH

Auteur/Présentateur : Théonille Mukabarasi, c/o FHI-Rwanda, BP 3149, Kigali, Rwanda. Phone:
(250) 576193 Fax: (250) 574038 Email: theonillem@fhirw.org
Co-auteurs: Mlle Dina Martinez, Dr. Joseph Nzabandora


Contexte
Les personnes vivant avec le VIH sont sujettes aux contradictions internes et aux
relations sociales conflictuelles qui varient en fonction de la progression de l’infection
à VIH. En effet, les bouleversements émotifs, la perte du statut social, les difficultés
de communication liées au secret entourant le statut infectieux au VIH et la remise en
question des grands projets de la vie constituent autant de sources de perturbations
psychologiques et sociales des PVVIH. La détérioration de l’image de soi découlant
des maladies opportunistes et du stress psychologique conduit à la fois à l’isolement
et à la discrimination des PVVIH. Avec les ARV, c’est un retour à la santé qui s’opère
avec le renforcement des capacités physiques et fonctionnelles et des aptitudes
psychologiques.


Objectifs spécifiques de la recherche : Les objectifs spécifiques de la recherche
étaient de comprendre le vécu psychologique, émotionnel et social des PVVIH, de
dégager et expliciter l’impact psychosocial du traitement antirétroviral chez les
personnes vivant avec le VIH.


Méthodologie
La recherche a été menée au Centre Médico-Social de Biryogo qui offre le traitement
antirétroviral depuis février 2003 avec l’appui de FHI-Rwanda sous le financement de
l’USAID. La population mère de l’étude est constituée de 377 personnes vivant avec
le VIH/SIDA sous le traitement antirétroviral depuis au moins douze mois au 31 mai
2006 ; période jugée suffisante pour mesurer le changement attribuable aux ARV. Les
patients sont âgés de 15 ans et plus. La taille de l’échantillon a été déterminée par
échantillonnage systématique allant de 1 à 40% de la population mère de l’étude.
Ainsi 120 unités représentant 32% de la population mère ont été retenues. En fixant le
pas d’échantillonnage à 3, les 120 unités constituant l’échantillon ont été tirées parmi
toutes les unités de la population mère. Un questionnaire standard a été administré à


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chacun d’entre elles et des discussions de groupe dirigées organisées pour collecter
des données qualitatives afin de compléter et enrichir les données quantitatives. La
collecté des données a duré 15 jours.


Principaux résultats
L’âge moyen des enquêtés est de 41 ans. La grande proportion sont des veufs (44%)
et les femmes en représentent 40,8%. 71,7% indiquent que les jours suivant la
connaissance de la séropositivité au VIH ont été caractérisés par l’attente de la mort.
73,3% ont déclaré que leur vécu psychologique a été assombri par les périodes de
maladies, 46,7% par l’assistance à la mort atroce des autres PVVIH. Le rejet et
l’isolement par la famille et les amis ont frappé 78,8% et 75,6% par les attitudes
discriminatoires dont l’étiquette de sidéens maudits et fantômes. Les enquêtés à
travers les discussions de groupes ont déclaré que pour pouvoir composer avec leur
nouveau statut, ils recourent à d’autres nouvelles formes de solidarité notamment en
se retournant vers des personnes qui vivent les mêmes conditions : les autres PVVIH.
Concernant l’amélioration de la qualité associée aux ARV, 72,5% signalent la
réduction des maladies opportunistes, 50%         déclarent la recouverte de la force
physique. Elle est traduite par l’augmentation des CD4 et le gain du poids corporel
soulignés respectivement par 71,2% et 46,7% des enquêtés. %. La reconquête de
l’image de soi, du statut social ravive l’instinct de conservation. Les résultats des
discussions de groupe dégager la participation active des PVVIH à leur traitement qui
se mesure à travers les informations dont elles disposent sur l’évolution de leur état de
santé notamment l’augmentation des CD4 et le gain du poids corporel.
L’épanouissement psychologique traduit par l’espoir de vivre plus longtemps et la
reconquête de la confiance en soi sont respectivement indiqués par 64,2% et 41,7 Les
manifestations de la réinsertion sociale sont notamment la capacité de travailler et la
considération sociale citées respectivement à 85% et 38%.


Conclusion
La séropositivité au VIH affecte profondément la vie psychosociale des personnes
infectées par le VIH. La stigmatisation et la discrimination persistent et empêche les
PVVIH d’une certaine catégorie sociale de se dévoiler. L’amélioration de la qualité de
la vie par le traitement antirétroviral attenue le stress psychologique et contribue à la
réinsertion sociale des PVVIH. L’efficacité des traitements antirétroviraux et leur


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impact sur les conditions socio-économiques des individus, des ménages et de la
société justifient le combat pour l’accès universel aux ARV afin de donner des
chances de survie aux personnes vivant avec le VIH/SIDA surtout celles vivant dans les
pays à ressources limitées. Des interventions concrètes répondant aux défis liés au
traitement antirétroviral notamment les effets secondaires y compris la modification
de l’apparence physique doivent être initiées pour ne pas compromettre l’adhérence
au traitement jusque là très bonne.




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II-B-11. Evaluation de l’adhérence et de l’efficacité virologique des
principaux régimes de trithérapie antiretrovirale à la clinique CHUK
adulte

Auteurs :
Marie-ange Limberger¹ ; Vic Arendt 1 ; Olivier Courteille2 ; Julie Mugabekazi2;
Gilles Ndagayisaba¹ ; Nathan Makombe³ Christine Omès¹;
1
  Lux-development ; 2CHUK - 3LNR

Contexte
Les premiers traitements antirétroviraux ont été introduits à la clinique du CHU de
Kigali dès 2002. Les patients sont tous actuellement sous des trithérapies différentes,
certaines suite à l’échec d’une première combinaison de traitement. Il est important de
faire un état des lieux de l’efficacité de ces différentes combinaisons dans la cohorte
actuelle, dans le souci d’optimiser la qualité de la prise en charge à la clinique du
CHUK*


Objectifs spécifiques de l’étude :
   -   Evaluer l’efficacité virologique des différentes combinaisons de traitement
       antirétroviral à la clinique du CHUK
   -   Evaluer l’efficacité des traitements antirétroviral en fonction de l’adhésion du
       patient au traitement
   -   Evaluer la performance de la définition immunologique d’échec en
       considérant la CV< 40 comme gold standard (Amplicor, Roche)


Méthodologie
Sont inclus tous les patients sous combinaison d’antirétroviraux depuis plus de 6
mois et ayant un suivi régulier à la clinique du CHUK et se présentant à leur rendez-
vous durant la période d’études. La période d’étude s’etend de début février 2006 à
fin mars 2006, soit 2 mois d études. Il s’agit d’une étude transversale, analytique. On
définit un échec virologique pour tout patient détectable (> 40 copies/ml). L’échec
immunologique est, quand à lui, défini par un CD4 < au CD4 base line ou CD4 <
50% du pic value
Chaque patient inclus dans l’étude a reçu un counselling au cours duquel un
questionnaire d’adhésion a été rempli : l’oubli d’une dose mensuelle minimale est



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considérée comme le reflet d’une mauvaise observance. Durant cette visite, les CD4
et la charge virale ont été prélevés. L’encodage des données ainsi que l’analyse
statistique a été fait en utilisant les logiciels Access 2003 et épi info 2004.


Résultats
193 patients adultes (<18ans) sont inclus dans l’étude.
L’échec virologique: 25,2% (mais 18,2% de cv > 1000) dont 25,4% en 1ère ligne (2
NRTI + 1 NNRTI) et 26% en 2ème ligne (2 autres NRTI + 1 AP). Pas de différence
significative (p> 0,05) d’efficacité des différentes combinaisons de traitements
La différence entre les patients ayant une mauvaise observance versus une bonne
observance, en échec virologique (41,6% sur 24 patients versus 59,6% sur 162), est
significative (p=0,048), donc il existe une corrélation entre mauvaise observance et
échec du traitement.
Par contre la différence entre les patients, non observants ayant des effets secondaires
et les patients observants     malgré la présence d’effets secondaires (96% sur 25
patients versus 81,5% sur 168) n’est pas significative (p>0,05) donc la mauvaise
observance n’est pas liée aux effets secondaires.
La définition de l’échec immunologique a une sensibilité basse de 38,2% des cas par
rapport à la cv (sur 186 patients) mais la spécifité est plutôt bonne (87%). Dans 75,2%
des cas, les échecs et succès immunologiques correspondent aux échecs et succès
virologiques donc la performance globale des CD4 comme indicateur de suivi de ttt
est plutôt bonne. Cependant, la valeur prédictive positive de l’échec immunologique
par rapport au gold standard de la charge virale est de 48,5%.


Conclusion:
    -   Les taux d’échec en première et deuxième ligne sont équivalents et rejoignent
        les taux retrouvés dans la plupart des études ailleurs en Afrique. Il y a une
        nette amélioration de la prise en charge par rapport aux taux d’échecs
        retrouvés en 2002 (43% d’échec sur 60 patients).
    -   Il n’y a pas de différence d’efficacité en première ligne entre NVP et EFV
    -   La mauvaise observance        est un facteur d’échec au ttt d’où l’intérêt de
        renforcer le counselling
    -   Les effets secondaires ne sont pas un facteur de mauvaise observance



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-   Si on se basait sur la définition de l’échec immuno pour changer le ttt, on
    changerait de traitement dans 48,7% des cas de manière abusive ; Il serait
    donc moins coûteux d’effectuer une cv chaque fois qu’on a une suspicion
    d’échec immuno avant de changer de combinaison d’antirétroviraux.




                                                                           133
II-B-12. Evaluation de l’adhérence et de l’efficacité virologique des
principaux régimes de trithérapie antiretrovirale au TRAC/CHUK
chez les enfants

Auteurs
Marie-Ange Limberge; Jules Mugabo ; Gilles Ndayisaba ; Olivier Courteille ;
Nathan Makombe ; Christine Omès; Tharcisse Muganga ; Sebahumgu Fidèle ;
Alexandra Peltier
Lux-development ; CHUK ; LNR ; TRAC

Contexte
Les premiers traitements antirétroviraux ont été introduits au Rwanda dès 2002. Les
patients sont tous actuellement sous des combinaisons d’antirétroviraux de 1ère et de
2ème ligne. Il est important de faire un état des lieux de l’efficacité de ces différents ttts
dans la cohorte pédiatrique afin de noter s’il existe une différence de prise en charge
entre les adultes et les enfants. Les enfants de cette étude ont eu leur ttt initié au
CHUK pour la plupart et un suivi effectué par le TRAC ou la clinique du CHUK


Objectifs spécifiques de l’étude :
    -   Evaluer l’efficacité virologique des différentes combinaisons de traitement
        antirétroviral à la clinique du CHUK
    -   Evaluer l’efficacité des traitements en fonction de l’adhésion du patient au
        traitement
    -   Evaluer la performance de la définition immunologique d’échec en
        considérant la CV< 40 comme gold standard.


Méthodologie
Concerne des patients <15 ans, sous combinaison d’antirétroviraux, depuis > 6 mois
qui se sont présentés à leur rendez-vous durant la période d’étude. Celle-ci s’est
étendue de mi-juin 2005 à fin mars 2006. Il s’agit d’1 étude transversale descriptive
Chaque enfant inclus dans l’étude a eu son counselling au cours duquel un
questionnaire d’adhérence a été rempli, par l’accompagnant adulte de l’enfant, l’oubli
d’une dose mensuelle minimale est considérée comme le reflet d’une mauvaise
observance. Dans le même temps, CD4 et charge virale ont été prélevés. L’encodage
des données ainsi que l’analyse statistique a été fait en utilisant les logiciels excel
2003 et épi info 2004.



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L’échec virologique est défini, dans la présente étude, comme une charge virale < 40.
L’échec immunologique est défini comme retour CD4 < ou = au base line, ou < 50%
du pic value.


Résultats : 62 patients étaient inclus dans l’étude.
Sur 51 patients possédant des cv, l’échec virologique global selon notre définition
d’échec, est de 37% (mais 21% des charges virales sont > 1000cp/ml), exclusivement
en 1ère ligne puisqu’un seul enfant reçoit un traitement de 2ème ligne, qui n’est pas en
échec. Il n’existe pas de différence significative (p>0,05) d’efficacité de ttt en 1ère
ligne entre nvp et efv (respectivement 44% d’échec sur 29 patients versus 26,3% sur
19)
      -   Pour 50 enfants, La différence entre les patients ayant une mauvaise
          observance versus une bonne observance, en échec virologique (22% sur 9
          versus 41% sur 41), n’est pas significative (p=0,24 sur test Fisher), donc il ne
          semble pas exister de lien établi entre mauvaise observance et échec
          virologique chez l’enfant. Il s’agit sans doute d’une mauvaise évaluation de
          l’observance du patient. Le questionnaire, qui a été rempli par les tuteurs des
          enfants, n’est pas forcément le reflet de la véritable observance de l’enfant.


La différence entre les patients adhérant mal au ttt et ayant des effets secondaires et
les patients ayant une bonne adhérence au ttt malgré la présence d’effets secondaires
n’est pas significative (p>0,05) (respectivement 26 versus 5 sur 58 patients) donc la
mauvaise observance n’est pas liée aux effets secondaires.
Comme aucun des patients n’est en échec immuno, on ne peut établir la sensibilité de
la définition de l’échec immunologique par rapport à l’échec virologique, ni comparer
les 2 types d’échec.
Spécificité : 100% =23 sont à la fois en succès immunologique et virologique
la performance globale ne peut être établie, en absence de l’évaluation de la sensibilité
des CD4.


Conclusion:
      -   Les taux d’échec au ttt retrouvés chez les enfants en 1ère ligne sont de 37%
          (versus 25,4% chez les adultes, mais seulement de 21% (versus 18,5% chez
          les adultes) si l’on considère la cv >1000.


                                                                                           135
-   Il n’y a pas de différence d’éfficacité de traitement retrouvé entre les 2 NNRTI
    recommandés en régime de 1ère ligne au Rwanda après 6 mois de traitement
    antirétroviral.
-   Il ne semblerait pas y avoir de lien entre échec au ttt et mauvaise adhérence
    (contrairement aux adultes) mais il faut réfléchir à ce type de résultat associé à
    un taux d’échec de 37% ;
-   Les effets secondaires ne sont pas ici un facteur de mauvaise observance.
-   Les données ne sont pas assez parlantes pour comparer l’indicateur CD4 et
    l’indicateur charge virale dans le suivi du ttt.. On peut juste noter qu’aucun des
    enfants en échec virologique, au vu des CD4, ne semble avoir atteint le niveau
    d’échec immunologique, ce qui plaide en faveur de l’utilisation de la charge
    virale comme indicateur d’échec au traitement antirétroviral.




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II-B-13. Suivi des adolescents infectés par le VIH, annonce du
diagnostic et préparation à la vie adulte. Expérience de deux cohortes
d'adolescents

Auteurs : A. Mujawamariya1 A. Waelbrouck3, A. Peltier1-3, J. Niyibizi4, E. Havuga1, V. Arendt2,
S. Wibaut1, C. Omes1
1
  Projet ESTHER Luxembourg, Lux-Development ; 2Maladies infectieuses, CHL,
Luxembourg, Luxembourg ; 3Pédiatrie, CHU Saint Pierre, Bruxelles, Belgique ;
4
  TRAC, Ministère de la santé du Rwanda, Kigali, Rwanda


Contexte
Description de deux cohortes d'adolescents suivis respectivement au CHU St Pierre et
à Kigali afin d'améliorer la formation dans le domaine de la prise en charge des
adolescents infectés par le VIH pour lesquels un suivi adapté reste insuffisant dans les
pays à ressources limitées ainsi que dans les pays industrialisés.


Méthodes
Au CHU St Pierre, 127 enfants infectés par le VIH (transmission verticale) sont suivis
dans le Service de Pédiatrie dont 80% ont un âge>10 ans. Une méthode pédagogique
avec dessins, CD-ROM et Bande dessinée crées au CHU St Pierre ont permis de
développer un dialogue facilitant l'annonce du diagnostic et d'aborder les questions de
sexualité avec les enfants et les adolescents. Les équipes multidisciplinaires prêtes à
suivre des adolescents sont encore peu développées. La recherche dans le domaine du
métabolisme des antirétroviraux chez l'adolescent et une approche globale doit
absolument se développer au niveau international. A la clinique du TRAC, à Kigali,
1330 jeunes patients (< 24 ans) sont suivis dont 43% ont moins de 19 ans


Résultats
La charge virale est indétectable chez 78% des adolescents suivis au CHU St Pierre
(naïfs et exposés) où ont été développés des outils didactiques pour faciliter l'annonce
du diagnostic. Au TRAC (Kigali), 376 enfants ont reçu l'annonce de leur diagnostic
avec ces outils et 285 adolescents participent à des groupes de soutien suite à cette
annonce. 12 conseillères ont été formées à cette prise en charge spécifique et vont
former au niveau des districts d'autres conseillères travaillant en région rurale dans les
centres distribuant les antirétroviraux.



                                                                                          137
Conclusion
Des outils de communication permettent d'améliorer le suivi des adolescents dans les
pays industrialisés et dans les pays à ressources limitées mais une formation et des
outils complémentaires sont indispensables pour améliorer le suivi et la transition des
adolescents vers la vie adulte. Un encouragement à la spécialisation en suivi
d'adolescents permettra d'améliorer les possibilités des équipes pédiatriques et adultes
à faire face aux problèmes de santé publique que constituent les adolescents infectés
par le VIH.




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II-B-14. Valeurs de référence, selon l’âge des lymphocytes CD4.
Etude menée au Rwanda chez des enfants non-infectés nés de mères
séropositives pour le VIH

Auteurs : Rutanga Claude1, Ndimubanzi C. Patrick1, Ndayisaba Gilles1, Ndamage François2,
Havuga Emmanuel1, Dhont Nathalie1, Omes Christine1, Peltier C. Alexandra1
1
Projet ESTHER Luxembourg, Lux-Development
2
 Treatment and Research Aids Center, Ministère de la santé Rwanda, Kigali,
Rwanda

Introduction
La numération des CD4 a fait l’objet de nombreuses études et dans les populations
caucasiennes les valeurs de références ont déjà été établies, même en Pédiatrie.
Nos données sont recueillies dans le cadre de l’étude AMATA, dans laquelle les
femmes enceintes séropositives font le choix de l’allaitement artificiel ou de
l’allaitement maternel sous trithérapie.


Objectif
Décrire l’évolution des lymphocytes CD4 chez des enfants de 0-7 mois non-infectés
exposés au VIH.


Méthodologie
Les femmes enceintes séropositives pour le VIH reçoivent une information sur le
PTME, et sur l’étude AMATA. Celles qui donnent leur consentement sont enrôlées à
partir de la 28ème semaine d’aménorrhée et mises systématiquement sous trithérapie
antirétrovirale.
Endéans 72 heures de vie et au cours des suivis, une DNA-PCR et une numération des
CD4 sont effectuées chez tous les nourrissons. Ils sont revus en consultation à 15 et
45 jours de vie ainsi qu’à 3 et 7 mois d’âge. Les CD4 sont exprimés en valeurs
absolues et en pourcentage.


Résultats
Il s’agit d’une étude prospective sur 521 nourrissons dans 4 centres de santé au
Rwanda.
Au jour 1, (n=260), la médiane des pourcentages de CD4+ est 54% (5-95ème percentile
étant 37%-67%) et la moyenne des valeurs absolues des CD4+ est 1712 [164-5736].




                                                                                    139
40 nouveaux nés (soit 7,7%) dont la DNA-PCR est négative ont des valeurs de CD4
inférieures à 1000.
Au jour 15, (n=262), la médiane des pourcentages des CD4+ est 50% (5-95ème
percentile étant 31%-62%) et la moyenne des valeurs absolues des CD4+ est 2430
[407-7065].
Au jour 45, (n=304), la médiane des pourcentages des CD4+ est 41% (5-95ème
percentile étant 24%-56%) et la moyenne des valeurs absolues des CD4+ est 2151
[862-5776].
A 3 mois (n=134), la médiane des pourcentages des CD4+ est 37% (5-95ème percentile
étant 25%-49%) et la moyenne des valeurs absolues des CD4+ est 2071 [326-8202].
A 7 mois (n=179), la médiane des pourcentages des CD4+ est 38% (5-95ème percentile
étant 22%-52%) et la moyenne des valeurs absolues des CD4+ est 2241 [614-6236].


Conclusion
Les valeurs moyennes des CD4 chez les enfants rwandais ne diffèrent pas de celles
des autres populations. Par ailleurs, on note aussi une variabilité des valeurs de ces
lymphocytes chez un même enfant.




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II-B-15. Estimating HIV incidence in high-risk women in Kigali in
preparation for microbicide trials: recruitment update and first
results

Authors: E Geubbels1,2, C Ingabire1, S Braunstein3, M Umulisa1, J Ntirushwa1, K Ford1, E Gahiro1,
C Tuijn2, M Sadat4, J Vyankandondera1, J van de Wijgert1,2.
1
  Projet Ubuzima; 2Center for Poverty-related Diseases, University of Amsterdam; 3Columbia
University, New York; 4 International Partnership for Microbicides

Context: No current information on HIV incidence in high-risk women (HRW) is
available in Rwanda. This is critical information for the design of a microbicide
efficacy trial, in terms of planning the study sample size and recruitment strategy.
Information on incidence, in addition to prevalence, is also important for tracking the
HIV epidemic in Rwanda.


Objectives: To include 800 HRW in Kigali in a cross-sectional survey and among
these, to include 400 HIV-negative HRW in a cohort that will be followed for one
year to determine incidence of HIV and prevalence and incidence of other sexually
transmitted infections (STIs). The recruitment strategy and early results of this study
are described in this abstract.


Methodology: Contacts were made with local authorities of imidugudu (“villages”) in
Kigali with a high concentration of women at high risk for HIV, many of whom are
sex workers. In collaboration with local authorities and our community advisory
group, community mobilisers (CMs) were identified, who live in each of the
imidugudu. CMs invite the HRW in their umudugudu to recruitment sessions where
the study procedures and eligibility criteria are explained. Eligibility criteria are being
18 years or older, being willing and able to give informed consent, not having
received an HIV positive test result before, not participating in another HIV
intervention study and being at high risk for HIV infection, as defined by having
exchanged sex for money at least once in the last month and/or currently having sex
with multiple partners and having sex at least twice per week. Interested HRW come
to Projet Ubuzima’s research clinic for eligibility screening, informed consent,
counseling, free condoms, HIV and HSV-2 testing and an interview about sexual and
other risk behavior for HIV infection. HIV-negative women who are enrolled in the
cohort are also tested for other STIs.



                                                                                            141
Results: The collaboration with local authorities and CMs has been very pleasant and
productive. From the start of the study in October 2006 until end January 2007, 675
HRW attended 19 recruitment sessions. 375 women came to our clinic, of whom 347
were included in the cross-sectional survey. The majority of these HRW self-
identified as sex workers, with their average number of clients per week ranging from
1 to 21. The majority of sex workers said they used condoms with clients ‘often, but
not all of the time’. Condom use with steady partners was low. The overall HIV
prevalence was 24% and 60% of women were found to be positive for HSV-2. Per
end January 2007, 167 HRW had enrolled in the prospective cohort. At entry into the
cohort, prevalence of syphilis and trichomoniasis was 6% and 12% respectively.


Conclusion: In close collaboration with local authorities and community mobilisers it
is possible to successfully recruit women at high risk of HIV infection in Kigali,
Rwanda. The HIV prevalence among our currently enrolled HRW participants who
have never had a positive HIV test result before is almost 4 times as high as the most
recent   estimate   of   the   prevalence   in   the   general   female    population




                                                                                  142
II-B-16. Women’s experiences with HIV testing during antenatal
care in Rwanda


Authors: Batya Elul, Felix Ndagije, Dominique Roberfroid, Thérèse Delvaux,
Elevanie Munyana, Vianney Nizeyimana*, and Ruben Sahabo

Background: Prevention of mother-to-child transmission (PMTCT) services have
scaled up rapidly in Rwanda since 2001. As part of those services, women are offered
voluntary HIV counseling and testing at their first ANC visit and counselors
encourage testing of their partners. Little is known, however, about how women
experience these services.


Design/methods: As part of a larger evaluation of the PMTCT program conducted at
12 sites in April-May 2006, we surveyed 236 HIV-infected and 162 uninfected
women who received ANC and were tested for HIV during their last pregnancy. At
two other sites, in-depth interviews were conducted with 26 HIV-infected women and
10 post-test counseling sessions were observed.


Results: Most women (~80%) knew that they would be offered HIV testing as part of
their ANC and 92% said they were offered it at their first ANC visit, with no
difference by HIV status. Reports of “pressure” to get tested were restricted to 12-
15% of women, with no difference by HIV status. During qualitative data collection,
however, several women noted being tested without their consent or being threatened
with reduced access to labor and delivery services if they declined testing. Qualitative
data also suggest that health workers were ill equipped to deal with women’s
substantial psychological needs when results indicated they were HIV-infected and
that discussion of women’s ability to share their test results with family members
and/or the existence of social networks for PLWHA was minimal. HIV-infected (vs. -
infected) women were significantly less likely to disclose to their partners (84% vs.
96%) and more likely to share results with someone else (73% vs. 61%). Forty-seven
percent of partners of infected women and 61% of partners of uninfected women were
tested during the index pregnancy. Ultimately 40% of all infected women and 19% of
all uninfected women were unaware of their partner’s HIV status, and sero-




                                                                                    143
discordance was reported by 21% of HIV-infected women and 3% of HIV-uninfected
women.
Conclusions: More than five years since the rollout of the Rwandan national PMTCT
program, access to and uptake of HIV testing during ANC remain commendably high.
Additional training, however, is needed to ensure that health workers obtain
meaningful consent from all women and are able to deal adequately with women’s
psychological needs when they learn they are HIV-infected, including offering them
appropriate referrals to PLWHA associations.




                                                                              144
II-B-17. Preliminary outcomes of patients receiving supervised
antiretroviral therapy in rural Rwanda
Auteurs: Epino HM1, Niyigena P1, Karamaga A1, Uwimana Y1, Mbyamu R1, Stulac SN1, Mukherjee
JS2,3, Farmer PE2,3, Rich ML2,3

1.Partners In Health, Boston, MA, USA, and Inshuti Mu Buzima, Rwinkwavu and Kirehe, Rwanda.
2.Department of Social Medicine, Harvard Medical School, Boston, MA, USA.;
3. Division of Social Medicine and Health Inequalities, Brigham and Women's Hospital, Boston, MA,
USA.


Geographic location of the project: Rwinkwavu Hospital, Kirehe Hospital, Rukira
Health Center, Mulindi Health Center, Nyarubuye Health Center, and Rusumo Health
Center, in Kayonza and Kirehe Districts, Rwanda


Project description and characteristics of the beneficiaries:
Limited data are available on outcomes of highly active antiretroviral therapy among
poor, rural communities. We report on preliminary outcomes of the first cohort of
patients to be enrolled in supervised antiretroviral therapy from primary care clinics in
rural, southeastern Rwanda.


Context/Problem statement:
Worldwide, 42 million people are living with HIV infection; an estimated 6.5 million
need antiretroviral therapy (ART). Methods of rapid enrolment and rigorous follow-
up must be established, often in regions bereft of basic health services. We describe
the preliminary outcomes of a project to provide comprehensive health services
through public institutions in an HIV-affected region of rural southeastern Rwanda.


Study objective (s):
This is a prospective cohort study of 1,938 HIV-positive patients initiating ART
between June 2005 and February 2007. The treatment package included nutritional
support, daily visits from an accompagnateur to supervise therapy, provide social
support, and evaluate the patient for opportunistic infections or serious adverse
events. Age, CD4, sex, and weight were all recorded at baseline; weights were
recorded monthly after treatment initiation and CD4 was recorded again at 6 and 12
months. Accompagnateurs visited patients on a daily basis and referred them for
hospitalization when indicated.


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Results:
67,137 people were referred for VCT for HIV at 6 sites in southeastern Rwanda.
Amongst the HIV-positive, tuberculosis was diagnosed in 391, and 1,938 patients
initiated ART. The mean CD4 count for adults at treatment initiation was 237.1 ±
168.3. Mean adult baseline weight was 53.6kg ± 8.3.           1,580 (81.5%) patients
received fixed dose combination stavudine, lamivudine, nevirapine twice daily.
During the study period, 29,280 food baskets were distributed. Among adults at
twelve months, CD4 levels had increased by a mean of 161.5 and the mean weight
gain was 4.7kg. During the study period, 59 patients on ART (3.0%) died.


Conclusion/Lessons learned:
Ambulatory delivery of ART in poor rural communities in Africa is feasible.
Accompagnateurs can assure the delivery of therapy with excellent adherence. The
model of care, which includes nutritional support, can result in rapid weight gain and
improved immunological status among patients receiving ART.




                                                                                  146
II-B-18. Problématique de la prise en charge psychologique des
couples discordants à l’infection à VIH

Auteurs :
Majyambere Adolphe, TRAC, Dr Dusingizemungu Jean Pierre, UNR.


Introduction
Lorsque l’on considère le nombre de couples testés en milieu urbain du Rwanda, les
statistiques montrent que, entre les couples dont l’un des partenaires est séropositif et
les couples des conjoints infectés par le VIH/SIDA, il n’y a pas de grand écart en
termes de statistiques puisque sur 100 couples testés, 10 sont concordants positifs et
10 autres sérodiscordants et 80 sont séroconcordants négatifs.
L’annonce et la réception du résultat sérodiscordant chez les couples constituent la
situation la plus délicate dans le test du VIH/SIDA. Cette annonce est suivie par des
réactions diverses et dans la plupart des cas ayant des répercussions sur le vécu
psychoaffectif et amoureux des conjoints. Certains manifestent d’intenses émotions
tel que la colère, la tristesse, le chagrin, la crainte de la séroconversion, de l’infection,
de la maladie et de la mort. On observe dans la suite, des sentiments de perte,
d’abandon, de méfiance, d’impuissance et d’inutilité. Le stress et la mésentente
causés par     l’utilisation perpétuelle du préservatif et dans de nombreux cas,
l'incapacité de son utilisation correcte et régulière dans les rapports sexuels sont
souvent les causes majeures de la crainte de l’infection du conjoint séronégatif. Ceux-
ci constituent une source de tensions et de conflits incessants dans la relation
conjugale. Certains couples arrivent à des séparations, séparation de corps, voire
même des divorces. Toute cette problématique nous a poussés à effectuer une étude
qualitative qui avait les objectifs suivants:


Objectifs
    1. Relever les problèmes psychosociaux causés par la discordance à l’infection
        à VIH/SIDA chez les couples.
    2. Identifier les structures qui s’occupent de la prise en charge psychologique
        des couples discordants et les moyens dont elles disposent.
    3. Identifier les stratégies politiques proposées en matière de prise en charge des
        couples discordants à l’infection à VIH/SIDA au Rwanda.




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    4. Proposer des approches psychothérapeutiques pour une meilleure prise en
        charge des couples discordants à l’infection à VIH/SIDA.


Méthodologie
Pour pouvoir répondre à ces objectifs nous avons mené une étude qualitative .La
nature de cette étude nous a poussé à penser à une méthodologie permettant à
recueillir les données recherchées et proposer une esquisse        de prise en charge
psychothérapeutique en faveur de ces couples et leurs familles.
Ainsi un échantillon de huit couples sélectionnés dans la clinique du Centre de
Traitement et de Recherche sur le VIH ont répondu à notre entretien approfondi.
Les informations recueillies auprès des couples ne permettaient pas de répondre à
toutes les questions que nous nous posions, ainsi un autre entretien a été mené auprès
des conseillers qui font partie de l’équipe psychosociale de ladite clinique .En fin ,
un autre entretien a été fait auprès des autorités qui s’occupent de mise en place des
politiques et des stratégies des interventions auprès des personnes infectées et /ou
affectées par le VIH/SIDA .Après la récolte des données ,grâce à la méthode de
l’analyse thématique de contenus ,nous avons abouti aux résultats suivants :


Résultats obtenus
Nous avons remarqué que les couples sérodiscordants se heurtent à des problèmes
d’ordre médical, psychologique et social. Plus particulièrement les conjoints des
couples discordants à l’infection à VIH connaissent beaucoup de perturbations au
niveau émotionnel et sexuel. Néanmoins, la prise en charge psychologique de ces
couples présente des lacunes liées à l’insuffisance des connaissances en matière
d’interventions psychologiques et des ressources humaines et matérielles de la part
des formations sanitaires. La prise en charge psychologique des couples en général et
celui des couples discordants en particulier en tant qu’approche spécifique n’est pas
encore instituée dans les structures sanitaires du Rwanda. Les stratégies politiques
envisagées dans ce domaine portent essentiellement sur la sensibilisation des couples
aux conseils    et au dépistage volontaire et le renforcement des capacités des
intervenants en matière de lutte contre le VIH/SIDA en général au niveau des
formations sanitaires et des services de soutien à base communautaire.




                                                                                  148
Conclusion
La prise en charge des personnes vivant avec le VIH en général et celle des couples
sérodiscordants en particulier exige une intervention multidisciplinaire, c’est-à-dire
une prise en charge biopsychosociale, et la spécificité de chacun devra être prise en
considération. La prise en charge psychologique des couples sérodiscordants au
Rwanda se limite au counselling en tant qu’approche psychologique. Cependant,
d’autres approches d’intervention psychothérapeutiques devraient être envisagées
pour aider et accompagner ces couples qui vivent des situations très contraignantes.
La promotion du counselling et dépistage volontaires des couples comme approche
spécifique constituerait une étape importante non seulement pour la prévention de la
propagation du VIH chez les couples mais également pour la prévention des conflits
intrafamiliaux liés au VIH. Cette approche constituerait aussi une base solide pour la
prise en charge globale des personnes vivant avec le VIH.




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II-B-19. Supervision Formative de la fiabilité des données et feedback
des services VCT, PMTCT, ARV au Rwanda : Fiabilité des données

Auteurs : Mukandori.D (M&E Unit, TRAC), Scialfa T (Tulane University), HAJABASHI, J.
(M&E Unit, TRAC)


Contexte
Le nombre de sites VCT, PTME et ART a augmenté de (129 à 228), de (120 à 209)
et de (33 à 84) respectivement entre janvier 2004 et décembre 2005. Le TRAC doit
assurer la fiabilité et la validité des données y provenant. Lors des visites de
supervision et pendant le traitement des données provenant des sites, les unités de
PMTCT, VCT, ART et ICT ont constaté des lacunes en rapport avec ces données.
Elles ont aussi mentionné leur souci relatif à la difficulté d’assurer le feedback ainsi
q’une bonne qualité des services vis-à-vis de l’accroissement rapide des sites.


Objectifs
(1) Déterminer le niveau de la fiabilité des données provenant des rapports mensuels
(RM) confectionnés par les sites et les mêmes données agrégées dans les bases de
données du TRAC (2) Déterminer le niveau d’effort nécessaire de confectionner les
rapports mensuels (3) Fournir un feedback et déterminer les capacités des prestataires
d’interpréter et d’exploiter leurs propres données (4) Collecter les rapports mensuels
manquants.


Méthodologie
La supervision avait des composants qualitatif et quantitatif : une hybride d’un audit
des données et une évaluation formative, transversale. La collecte des données a eu
lieu entre le 10 octobre 05 et le 05 décembre 05 dans 68 sites où il y a des services
PTME (n=60), VCT (n=62) et ARV (n=24). L’échantillonnage a été raisonné basé
sur (a) nombre de RM manquant (b) perception de la qualité des données et des
services aux sites (c) ≥ 1 site pour chaque partenaire international œuvre dans le VCT,
PTME, ART (d) une bonne distribution géographique. Nous avons élaboré un outil
de supervision organisé en 6 composantes y compris 1) Assurance de qualité, 2) Type
et Source de données (TSD), 3) Format/contenu de TSD, 4) Confection des RM, 5)
Feedback, 6) Fiabilité des données. L’outil a été rempli par observation, calcul et
entretiens avec les prestataires.    L’analyse suivait les normes de la recherche


                                                                                    150
qualitative formelle sauf l’aspect quantitatif pour déterminer le niveau de fiabilité
(comparaison d’un RM confectionné et octroyé par le site avec ce re-confectionné par
l’équipe de supervision sur place). A la fin de la visite de chaque site, il y avait une
séance facilitant avec les prestataires au cours de laquelle les résultats de la
supervision étaient discutés ainsi que le feedback sous forme graphique de l’évolution
des indicateurs de leur site des résultats provenant des bases de données du TRAC.


Résultats
La fiabilité des données dans environs 50% des sites VCT, 66% des sites PTME et
38% des sites ART était excellente (aucune discordance entre les 2 RM). Pour les
sites avec une discordance, les erreurs sont légères et aléatoires. Il y a 6 TYPES de
sources de données pour le VCT au Rwanda ; la majorité des sites utilisent 4 TYPES
et 4 à 6 SOURCES de données (min 3, max 15) pour confectionner leur RM. En
PTME, pour la seule composante de CPN, il y a 7 TYPES de sources de données ; la
majorité des sites utilisent 4 à 6 TYPES et 4 à 6 SOURCES (min 3, max 12) pour
confectionner leur RM. En ART, il y a 23 différents TYPES de sources de données
dans le Pays mais un site ne dépasse pas 9 TYPES pour confectionner un RM. La
perception des prestataires vers la confection des RM est (1) le VCT est facile (2) le
PTME exige beaucoup d’attention suite au 4 composantes et (3) ART est difficile. A
peu près 70% des prestataires pouvaient lire et interpréter le feedback sous forme
graphique sans nécessiter des explications et de l’aide.


Conclusion/Recommandations
Tous les prestataires ont montré une grande volonté d’assurer une bonne fiabilité. Les
nombres des différents TSD utilisés pour confectionner leurs RM est une facture
contribuant aux erreurs de fiabilité; la correction des erreurs exige une supervision
formative régulière et, surtout, une simplification et une standardisation des TSD. La
fiabilité, le feedback et l’interprétation des données devaient être prise en compte lors
de toutes les supervisions. La majorité de prestataires peuvent lire et exploiter leurs
données ; donc il ne faut pas nécessairement attendre une formation pour y amener le
feedback. Désigner ou embaucher des personnes chargées de la gestion des bases de
données dans les différents hôpitaux et centres de santé et améliorer les systèmes
d’archivage d’information.



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II-C: EPIDEMIOLOGIE ET PREVENTION




                                    152
II-C-1. Enhanced Syndromic Management of STIs in Sex Workers:
A Dual Opportunity for Service Provision and Prevention of HIV
Authors : Livinus Bangendanye*, Cyprien Niyonteze*, Jessica E. Price*, Waldina
Martinez**, Chantal Wakaganda**, Florence Uwamariya**, Bellancille
Mukamurara**, Béatrice Niyoyita**

*Family Health International-Rwanda; **Centre Médico-Social Biryogo.

Context/Background: Presence of an STI increases the risk of transmission of HIV
and evidence from multiple studies show that effective prevention and treatment of
curable STIs is an effective HIV prevention strategy at the individual level. The
impact of STI management on HIV transmission is especially important in
populations where STIs are highly prevalent, including in female sex workers. In
Rwanda, however, services targeting these women are limited. In this presentation,
we describe an intervention to provide STI management and other support services to
sex workers in Kigali.

Project Description and Results: Based on successful interventions of providing sex
workers with STI care, Biryogo Social and Health Center (with technical assistance
from FHI and funding by USAID) launched services for female sex workers in
November 2005. The intervention applies an “enhanced syndrome management”
approach, which combines presumptive treatment for STIs with limited etiologic
diagnosis. The intervention also includes prevention education, support for family
mutuelles fees, HIV counseling and testing and referral to clinical care as necessary,
and access to micro-credit. Women are enrolled in the project through a “snowball”
contact approach. New clients are enrolled each week, wherein the women: (i) are
presumptively treated for gonorrhea and Chlamydia; (ii) receive a clinical
examination for other STIs and are treated accordingly; (iii) have vaginal and blood
specimens taken for laboratory diagnosis and, based on lab results, are treated
accordingly; and (iv) are offered HIV counseling and testing and enrolled in care and
treatment services as necessary.

Lab diagnosis is limited to wet mount and gram stain microscopy of vaginal
specimen, and Rapid Plasma Reagin (RPR) test, confirmed by Treponema Pallidum
Haemagglutination Assay if RPR+. Women return each month to participate in
educational sessions and for consultation with a clinician. During these routine return



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visits, clinical examination and treatment are conducted as indicated. Laboratory
diagnosis is repeated every three months. At each visit, women receive treatment as
clinically indicated. To ensure adequate follow-up, enrollment of new clients was
suspended in August 2006. From November 2005 to August 2006, 146 women were
enrolled in the program. Results to date include:

Sexual risk behavior, history of STIs and treatment seeking: At the first visit, 112 of
all enrolled women reported sexual activity the week prior. 53% of these women
reported having had sex with more than 2 sex partners and 30% reported inconsistent
use of condoms with these partners. 28% of the 146 enrolled women had an STI
within the 3 months prior to the first consultation; of these, 29% self-medicated rather
than consulted a professional service provider.

STI diagnosis and HIV infection: 64% (94) of the 146 women enrolled complained of
STI symptoms at the first consultation; in 57% of these women at least one STI was
confirmed by clinical and/or laboratory exam. 36% (52) of all enrolled women were
asymptomatic at the first consultation. Despite experiencing no symptoms, among
these women 40% also had at least one STI confirmed by clinical and/or laboratory
exam. In total, 54% of all enrolled women had at least one STI confirmed. Vaginal
candidosis (22 cases), bacterial vaginosis (20 cases), syphilis (9 cases) and vaginal
warts (9 cases) were the most common STIs found. 71% (103) of the 146 women
enrolled were HIV-infected.

Social support and adherence to the program: 118 of the women received assistance
with family mutuelle fees; 93 were supported in micro-enterprise activities; and 107
(73%) of the women remained engaged in the program as of December 2006.

Conclusions/Lessons Learned: Female sex workers are a highly vulnerable group in
need of specialized clinical and social support services. The high risk behavior, high
STI rates and high HIV infection rates in these women further underscore the
importance of targeting female sex workers with STI management as a core HIV
prevention strategy. Further, the high rate of asymptomatic STI infections found in
the 146 women enrolled in this program points up a need to develop enhanced
syndromic management guidelines adapted to this specific and epidemiologically
important population.



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II-C-2 Les comportements à risque de VIH dans la population des
transporteurs routiers du Rwanda en 2000 et 2006

Authors: J. Byaruhanga1, JP Tchupo2, J. Price2, A. Assimwe1, E. Kayirangwa3, C.
Kayitesi1, V. Nizeyimana1, A. Kabeja1

1
    TRAC, 2FHI, 3CDC


Contexte: Les camionneurs sont en général des hommes adultes et mariés et dont
leurs activités les obligent à séjourner longtemps hors de leur lieu de résidence
habituel. De ce fait, ils sont exposés aux rencontres sexuelles occasionnelles. On les
considère en général comme étant une « population pont » qui véhicule le VIH des
populations à haut risque de VIH que sont les prostituées vers la population générale.
Au Rwanda, cette population des transporteurs routiers constitue l’un des groupes
ciblés dans les stratégies de prévention. Les actions menées en direction de ce groupe
par l’ensemble des acteurs de la lutte contre le VIH/SIDA ont-elles suscité des
changements de comportements et réduit le risque des IST et du VIH/SIDA?
Le but de l’étude était d’examiner l’évolution du risque de contracter les IST et le
VIH dans la population des transporteurs routiers au Rwanda.


Méthodes: Les données analysées proviennent de deux phases d’enquêtes de
surveillance de comportements réalisées en 2000 et 2006 respectivement. Il s’agit
d’enquêtes socio comportementales menées à intervalles réguliers auprès des groupes
les plus à risque de VIH dans un pays ou une région. Les données ont été collectées
auprès d’échantillons des transporteurs routiers et de leurs convoyeurs, circulant sur
les routes du Rwanda. Les interviews ont été réalisées sur les points de stop des
camionneurs. Dans chacun des points, l’ensemble des camionneurs presents sur le site
ont été interrogés. La taille de l’échantillon était de 481 en 2000 et 680 en 2006. Le
test de X2 a été utilisé pour déterminer si les changements observés entre les deux
périodes sont statistiquement significatifs.


Résultats:
Connaissance des IST et du VIH : L’index de connaissance construit sur la base des
symptômes d’IST connus et spontanément mentionnés par les répondants ne montre
aucune amélioration du niveau de connaissance des IST chez l’homme ou chez la


                                                                                  155
femme entre 2000 et 2006. La connaissance approfondie du VIH a cependant
augmenté de façon significative entre les deux périodes (p<0.05). Il s’agit d’un
indicateur composite3 obtenu à travers une série de questions sur la connaissance de
méthodes de transmission du VIH et le rejet de méthodes erronées.
Comportements sexuels : La grande majorité des routiers interrogés en 2000 et en
2006 vivent en union et au cours des 12 derniers mois, la plupart ont séjourné au
moins un mois en continue hors de leur lieu de résidence habituelle. Le
multipartenariat sexuel reste très présent dans le milieu des routiers mais entre 2000 et
2006, il a baissé de façon significative (p<0,01). La proportion de ceux qui affirment
avoir eu des rapports sexuels avec les travailleuses de sexe a également baissé de
manière considérable (p<0,01). Le niveau d’utilisation du condom lors du dernier
rapport sexuel et l’utilisation systématique au cours des 12 derniers mois avec les
prostituées reste relativement faible, bien qu’il ait augmenté (p<0,05) entre 2000 et
2006. Mais avec les partenaires occasionnels non payants, ce niveau est resté
constant. La proportion des personnes qui affirment avoir eu des signes d’IST au
cours des 12 derniers mois a diminué considérablement (p<0,01) bien que l’on n’ait
pas observé une amélioration du niveau de connaissance des IST au cours des deux
périodes.
Recours aux services de dépistage volontaire : En 2006, la proportion des routiers
connaissant un endroit où faire le test de dépistage du VIH avait connu une
augmentation hautement significative (p<0,01) comparativement à 2006. Une
augmentation tout aussi considérable était observée dans la proportion des routiers
ayant effectué volontairement un test de VIH (p<0,01).


Conclusion: Bien que le recours aux prostituées semble avoir diminué au fil du
temps, peu de camionneurs pourtant mariés pour la plupart disent utiliser
systématiquement les condoms avec les partenaires occasionnels. Or, seule une faible
minorité utilise les préservatifs avec leurs partenaires réguliers. Les campagnes
d’information destinées à cette population devront mettre l’accent sur la nécessité
d’utiliser systématiquement le condom lors des rencontres occasionnelles et le risque
qu’ils courent d’infecter leurs conjoints en ayant des rapports sexuels non protégés
avec ces partenaires occasionnels.


3
    Indicateur PEPFAR sur la connaissance du VIH.


                                                                                     156
II-C-3. High Risk HIV Behavior in Rwanda: A Synthesis of the
PLACE Study with Comparisons to the 2005 Demographic Health
Survey.
T. Bishagara1, M. Borda², S. Cummings³, S. Moreland4, F. Katangulia5*
¹Constella Futures, 2Constella Futures; ³MEASURE Evaluation; 4Constella Futures;
5
  2005 Rwanda PLACE Study Team; *currently a consultant to MEASURE
Evaluation.

Background: Rwanda, like many sub-Saharan African countries, has long struggled
with the AIDS epidemic. In 2003, the prevalence of HIV at antennal clinic sentinel
surveillance sites in Kigali was 16 percent, with a median prevalence of 6 percent in
other urban sites in Rwanda. Elsewhere, with the expansion of the sentinel
surveillance program, the median prevalence among pregnant women at rural sites
was estimated to be nearly 3 percent . As a result of the high HIV prevalence, research
has been conducted to better understand the epidemic in Rwanda. In 2005 the
Rwandan Comité Nationale de Lutte contre le SIDA (CNLS), with technical
assistance from MEASURE Evaluation, implemented the PLACE protocol in 12
provinces in order to assess HIV prevention program coverage and acquisition of
sexual partners among the population at public places. Additionally, in 2005 the
Institut Nationale de la Statistique du Rwanda (INSR) and ORC Macro administered
the third Demographic Health Survey (RDHSIII) in part to gather information on
knowledge, attitudes and practice surrounding HIV/AIDS and HIV prevalence and
associated factors. Both PLACE and RDHS data are complementary, and are useful
tools for program managers wishing to focus scarce resources in effective HIV
prevention. This paper will focus primarily on the Rwanda PLACE data, but will
make some comparisons to RDHS data.


Methods: The PLACE survey was implemented in all 12 provinces in Rwanda, from
which 23 Zone d’Intervention Prioritaire (ZIP) were selected. In each ZIP
interviewers solicited from informants the name and location of public sites where
people meet new sexual partners. These sites were verified by the interviewers and
further information about the site was collected from a knowledgeable informant.
Further interviews were conducted using a questionnaire derived from the PLACE
protocol in sample sites.




                                                                                   157
Results: Over 14,000 interviews were conducted at more than 550 sites. A
comparison of PLACE and RDHS results shows that each tool reaches very different
populations. This analysis adds to previous research [3] that finds that the PLACE
data captures a population that is more likely to be sexually active, have more sexual
partners, more likely to use a condom, be less educated, more likely to be unmarried
and more likely to have had an HIV test than the population captured by RDHSIII.


Conclusion: The PLACE survey successfully identifies populations at sites that could
benefit from HIV/AIDS prevention programs. When used in conjunction with other
data sources such as household survey and sentinel surveillance data, it can provide a
clearer picture of the HIV epidemic at the local level, and better inform program
managers on how to allocate resources to fight the AIDS epidemic.




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II-C-4. Assessment of the role of forum theatre in HIV/AIDS
behavioral change process among secondary school adolescents in
Butare province, Rwanda.

Basinga Paulin*, Bizimana Jean de Dieu*, Munyanshongore Cyprien*
* Rwanda School of Public Health/ National University of Rwanda.
This study was funded by SIDA/SAREC through the Research commission of The
National University of Rwanda.
Key words: HIV/AIDS, Youth, Theater

Background
Since the beginning of the HIV/AIDS pandemic, sub-Saharan Africa is one of the
regions most severely affected by the infection.
In general, theatre is intuitively considered as an efficient sensitization tool that can
lead to a sustainable behavior change.


Objective
This study evaluates the efficiency of forum theatre in comparison with the classical
HIV/AIDS sensitization method regarding knowledge, attitudes and practices of the
youth in secondary schools.


Methodology
This research-action used the “pre- and post-test” assessment method. Two different
interventions in two secondary schools in Butare town were compared.
During the month of May 2005, 3 forum theatre interventions were performed for the
students of the Butare Official Secondary School (intervention group) and 2 classical
sensitization sessions in the Baptist Lower Seminary (control group). Observation
was carried out in the following six months. The final quantitative assessment was
carried out during the month of November 2005.


Results
In total, 11 indicators were selected to serve as a basis for the comparison between the
two schools.
The homogeneity test showed no statistically significant difference between the two
schools. Impact assessment at 6 months could not demonstrate statistically significant



                                                                                     159
differences due to the short observation period. However, a good improvement trend
for most of the indicators was observed in the intervention group as well as in the
control group.


Conclusion
The different impacts of both interventions are discussed and recommendations are
made to improve and intensify sensitization campaigns for the youth in Rwandan
secondary schools.




                                                                               160
II-C-5. Study of Knowledge and Attitudes Concerning Human
Immunodeficiency Virus And Acquired Immunodeficiency
Syndrome (HIV/AIDS) At Matara Primary School

Authors: GAHUTU JB1, TWAGIRUMUKIZA M2, KABAYIZA JC3, McLELLAN SLF4,
HAAS LJ5 1Head of the Service of Physiology, Butare University Hospital and Faculty
of Medicine (BUHFM), National University of Rwanda (NUR); 2Department of
Internal Medicine, BUHFM, NUR; 3Department of Pediatrics, BUHFM, NUR;
4
  Section of Infectious Diseases, Tulane University School of Medicine; 5Payson
Center for International Development, Tulane University

Institution: National University of Rwanda, School of Public Health (NURSPH)


Context: The education of children and adolescents with regard to HIV/AIDS and
means of prevention is one of the strategies supported by the Rwandan National AIDS
Control Commission (CNLS). The experience of Straight Talk Foundation, an NGO
based in Uganda specialized in medias on HIV/AIDS control for children and
adolescents, has proven that not only adolescents but also children 10 – 12 years old
can beneficiate from messages for HIV/AIDS prevention, such as abstinence. The
Rwanda 2005 – 2009 National Strategic Framework in Communication for Behavior
Change related to STIs/HIV/AIDS elaborated by the National AIDS Control
Commission identifies youth 7-24 years old, in school or not, as the first priority
target group for such education. Our study was designed to evaluate the current state
of knowledge and attitudes of the pupils of a representative primary school
concerning HIV/AIDS.


Specific Objectives:
1) Assess the level of knowledge of the pupils of Matara Primary School concerning
causality, transmission, prevention and treatment of HIV/AIDS.
2) Assess the perceptions and attitudes of the pupils of Matara Primary School
towards the HIV/AIDS problem, and persons living with AIDS (PLWHA).
3) Assess by which means and how frequently the pupils of Matara Primary School
are informed about HIV/AIDS.
4) Assess the faculty’s perceptions of and attitudes toward the teaching of HIV/AIDS
education in school.




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Methodology:
Study Population: Students and faculty of Matara Primary School.
Tools and Time Period: For the pupils, a questionnaire was employed, which was
read to the pupil and the answers directly filled in by the researcher. A focus group
was held with the teachers. The data collection was conducted during a three week
period in October, 2006.
Sampling: For each grade, one class was chosen (out of parallel classes) and all
pupils were accepted who presented for the study within the available time frame. The
twelve teachers of Matara primary school (including the director) participated in the
focus group.

Statistical Methods: The data were analyzed on the computer with Epi-Info software.
The results of data analysis are presented as percentages, means, medians, ranges and
percentiles.
Results: All children in P4 and above knew that HIV was transmitted by sexual
intercourse and that abstinence was a means of prevention, and correctly identified
activities which were not associated with transmission (i.e. talking with or sharing
food with a person with HIV). However, only 3 of 26 (< 12%) P6 students mentioned
condom use as a means to prevent transmission of HIV. The students gained a great
deal of their information from school teachers and from visiting clergy. Most children
in P4-6 also reported speaking to a parent at least once per week on the subject of
HIV/AIDS. The teachers’ focus group indicated that the instructors were willing to
teach the students about HIV/AIDS and that parents were favorable to such education
at school. However, there is not yet any curriculum or syllabus to guide school
teachers.
Conclusions: Even though there is no gold standard at national level about what
pupils should know about HIV/AIDS in each primary grade, the knowledge and
attitudes observed in Matara Primary School compare well to results of other studies
in terms of percentages of correct answers. However, very few students mentioned
condoms as a way to protect against HIV. Data from studies included in the 2004
UNAIDS HIV Epidemiologic Update suggest that a large proportion of adolescents in
Africa begin sexual activity before the age of 15. Hence it is imperative that
prevention messages include methods to prevent the transmission of HIV in the
context of sexual activity.



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II-C-6. Les groupes à haut risque sont moins couverts par les
programmes VIH/SIDA : Résultas d’une étude qualitative dans les
trois sites de transport au Rwanda

Auteurs : Protais Ndabamenye*, Melchiade Ruberintwali*, GIMU Shyikiro
Ntayoberwa*, Gail Goodridge* Rugaju Déo**, Eugène Gasirabo***, Victoire
Kimonyo***, Maurice Mpfizi***, Evariste Kimenyi*** (* FHI, ** Directeur de la
santé Rusizi, *** CLDS)

Institution responsable de l’étude: FHI /ROADS Project


Contexte
Les sites (où les camionneurs et autres populations mobiles passent la nuit) qui sont
surtout localisés autour des douanes y compris les frontières sont considérés comme
des sites à très haut risque pour contracter le VIH. La présence de cette population
mobile attire les femmes à faible revenu et les jeunes filles pour gagner de l’argent et
cette situation augmente le risque de propagation du        VIH aussi bien parmi la
communauté locale que chez cette population mobile et ce risque s’étend même au
niveau de leurs familles. C’est cette situation qui a poussé l’USAID à financer un
programme régional de lutte conte le VIH/SIDA le long des axes routiers qui cible 9
pays de l’Afrique de l’Est dont le Rwanda. Avant le début des activités au Rwanda,
une évaluation qualitative de base a été conduite dans les trois sites : Ville de Kigali
(autour de Magerwa et Gatsata), Gatuna et Rusizi.


Objectifs spécifiques de l’étude
(i) Collecter les informations en rapport avec les différents programmes et partenaires
présents dans les sites, (ii) collecter les informations sur les facteurs de risques
individuels et environnementaux qui augmentent la vulnérabilité de la communauté au
VIH/SIDA: (iii) impliquer la communauté dans le processus de programmation pour
maximiser leur appropriation au programme.


Méthodologie
La collecte des données dans les trois sites a été faite entre septembre et novembre
2006 à travers des discussions dirigées (FGD) avec les groupes cibles. Les
informations collectées ont été complétées par des interviews directes avec des
informateurs clés et l’exploitation de la littérature au niveau local et national. Sous



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l’invitation des maires de districts et des représentants des comités de district de lutte
contre le VIH/SIDA (CDLS), 557 personnes dont 109 représentants de différentes
institutions (ONGs, associations, institutions publiques et privées), 84 jeunes, 133
PVVIH, 67 prostitués, 130 femmes à faible revenu, 22 camionneurs et 39 pécheurs
ont participé aux discussions. Un guide de discussion pour le modérateur a été préparé
et a couvert les différents thèmes en rapport avec les objectifs de l’évaluation. Les
données ont été analysées par rapprochement des similarités et des divergences en
fonction des différents groupes rencontrés. Des réunions de restitution des résultats
ont eu lieu dans chaque site auprès des groupes ayant participé à l’évaluation pour
valider l’information.


Principaux résultats
(i) Au niveau de la frontière de Gatuna, environ 100 camions entrent chaque jour. 100
camions entrent dans l’entrepôt de Magerwa dont 70 y passent la nuit. A Gatsata et à
Rusizi, environs 30 camions sont dénombrés chaque jour. (ii)Pour tous les groupes
rencontrés, les principales préoccupations de la population sont : la pauvreté, le
VIH/SIDA et le chômage. Les femmes et les PVVIH ajoutent le problème de prise en
charge ou d’assistance de leurs enfants. Les PVVIH particulièrement évoquent le
problème d’accès à un appui alimentaire surtout ceux qui sont sous le traitement
ARVs et l’appui à la scolarisation de leurs enfants. (ii) les groupes à haut risques cités
par les groupes rencontrés sont: les prostituées et les chauffeurs, les motards et les
mécaniciens (Gatsata), les jeunes (étudiants et élèves), les femmes vendeuses, les
femmes à faible revenu surtout celles qui vivent seules, les hommes riches, les
militaires et les policiers. (iv) Les principaux facteurs de risques tel que cités par tous
les mêmes groupes sont : la pauvreté, l’ivresse/Drogue surtout à Gatsata, le célibat
géographique, la violence, la proximité des groupes à haut risque, le chômage, la
convoitise des jeunes. Les jeunes étudiants ont été cités comme partenaires des
prostitués surtout à la rentrée scolaire. En plus, les SW ont rapporté la chute de prix
durant la même période suite aux jeunes filles élèves. Les pécheurs de Rusizi sont
revenus sur leur vulnérabilité au VIH suite aux rapports sexuels faits dans les bateaux
et aux côtes du lac surtout le soir. Le condom existe dans les sites visités, mais il est
moins utilisé. Ce sont surtout les hommes et les jeunes garçons qui ne veulent pas
l’utiliser. Certaines SW VIH+ rapportent qu’elles continuent d’avoir des rapports
sexuels sans condom (v) Les groupes à haut risque sont les moins à se faire tester


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pour le VIH dans certains sites tel que Rusizi, Gatsata et Gatuna. La principale raison
est la peur du résultat positif. Dans le site de Gatsata, aucun programme structuré VIH
n’a jamais ciblé la population locale surtout les SW, les garagistes, les femmes à
faibles revenus. Les autorités administratives locales ont confirmé cette information.
Aucun service de dépistage n’existe dans ce quartier, le plus proche est celui du
dispensaire de Muhima. Les pécheurs de Rusizi qui constituent pourtant un groupe
important (plus de 5,500 personnes) n’ont pas eu non plus de programme VIH/SIDA.
Dans les autres sites, des partenaires dans la lutte contre le VIH/SIDA existent mais
leurs actions ne sont très visibles sur terrain à cause du problème de couverture.


Conclusions
(i) Les prostituées, les jeunes scolarisés ou non, les chauffeurs/camionneurs, les
étudiants, les élèves commerçants, femmes seules/veuves sont les principaux groupes
à haut risque identifiés par les membres des groupes rencontrées. Leur vulnérabilité
est influencée principalement par la pauvreté, la consommation d’alcool/drogue et
leur mobilité. (ii) La plupart des groupes à très haut risque ont eu un accès limité aux
programmes VIH/SIDA. D’autres n’ont pas été ciblés (Gatsata et les pécheurs de
Rusizi). Pour améliorer cette situation, il faudrait renforcer les programmes qui
existent et en développer d’autres pour les groupes de Gatsata. Le système de Cluster
entre les associations qui existent permettrait d’assurer une meilleure couverture et de
bons résultats. Les opportunités de dépistage mobile, de création d’emploi en faveur
des femmes à faible revenu et de lutte contre la consommation d’alcool doivent être
prises en compte.




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II-C-7. Using networks of PLWHA to increase family-focused HIV
counseling and testing in Rwanda

Authors: Maaza Seyoum, Eugénie Ingabire, Odette Mukansoro, Therese Mutesayire,
Shakilla Umutoni, Ruben Sahabo

Affiliations: The authors are with Columbia University ICAP (Kigali, Rwanda) and
the Rwandan Network of PLWHA

Location of Project/Team: Kigali, Rwanda
Key Words: Peer Education, HIV testing, PLWHA associations, Family based care


Context: The International Center for AIDS Care and Treatment Programs (ICAP) of
Columbia University supports a family approach to HIV care. Outreach activities
with PLWHA associations found that many members had not disclosed their status to
their families or encouraged them to be tested.


Approach: Working with the National Network of PLWHA (RRP+), District
Medical Officers (DMOs), and District leadership in two rural areas, ICAP
implemented an innovative community based testing program to increase testing of
partners and children of PLWHA association members. 29 peer educators (PE) –
HIV+ members of local associations who were adherent to care and had disclosed
their status to their families – each conducted outreach to 10 families in their
association. They counseled their peers about disclosure and the families about
testing. At each site 1 community-based testing (CBT) day was dedicated per week to
test individuals who presented with invitations distributed by PE.


Outcomes and challenges: 93.5% of targeted family members agreed to be tested.
The number of people tested through the CBT model (1 day/week) far surpassed the
average number tested in the previous 3 months at regular VCT (5 days/week): 250
vs. 85 at one site and 314 vs. 116 at the other. Using the same comparison, the
number of children tested increased from 8 to 157 and from 7 to 111. The HIV
prevalence of individuals tested on the CBT day was ~3 times higher than the average
VCT prevalence (4.4% vs. 1.5% and 4.8% vs. 1.3%). All HIV+ individuals were
immediately referred into care. The project was effective in reaching a high risk
population and increasing the number of children accessing care. The involvement of


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PLWHA as well as the collaboration with RRP+ and local authorities worked
extremely well. Challenges included the added responsibilities for health facility staff,
adolescent testing and access to family members of enrolled patients due to concerns
about confidentiality. Partnership with RRP+ allowed for immediate access to
associations of PLWHA and government buy-in. Work with local authorities led to
increased acceptance of the project at community-level.


Key Recommendations: Collaboration with government and local authorities early
in the process of program development, involvement of PLWHA, reduction of
barriers to testing and care as well as continued education to the community about
living with HIV, and HIV testing and care (particularly regarding children) are
essential.




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II-C-8. National Integrated Program for HIV/AIDS Prevention, Care
and Support to PLWHAs and OVCs

Auteur: Sarah Myers, Charles Karekezi, Esther Gwan
Authors’ Title and Adress: Director of Programs, Mobilizing for Life Program
Manager, Deputy Director of HIV and AIDS Africa: World Relief Rwanda, BP 6052
Kigali. Email: SMyers@wr.org, CKarekezi@wr.org, EGwan@wr.org

Geographic location of the project: National

Context/Background: Prior to President Bush’s Emergency Plan for AIDS Relief
(PEPFAR), the GOR identified HIV/AIDS as a high priority investment area in health
and initiated prevention and treatment programs. These were funded through the
Global Fund to Fight AIDS, Tuberculosis (TB), and Malaria (GF); the World Bank
Multi-Country AIDS Program (MAP), and other sources. In 2002, the GOR put in
place the National AIDS Control Commission (CNLS), commonly known by its
French acronym, CNLS. It coordinates all HIV/AIDS activities in the country.


World Relief started in Rwanda in 1994 to help victims of the genocide through the
churches. HIV/AIDS activities started in 1998 by helping church leaders to better
understand the epidemic, reduce stigma, and make informed choices on areas of
intervention. The 2002 demographic statistics of Rwanda show that over 90% of the
population affirms a faith based affiliation making this an almost universal
characteristic of the population. World Relief’s initial activities using an integrated
approach in Kigali Ville, Kigali Ngali and Ruhengeri formed the platform for scale up
with PEPFAR funding in 2004. Activities expanded first to five, then eight provinces,
to reach national coverage in 2006. The program, originally designed for church and
school youth age 10-24 years uses an interactive age graded curriculum that has cut
through age and religious barriers attracting adults and Muslims.


Project objectives: Mobilize community through the churches and schools for HIV
prevention by engaging youth in interactive learning to encourage self-assessment,
goal development, abstinence and relevant discussion for sexually active youth.
Mitigate the impact of the Pandemic in Rwanda though interventions that ensure food
sustainability, poverty alleviation and education of OVCs




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Program approach: Integrated program, multiple funding tracks, synchronized with
national effort through donor directives and CNLS coordination, peer collaboration
for community mapping, sharing curriculum, and volunteer training.


Description of interventions: Training of Trainers (TOT), community volunteers,
through District Interfaith Committees, reaching families, facilitating adult
interpersonal dialogue with youth. Training school authorities, classroom teachers,
peer educators using approved manual (Choose Life or Hitamo Kubaho). Radio spots
and community events featuring sports, songs, folklore, and poetry enhance program
by reinforcing the values of abstinence and being faithful. The originality of the
program is the channelling of faith based values of premarital abstinence, conjugal
fidelity, and compassion for prevention and impact mitigation. Activities are built on
church structure, to encourage community ownership and ensure sustainability.


Beneficiaries and partners: Beneficiaries include youth in churches and schools;
youth in difficult circumstance; adult influencers of youth; church partners, and
school authorities,


Peer Linkages: Catholic Relief Services (CRS) and Food for the Hungry
International - Curriculum sharing and CARE International for collaboration in
Training volunteers


Achievements: For Prevention: 224,814 individuals (108,334 males and 116,480
females) were reached in FY 2006 representing 89.92% accomplishment of the
overall program objective. 11,696 of these were trained youth leaders (5,920 females,
5,776 males). The year’s target was 500 youth leaders per province for 6,000 youth
leaders nationwide. The achievement in the number of trained youth leaders
represents 194% accomplishment of the target. 103 leaders were trained for youth
rehabilitation centers, and guided a total of 1,142 youth in difficult circumstances
(456 females, 686 males) to commit to premarital abstinence for one year. This
represents 107% of the target for training and 300.6% of the target for number of
youth reached in rehabilitation centers. 584 church leaders were trained to facilitate
interpersonal dialogue between parents and the youth. These cumulatively reached
28,417 parents (17,197 females and 11,220 males), representing 97.3% of the target


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for the number of church leaders trained and 236.8% of the target number of parents
reached. 459 secondary school teachers, 1,338 peer educators, 615 primary school
teachers, and 181 university student leaders, were trained this year in 936 schools and
six universities.


Palliative care achievements:        Leaders from 149 Associations of PLWHA
completed business development training and received revolving funds between
March and July 2006. 635 community leaders were sensitized on nutritional needs of
PLWHAs. Palliative care volunteers completed training in the following areas: 139 as
trainers to train 5 peers for community nutritional counseling needs of PLWHAs for a
total of 695 nutrition volunteers;
715 volunteers as community counselors to provide psychosocial and spiritual support
to PLWHAs; 700 volunteers for the special needs of bedridden PLWHAs; and 1000
volunteer kits were replenished.


OVC Activities Achievements: 750 community volunteers and 310 teachers were
trained on the counseling needs of OVCs; 1423 secondary school OVCs received
school fees; 200 OVCs in vocational training received start up equipment and VCT
facilitation (fees and transportation) drew large numbers for a total of 17672 OVCs.


Conclusion/Lessons learned: Behavior change must remain a focus, using reflective
learning methods, peer support, a high quality curriculum cutting through age and
religious barriers with lessons that build user confidence and competencies.
Cascading levels of training increase output enabling trained youth leaders and
teachers to train and supervise peers who in response reach large numbers. Parents
and other adult influencers of youth are critical resources responsive to interventions
targeting them, and learning important skills in relating to their own children more
effectively. Protecting youth requires partnership—a) with other non-governmental
organizations (NGOs) and government resources to provide help for high risk youth,
voluntary counseling and testing (VCT) and sexually transmitted infections (STIs)
treatment services, b) with employers of youth, c) with other faith-based partners to
reach targets, and d) with other funding sources, including other USAID- funded
programs. While our M&E systems in all MYFL operation are well-established to
maintain quality of interventions, it has become evident that manually preparing


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reports is consuming an excessive amount of staff time raising the need for a
functional database system into which staff feed data. Interest of volunteers has been
maintained by tiered training levels from youth leader, to youth leader TOT, Master
TOT, support to volunteer initiated projects, and the recruitment of paid staff from
exceptionally performing volunteers.




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II-C-9. The role of peer education in the prevention of HIV and
AIDS.

Auteur: Natascha Hermann, Advocacy Officer
Author’s Title and Adress: Advocacy Officer; VSO Rwanda, PO Box 4599, Kigali

Geographical location of the project: Eastern and Southern Provinces, Rwanda

Context/Problem statement: In sub-Saharan Africa nearly half of all new HIV
infections occur among young people aged 15 – 24. Knowledge about how to prevent
HIV infections among youth is crucial to successfully fight HIV and AIDS.


Project objectives:
The overall aim of the PHARE project is to prevent HIV and AIDS infections among
vulnerable groups in the Eastern and Southern Provinces of Rwanda. The objectives
are :
•   To promote behaviour change amongst students in school through mutual support
    and peer education
•   To establish holistic school based responses to HIV and AIDS that are supported
    by education managers, teachers and students and Rwanda policy
•   To build HIV and AIDS networks between schools and communities in order to
    break down stigma and increase access to care and support services in their
    communities


Project description: The PHARE project started as a pilot project aimed at
preventing new HIV infections amongst the school population of Gitarama,
Gikongoro and Umutara provinces. Due to the success the project expanded and
covers now the whole Eastern and Southern provinces. It is working with secondary
schools to facilitate knowledge, awareness raising and behaviour change in the whole
school community. Whilst the school managers, teachers and students of the 147
schools participating in the project are the direct beneficiaries, it is also anticipated
that the wider community will benefit from the behaviour change at school level.


Achievements :
Peer education is the core element of the PHARE project. Students were trained in
education techniques and communication skills when interacting with their colleagues


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and friends. Having peers educating peers allows an openness in discussions that is
otherwise often missed because students are too shy or intimidated to speak to their
teachers or other staff. By empowering individuals with training, exposure to new
activities and contact with people living with HIV and AIDS, students increased their
self-confidence. This approach enabled the students to promote positive behaviour
change and to seek to reduce the levels of stigma and discrimination.


Conclusion/Lessons learned:
Peer education has proven to be an effective way to prevent HIV infections among
young people. Despite the success so far a number of challenges remain:
•   Peer education requires ongoing training and support. There is the need to initiate
    peer counselling training.
•   It is necessary to establish and strengthen the working links between schools and
    their communities, so that the wider community benefits from the peer education
    model too.
School managers need to be trained to understand and support HIV programs. In the
past they have often misinterpreted the concept of peer education as a negative way to
encourage sexual activity among youth.




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II-C-10. More BCC Methods from RAPSIDA; Use of Non-fictional
Candlelight Ceremonies

Author: Jesse Hawkes
RAPSIDA Program Director

The deep effect of personal interactions with LIVE actors was facilitated as well
during the non-fictional, candlelight ceremony during the morning session on Sunday,
which had nothing to do with the fictional characters in the play. This time, the
audience’s deep interest/respect for the play was based on their mutual testimonials
with the actors during the candlelight ceremony. The candlelight ceremony must have
created a deep emotional connection between the people who were in the audience
and the actors who were in the play later on in the day. I say this because I felt it
myself. Based on the testimonies during the candlelight ceremony, the audience, like
me, could see that the talented actors in our group are real people whose lives have
been deeply affected by HIV/AIDS, just like them. I learned for the first time that one
of my actresses lost her mother to HIV/AIDS, and one of our singers lost both of her
parents. It was heartbreaking when they got up and testified about this during the
public candlelight ceremony, but their effort certainly created a sense of sister-
/brotherhood between them and the rest of the people in the room. This was important
both for the PLWHA, but also for those people who did not believe their lives were
greatly affected by the disease. If someone who normally discriminates against people
with HIV/AIDS actually likes an actress in the play who later tells the audience that
she is suffering from the effects of HIV/AIDS, this leads the discriminator to gain a
greater respect for PLWHA via the actress. Seeing her courage, I gained significant
respect and trust for the actress as a person and I was prepared more to listen to her
character’s message in the play.”


Involvement of PLWHA in the discussions:
When one involves members of an association of PLWHA with people from the
general public in a debate or discussion about the play, the public can easily see that
PLWHA have just as much intelligence as anyone else, and much more experience
and expertise on the topic at hand.




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Demonstrating Care/Support:
The inclusion of demonstrations of care for PLWHA in and with ceremonies that also
involved highly entertaining and provocative theatrre was one of the most surprising
and effective ways to reduce stigma and increase the possibility of prevention.


At the school, when asked how they felt about the moments where RAP and the anti-
AIDS club offered care/support to the association of PLWHA, all of the respondents
were either “pleased” or “happy” and one was “surprised” as well.              Showing
care/support during the play, no matter how small the gift, seemed to be a way of
getting people to think about PLWHA in a way that might actually contribute to the
efficacy of the prevention messages in the play, some of which were coming from the
PLWHA; that offering care/support is a prevention strategy in and of itself.


When asked if they would be willing to visit PLWHA and why, one half of
respondents at the school said they would (or already do) visit with PLWHA, “to see
how AIDS kills badly,” “to see how terrible AIDS is,” and “to show them love and
help and care,” but the other half of the respondents at the school said they would be
too scared or sad to visit. This group of respondents included some of the original
actors, who subsequently changed their minds after staying in the homes with
PLWHA in Kabuga. It is for this reason that RAP felt bringing the association of
PLWHA into the play, having them prepare food in conjunction with the play at
Kabuga, and having students visit and even spend the night had a great impact on the
students in the play and that that impact will soon resonate with their peers at school
when the news spreads in the school.


During the planning process for the conference, RAP and Girimpuhwe realized more
fully that they were creating a new model for approaching the HIV/AIDS epidemic in
Rwanda, fusing the traditional tools for behavior change communication (such as
plays) with various demonstrations of care and support to PLWHA. It was, in effect, a
way of creating mini-celebrities (fantastic student actors who already had a taste for
being on-display and in the public eye) who could then have a great impact through
their celebrity status. RAP believed that, if only the audience could identify with and
respect more fully PLWHA, then perhaps it would change behavior based on the
knowledge gained from interacting with PLWHA. If a person in the audience sees


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someone he/she respects (like one of the actors or singers) showing care and support,
then that audience member may begin to respect PLWHA via the actors. This, in turn,
will encourage the person to offer PLWHA support, to get to know the PLWHA, and
then to identify with that person on some level. Showing respect for PLWHA was
something that the play was asking students to do through the lives of the characters,
but having the real PLWHA and showing them real care/support was now a necessary
component of the play as well. The power of theatre/performing would attract the
audience. The power of care and support not only would bring benefits to PLWHA
but would also bring the audience into real/tangible contact with PLWHA. And the
contact with PLWHA would bring about behavior change in the audience members.
Skeptics might feel that calling this “the creation of mini-celebrities” is
overestimating the impact that these student groups could have. However, one only
had to watch the 400-strong audience cheer and scream for their fellow students at the
school during their previous miming/open-mic sessions to realize the respect the
student body had for the actors at the school, something that is quite different from
high-schools in the United States. The students in Rwanda really appreciated the
talents of their peers.
In addition, in RAP’s limited experience touring with the play to outside
communities, we found that not only did the level of professional artistry in the group
impress the communities where the play was shown, but the fact that these were
educated students could make a big difference in their impact because, as students,
they were perceived as heroes by a community of people who mainly lacked a
traditional, foundation in education. The students aided this impact, of course, with
their ability to avoid the usual trappings of stardom (i.e. arrogance, lack of interest in
the issues they were speaking about). They proved that they could be popular and
respectable. This should be required in the expansion of the project.


No where were the benefits of mini-celebrity status more strongly seen than at the
Kunda Ubuzima weekend at Kabuga, and specifically the overnight stay at the homes
of PLWHA. The overnight stay made a big impression on everyone: on the students,
on the people living with HIV who hosted those students, and also on the community
and neighborhoods around those homes. on the people in the neighborhood as well.
One student actor, Christian, stayed with a 30 year old man named Clavelle who is
HIV +. Christian said that in the morning he walked around and spoke with some of


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the people in Clavelle’s neighborhood. Christian said that one woman said she usually
offered assistance to Clavelle, but she didn’t really feel comfortable giving him help,
that she still had reservations about getting close to him. “She seemed like she just did
it because it might please him, but she still had fear in her heart.” Christian went on to
say that “I think our spending the night with Clavelle helped to show people like this
woman that people who have HIV are just like everyone else. You can treat them like
normal people. You can help them and care for them, get to know them, and like
them. Afterwards, this woman actually came over to visit with Clavelle.” It is not
clear whether Christian’s story about the woman in the neighborhood exemplified the
impact that the visit had generally on the community or whether it was an isolated
incident. Clavelle reported that, “I informed my neighbors in advance that I would be
hosting the students on Saturday night. All the neighbors were happy about the idea.
They all know that I am HIV+ and generally they support me, especially when I get
ill. But it was not always like that and sometimes stigma is silent so it is hard to tell if
everyone is sincere in their support even now. So the overnight made me feel like they
would respect me more. I was also happy with the night because the boys who stayed
with me shared stories and experiences. I hope that this kind of experience can be
brought to the villages where stigma is still a major issue.”


One HIV+ host, Isaac, reported that it made me him feel “wonderful” to have the
students staying with he and his HIV+ partner, Jean-Darc, because “many of the
people in our neighborhoods have not studied and are illiterate, and to have the
students staying in our homes brought us a lot of respect from our neighbors.” Jean-
Darc said, “It made me feel very happy, because the action of staying over night with
us showed that we are humans just like everyone else. You can eat and sit with us.
You can sleep in the same bedroom with us.” Positive psychological effects improve
HIV+ individuals’ abilities to fight the virus. The mini-celebrity status the students
held had abetted this impact. This should all be included in the expansion of the
project.
Jesse Hawkes of RAP stated, “Sure, we could wait for a widely recognized star such
as Celine Dion to come to every village in Rwanda and use her star power to convince
people to show PLWHA support, or we could create (and we are creating) respectable
stars from the talented youth in Rwanda and have them convince the others.”



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II-C-11. Influence of the Red-Ribbon Badges of hope.
Author: Jesse Hawkes
RAPSIDA Program Director

At the conclusion of RAP’s workshop with hotel and restaurant workers in Nyagatare
in April 2006, the workers agreed to wear the small badges all the time they are at
their restaurants; then one week later they agreed to come to a follow-up meeting to
discuss their experience with RAPSIDA.
One week later, interviews with the workers revealed the amazing effect their training
had had on them, their bosses, the other workers, and even the general public. The
bosses at some restaurants had asked for reports from the trainees and asked them to
start training their peers at work. Some bosses gave all of their workers time to meet
one another when they were not very busy. Several of the workers reported that they
were proud to provide condom demonstrations to their peers. They were pleased to be
given knowledge about condoms because they generally receive messages only about
abstinence from faith based organizations.
Specifically, the bead-badges with the image of the red-ribbon had a great effect. All
workers at the follow-up meeting stated that they had worn their badges with pride for
the whole week. Some trainees reported that their co-workers and customers had
accused them of being HIV+ for wearing the red-ribbon, but the trainees did not
become shy. They did not remove the badges. Rather, they explained to the restaurant
clients and co-workers the true meaning of the red-ribbon and how it encourages
people to talk about HIV and AIDS, to try to prevent behaviors that lead to HIV
transmission including sexual harassment, and also commit to supporting those who
are HIV positive. The trainees added, “We felt strong because of the workshop; the
information we gained from RAPSIDA helped us feel confident.” Some of those
customers who had inquired about the HIV status then asked if they also could wear
the badge.
Most importantly, some of the customers viewed the red-ribbon wearers as
trustworthy and caring; they entrusted them with life-saving information. One
customer asked one of workers if he would purchase a condom for him. The customer
was too shy to go and buy one at the store; there were no condoms available in the
hotel bathrooms or bedrooms; he was going to have sex regardless. After discussing




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the significance of the bead-badge worn by the RAPSIDA trainee, this man knew he
could trust the trainee to help him do the right thing.
These are just several examples of the kinds of conversations that arose when the
trainees wore the red-ribbon consistently and responsibly. They now know what the
ribbon means and they are committed to spreading its message and information about
HIV and AIDS.
At Savannah Restaurant, Trainee Prosper Wears his Red Ribbon at Work.




                                                                              179
II-C-12 Evaluation of RAP BCC theatre methods
Author: Jesse Hawkes
Program Director, RAPSIDA

Musical Theatre:
RAP has found that musical theatre is foreign to most artists and audiences in
Rwanda, but it seems to have instant appeal, perhaps due to Rwandans’ penchant for
melodramatic songs and a need for excitement and release. Thus the surprise factor
and the entertainment appeal of Musical Theatre made it a doubly effective method.


RAP delivered a musical theatre workshop that illustrated more succinctly the
efficacy of this particular method. With a few days of training and rehearsal, the
students created a 15 minute musical theatre play that brought several members of the
audience to tears with the unique combination of music, theatre, and choreographed
group movement on the stage.


Many of the youth in the drama clubs want to be “stars.” They get the attention of
their peers by dressing themselves up as their favorite hip-hop star and then mime
songs about wild parties and sex, just prior to performing a play about abstinence or
safe sex. With acting training and a good story to tell in an innovative and engaging
way, the students can wow their peers with a phenomenal performance and actually
get their peers to start thinking about the important message of the play. The musical
composition component and accompanying recording of the songs of the Putting a
Face on AIDS program actually affords the students an opportunity to gain real
experience in a recording studio and feel like a star, while providing a message that is
important.


Physical Theatre:
Physical theatre proved to be another surprising method that had instant appeal to the
audiences. Scenes where the actors created minibuses with only two benches and their
bodies, or where the actors improvised imaginary doors, cups, tables, etc. brought the
audience to laugh and cheer for the actors.




                                                                                    180
Serial Theatre:
Limited interviews with audience members showed that six out of nine students
reported that they enjoyed watching the play in weekly segments better than all at
once, for various reasons: “because I am now curious about what will happen;”
“because most of the time on Sunday, I have nothing to do in the evening;” “so that
we can learn slowly by slowly about AIDS.” Those students who wanted to see the
whole play at once seemed to be responding to their own positive curiosity about the
play rather than to any negative feelings. For example, one person said s/he yearned to
see what would happen to a particular character, the rapist, so s/he wanted to see the
rest of the play now. This result is what RAP hoped to achieve with the Serial
Theatre, to keep the audience curious about the characters week after week.


Interactive Theatre:
Eight out of twelve people said that they enjoyed having the MC pose questions to
them to keep them engaged and to make everything clear to them during the action of
the play. One student reported that during the discussions “the actors were very quick
and it wasn’t boring.” One student liked it when the MC gave the audience a quick
review of the previous episode at the beginning of the second, noting the “use of
simple words” as a positive aspect of helping to engage him/her. One reported that
they “made us curious about what will happen next,” and another that “they made us
pick up the information from the episode.” Several students said that the play was
interesting and clear “because of the discussions between actors and the audience.”




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II-C-13 Effectiveness of working with hotel and restaurant workers
Author: Jesse Hawkes, Program Director
       RAP-SIDA
Rwandans and Americans in Partnership (RAP)

Given the transient lifestyle and low pay scale of these workers, they are highly
vulnerable to the spread of HIV; for example, young waitresses often turn to
prostitution to supplement their wages, and condoms are not the norm. At the same
time, given their direct interaction with so many people on a given day at their
restaurants, these workers could also be highly influential in preventing the spread of
HIV and discrimination if they can be inspired to help spread educational messages.


In April, RAP began training these hotel and restaurant workers in Nyagatare. This
was the first program of its kind in Rwanda, according to health professionals—who
first heard about it over Radio Rwanda’s airwaves on April 21, 2006.


The program began with a three day session in April 2006 during which 22 workers
from 12 different establishments received training in HIV awareness and prevention
including condom demonstrations, from RAP and PJLS trainers. In addition, they
discussed their particular situations with RAPSIDA both in a large group and
separated according to gender. In addition, all of the trainees received pins/badges
with the internationally recognized symbol for HIV and AIDS Awareness, the “Red
Ribbon.” During the three day training, RAPSIDA Trainers explained the significance
of the red-ribbon to the workers, and created a list of reasons for wearing the badges,
providing each restaurant with a copy of the list. On the third day, the trainees
presented what they had learned to the owners of the restaurants and hotels at a
conclusion ceremony, which included a lunch prepared by a local group of women
who are openly HIV+.


Results:
During the workshop, the workers developed a strong collective understanding of
their vulnerabilities as well as an understanding of their special position of influence.
They even decided that they would like to organize themselves into a collective,
called Ibyiringiro “Hope” Association, so as to cater to their particular needs,



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such as fighting for workers’ rights and advocating for a dormitory, especially for
female workers. Overall, the restaurant owners were highly impressed with the
motivation and learning of the workers who had attended the training, which,
significantly, had taken place during normal working hours. The bosses also indicated
their support for the new collective of workers. Today, at least two of the restaurants
have established dormitories for their female workers and through the extra events at
the restaurants, over 4000 people have been sensitized and 300 people own the badges
of hope.




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II-C-14. Partenariat, communauté, prestataires et utilisation des
services de prevention et prise en charge du VIH/SIDA.

Auteur: Gérard Ngendahimana, M.D., Jean Gatana

Fonction et adresse de l’auteur: Gerard Ngendahimana, M.D., Deputy Director, The
Capacity Project, Kigali, Rwanda ; Jean Gatana, PMTCT Team Leader, The
Capacity Project, Kigali, Rwanda.

Localisation géographique du projet: Districts de Rulindo, Gicumbi, Nyagatare,
Gatsibo, Kayonza et Rwamagana

Contexte
Le Rwanda est l’un des pays les plus touchés par le VIH/SIDA. Pour ses 8,8 millions
d’habitants, la séroprévalence est de 3 % selon l’EDS 2005. Malgré de grands efforts
déployés dans la sensibilisation de la population pour le comportement sexuel
responsable, le changement est pratiquement insignifiant. Le Partenariat pour
l’Amélioration de la Qualité des soins (PAQ), une approche qui a été utilisée non
seulement pour l’amélioration de la qualité des services du VIH/SIDA et leur
utilisation, mais aussi pour l’éradication de la stigmatisation et la discrimination à
l’encontre des personnes vivant avec le VIH/SIDA.


Objectifs de l’intervention: Après la formation qui a été organisée par le projet,
chaque membre d’un comité PAQ doit sensibiliser au moins 10 personnes par mois,
voisins ou amis, sur la prévention du VIH/SIDA et l’utilisation des services de la
formation sanitaire. Chaque comité se réunit une fois par mois pour évaluer et
planifier ces activités, ce qui est aussi une occasion pour leur recyclage.


Description de l’intervention et caractéristiques des bénéficiaires: Au niveau de
chaque formation sanitaire deux comités PAQ sont élus, un comité PAQ-Adultes et
un comité PAQ-Jeunes. Le comité PAQ-Adulte est composé d’environ 14 membres
représentant l’administration décentralisée, les prestataires, les représentants des
jeunes, les représentants des confessions religieuses, les tradipraticiens, des
accoucheuses traditionnelles et des personnes vivant avec le VIH/SIDA. Le comité
PAQ-Jeunes comprend presque le même nombre de membres dont la moitié sont des
jeunes filles.




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État d’avancement des activités: Les services ci-après ont été davantage utilisés
dans les sites appuyés par IntraHealth/Capacity :
       Au Rwanda le taux des accouchements dans les formations sanitaires est
       estimé à 28%, pour les sites appuyés par IntraHealth/Capacity, il était de
       48,6% en décembre 2006, avec des sites comme Munyinya qui a atteint
       95.3% d’accouchements.
       La participation des partenaires dans les programmes PTME est estimée à
       56 % au niveau national; elle était de 74 % en décembre 2006, pour les sites
       appuyés par IntraHealth/Capacity, avec un taux de 100 % pour le site de
       Kajevuba, et 97 % pour le site de Ntoma.
       Pour le suivi des personnes vivant avec le VIH/SIDA sous ARVs, vers fin
       septembre 2006, aucun patient n’avait été perdu de vue comme le montrait le
       rapport du TRAC.
       824 couples de jeunes fiancés ont été reçus en consultations dans les sites
       appuyés par IntraHealth/Capacity.
       Vers fin septembre 2006, les statistiques montraient que 88 % des femmes
       séropositives utilisaient une méthode contraceptive.
       En 2006 un total de 1197 couples mariés ont été testés.


Leçons apprises
       L’implication des autorités locales et leaders d’opinion dans les comités PAQ
       permet leur réussite;
       La collaboration des prestataires avec les membres de l’équipe permet
       d’améliorer la qualité des services grâce à un feedback régulier;
       Le PAQ est une approche très appréciée qui développe l’éducation entre les
       pairs;
       En favorisant les discussions entre les jeunes de même sexes et entre les
       jeunes de sexes différents, l’approche PAQ les prépare à une meilleure
       utilisation des services de santé de la reproduction.


Cette approche PAQ qui est appliquée par IntraHealth/Capacity pourrait être étendue
à toutes les formations sanitaires pour améliorer leurs performances.




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II-C-15. Lutte contre le VIH/SIDA dans le monde du travail des
enfants : experience d’un syndicat
Auteur : Dominiko Nkiramacumu

Localisation géographique du projet:
District de Rulindo (Province du Nord) et District de Rwamagana (Province de l'Est)

Contexte/Problématique: Les enfants travaillant dans des conditions abominables
sont exposés au VIH/SIDA. Estimés à environ 175.185 (enquête MIFOTRA 2002) au
Rwanda, ils ne sont pas formés ou informés ni sur le VIH/SIDA ni sur la santé de la
reproduction. Parmi eux, les filles accouchent en bas âge. Ceux parmi eux qui seraient
infectés ne peuvent pas le savoir, ils restent chez eux et finissent par mourir suite au
manque de soins et de nourriture. Ces enfants peuvent aussi transmettre le virus aux
autres enfants et aux adultes qui travaillent sur les mêmes lieux ou qui cohabitent avec
eux.


Depuis 2003, ASC UMURIMO développe des actions de retrait et de réintégration
scolaire des enfants travailleurs en mettant un accent particulier sur l’angle de
développement. Grâce à ce Projet, l’accent est mis sur les actions de lutte contre le
VIH et les activités génératrices des revenus pour une rapide amélioration de la santé
des enfants.


Les objectifs de l’intervention du projet
Objectif global: Prévention du VIH/SIDA auprès des enfants engagés dans les pires
formes de travail.
Objectifs spécifiques :
- Doter les enfants travailleurs des connaissances nécessaires en matière de lutte
contre le VIH/SIDA ;
- Renforcer les connaissances sur le VIH/SIDA des adultes travaillant avec ces
enfants afin de réduire la propagation du VIH/SIDA aux enfants ;
- Protéger les filles travailleuses contre les violences sexuelles et grossesses précoces
afin de réduire le risque d’exposition au VIH ;
- Améliorer les conditions socio-économiques des enfants travailleurs.




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Description du projet, intervention et caractéristiques des bénéficiaires :
Le microprojet financé par le BIT pour une durée de 6 mois (septembre 2006 – février
2007) fait la prévention du VIH/SIDA auprès des enfants se trouvant dans les pires
formes de travail. Il cible notamment les enfants travaillant dans les mines et carrières
ainsi que les enfants travaillant dans les plantations de canne à sucre, de thé et ceux
faisant la pêche.


Réalisations/Etat d’avancement des activités:

- Sensibilisation des enfants travaillant dans les plantations des cannes à sucre, dans
les carrières d’extraction du sable, des pierres et des mines et orientation vers les
CDV;
- Soutien en matière de conseil aux enfants affectés ou infectés ;
- Formation des enfants enceintes et des enfants mères sur la santé de la reproduction ;
- Sensibilisation des parents sur leur rôle d'encadrement et de prise en charge des
enfants même mères ;
- Plaidoyer pour l'acceptation des filles mères pour l'obtention des services destinés
normalement aux femmes enceintes sans exiger les géniteurs, comme on le fait pour
les femmes mariées;
- Paiement des mutuelles de santé aux enfants travailleuses et travailleurs;
-   Distribution des animaux domestiques et matériels scolaires apprentissage de
l’élevage des cobayes et lapins pour améliorer leurs conditions socio-économiques ;
- Sensibilisation des employeurs, enseignants, parents et autres intervenants sur la loi
protégeant les enfants contre les pires formes de travail qui peuvent être un terrain
favorable au VIH ;
- Soutien psychologique (conseils) aux enfants ayant des problèmes particuliers.

Leçons apprises : Les enfants travaillant dans les pires formes de travail sont plus
vulnérables au VIH : ils n’ont pas d’accès à l’information sur le VIH/SIDA et ont des
rapports sexuels précoces; les filles sont en outre exposées aux violences sexuelles, au
harcèlement sexuel et aux grossesses non désirées.
La communication pour le changement de comportement et l’appui psycho-social
peuvent améliorer leur comportement et les prévenir du VIH/SIDA ainsi que des
grossesses non désirées.


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II-C-16. Projet de lutte contre le vih/sida : la prevention du
HIV/SIDA de l’Association Mwana Ukundwa (AMU)

Auteur : Uwizeye Glorieuse

Fonction : Adresse de l’auteur Coordinatrice du projet de lutte contre le VIH/SIDA
de l’A.M.U B.P 1719 Kigali, Tel 514648 ; Mob 08451670, email : gloryuw@yahoo.fr

Localisation géographique du projet: Kicukiro, Kigali Ville ; Huye province du
Sud et Karongi, province de l’Ouest.


Contexte/Problématique : L’A.M.U assiste 2000 orphelins et enfants vulnérables
principalement dans l’éducation formelle et informelle. Comme cette association
travaille avec les enfants et jeunes, il lui est impossible de croiser les bras face au
SIDA. C’est dans ce sens que depuis 2000, l’A.M.U intervient activement dans le
domaine de la prévention parmi ces bénéficiaires, au sein de leurs familles d’accueil
et la communauté locale.


Réalisations
- Formation et sensibilisation continues de 2000 bénéficiaires directs en matière de
lutte contre le VIH/SIDA, la santé de la reproduction, la violence sexuelle,
participation dans les activités des clubs anti-SIDA ainsi que la communication dans
la famille;
-   Formation des familles d’accueil, les enseignants des écoles primaires et
secondaires (58 enseignants et 6 directeurs) ainsi que 40 couples des pasteurs des
Eglises locales qui ont reçu le materiel nécessaire pour qu’elles puissent participer
activement dans la prévention du VIH chez les enfants et les jeunes qui sont dans
leurs familles, Eglises et écoles;
- Production des affiches, des autocollants, des livrets, et t-shirts en rapport avec le
VIH/SIDA;
- Organisation des compétitions des chansons, théâtres, poème et le sport dans le
cadre de faire passer les massage sur le VIH/SIDA avec des moyens plus créatifs,
attirant et permettant la participation des enfants et des jeunes.




                                                                                    188
Conclusion/Leçons apprises
- Pour protéger l’enfant ou le jeune il faut encourager non seulement sa participation
mais aussi celle de ses pairs, sa famille, son école et son Eglise.
- La production des documents est un moyen efficace et attirant qui permet à l’enfant
ou le jeune d’avoir accès à l’information qu’il peut transmettre facilement aux autres.




                                                                                    189
II- D. DOMAINE SOCIAL ET ECONOMIQUE




                                      190
II-D-1. Mentoring program for Child-Headed Households in Rwanda
BAMPOREZE ASSOCIATION
P.O. Box 2597 Kigali – Rwanda Tel: +250 08304120
Email: bamporeze2002@yahoo.fr

Background: Bamporeze Association is a local Rwandan Non Governmental
Organization (NGO) involved in activities that support Orphans and other Vulnerable
Children (OVC) in different parts of Rwanda. Bamporeze is officially recognized by
the government of Rwanda through the Ministerial Order n° 056 of November 6th
2002, as a local NGO.


Context: Rwanda has experienced civil strife that culminated in the 1994 genocide,
leaving more than 400,000 orphans without anyone to take care of them. The number
of orphans has increased tremendously with the increasing threat of HIV/AIDS. As a
consequence of the war/genocide, the social fabric was distorted; love, trust and
consideration for others were lost and the entire society became traumatized.


Emergency interventions like setting up orphanages and “foster-families” could not
yield significant results because orphans constituted a serious challenge. OVC
continued to experience trauma, isolation, and a vicious cycle of poverty. In response
to this complex situation, Bamporeze Association initiated the “Community Child
Mentorship Model”, which was innovated and is consistently being improved to
restore the cultural fabric that calls for each everyone in the community to collectively
take up the role of caring for children. 12,739 OVC have so far been integrated in the
program.


Bamporeze pioneered the Community Mentorship Program in November 2001, with
support of UNICEF in Rulindo District in the former Kigali-Ngali Province, currently
in the Northern Province. The program has now been extended to other districts in the
Northern and Eastern Provinces. New partners that have come to support the program
include: Kindernothilfe e.V. (Germany) and Firelight foundation (USA).


The concept of Community Child Mentoring: Community Child Mentoring or
Mentorship refers to the integration of vulnerable children into the community. The



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community takes up the responsibility to take care of the children as a collective
responsibility, basing on the Rwandan tradition, which emphasizes that “a child
belongs to everyone in the society”. Community Child Mentoring is based on the
following principles:
           •   Cultural norms and considerations;
           •   Community appreciation/participation;
           •   Respect of the child’s choice of his/her mentor;
           •   Voluntary spirit in the community;
           •   Love, trust, care, generosity, integrity and rationality;
           •   Child involvement and empowerment;
           •   Sustained dialogue of partners and stakeholders;
           •   Beneficiary/mentors support structures.


Case study project: “Empowerment of orphans and other Vulnerable Children
(OVC) and youth through Community Based Mentoring and Organic farming in
Rulindo District, Northern Province, Rwanda”


Results of the project
   o The project has provided a learning experience to everyone interested in Child
       Mentoring;
   o It is replicable and indeed has been replicated in other parts of the country;
   o    The project has revealed opportunities for further modification of the model,
       therefore flexible;
   o It is community owned and driven;
   o It has been widely appreciated by the community and local leadership.


Conclusion: Child Mentorship is an inspiration to children in difficult conditions and
therefore the best sustainable solution to the challenge of children infected/affected by
HIV and other OVC. However, there is still a lot to do with the ever increasing scale
up of the HIV/AIDS threat, and we call upon everyone concerned to join forces to
provide care and protection to the OVC.




                                                                                      192
II-D-2. Les différentes activités mises en place en vue de répondre
aux besoins dégagés par l’Etude PLACE, et les résultats obtenus par
l’intervention menée à musenyi.
Auteur : Marc Vaernewyck

Fonction et adresse de l’auteur : Directeur de programmes, BP 747 Kigali –
08303203

Localisation géographique du projet : Cellule Musenyi – secteur Karangazi -
District Nyagatare – Province de l’Est

Contexte/Problématique : Handicap International (HI) est une Organisation de
Solidarité Internationale présente au Rwanda depuis 1994. Fin 2005, Handicap
International s’est fixé comme objectif d’accroître sa capacité d’intervention dans le
domaine de la lutte contre le VIH/SIDA. Dans les premiers mois de 2006, la CNLS a
invité différentes ONGs, dont Handicap International, pour leur présenter les résultats
de l’Etude PLACE (Priorités Locales des efforts de Lutte Contre le SIDA). Les
ONG étaient sollicités pour des activités permettant d’augmenter la disponibilité des
messages et des outils de prévention dans les zones identifiées en se basant aux
recommandations de ladite étude.
HANDICAP INTERNATIONAL a décidé de travailler avec la communauté de
Musenyi, qui constitue une zone chaude car située sur le grand axe routier Kigali-
Kagitumba et à quelques kilomètres du Camp militaire de Gabiro.


Les objectifs de l’intervention/projet : Les objectifs de l’intervention sont repris ci-
après:
   1. Contribuer à la réduction de la séro-prévalence et du taux d’incidence dans la
         communauté de Musenyi;
   2. Renforcer les acteurs locaux pour une appropriation de la problématique du
         SIDA et une recherche des réponses adaptées aux besoins de la communauté;
   3. Encourager la communauté à se faire dépister et à mieux prendre en charge
         ses PVVIH;


Description de l’intervention et caractéristiques des bénéficiaires : Le projet
consiste à mener, à travers les acteurs locaux, une campagne de conscientisation au
sein de la communauté de Musenyi. Les bénéficiaires du projet, pour sa phase allant



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d’Août à Février 2007, ont été les écoliers de l’Ecole Primaire de Musenyi et les
jeunes pubères et adolescents, les femmes, les personnes vivant avec le VIH
appartenant à la section locale du RRP+, les membres du Club Anti-SIDA AMIZERO
ainsi que les tenanciers des cabarets et les boutiquiers.


Réalisations : L’intervention a commencé en Août 2006, et a connu les réalisations
suivantes :
   1. La Journée mondiale de lutte contre le SIDA a été célébrée, pour la première
       fois, à Musenyi, le 1er décembre 2006;
   2. Le club anti-sida AMIZERO, composé de militaires du Camp militaire de
       Gabiro et de civils de la localité de Musenyi avait été actif en 2005, mais
       n’avait mené aucune activité en 2006. Relancé en août 2006 avec le projet, ce
       club anti-sida a pu être lauréate du district Nyagatare dans les compétitions de
       la Journée mondiale de lutte contre le SIDA.
   3. Les leaders d’opinions ont favorisé un véritable dialogue social autour du sujet
       du VIH et SIDA, les occasions de rassemblement de masse, comme le Gacaca
       et les réunions des instances féminines ont été exploitées pour faire passer des
       messages;
   4. Environ 200 écoliers de l’Ecole Primaire de Musenyi ont suivi des activités
       d’encadrement et 20 d’entre eux ont participé à un concours culturel sur le
       VIH et le SIDA;
   5. Environ 42 personnes se sont fait dépister au Centre de santé de Karangazi et
       10 personnes vivant avec le VIH ont eu le courage de rejoindre la section
       locale du RRP+;
   6. La communauté a reçu du projet un modeste équipement d’IEC, à savoir un
       téléviseur et un magnétoscope. Une partie de calendriers que la CNLS a
       réservé à Handicap International a été donné à la communauté de Musenyi, et
       actuellement 80% des boutiques et cabarets de Musenyi ont affiché des
       calendriers ainsi que quelques affiches fournies par l’ONUSIDA.


Conclusion/Leçons apprises : Il a été constaté que l’approche proposée par l’Etude
PLACE est très efficace, car elle oriente des acteurs vers des zones spécifiques. Le
dialogue avec la communauté est plus que nécessaire pour que des résultats puissent
être pérennisés. Les leaders d’opinion et les structures de base sont incontournables


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pour s’assurer de la mobilisation de la population. Même si l’étude PLACE propose
des personnes/groupes cibles à approcher, il est apparu plus efficace de commencer
l’action sur le plan global (de la communauté) avant de se diriger vers des groupes
précis (comme les tenanciers de bars et de cabarets et les professionnelles du sexe).
L’aspect lié à la distribution des condoms est à examiner avec les acteurs locaux pour
s’assurer que les quantités données ne risquent pas d’être commercialisées. Des
affiches en Kinyarwanda sont à encourager pour la sensibilisation des communautés
rurales.




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II-D-3. Les différentes étapes à envisager afin d’asseoir la politique
de lutte contre le VIH/SIDA sur le lieu de travail.

Auteur : Marc Vaernewyck
Handicap International Rwanda
Localisation géographique du projet : Kigali


Contexte
Handicap International (HI) est une organisation de solidarité internationale présente
au Rwanda depuis 1994. Fin 2005, Handicap International s’est fixé comme objectif
d’accroître sa capacité d’intervention dans le domaine de la lutte contre le VIH/SIDA
afin de permettre aux personnes handicapées de bénéficier davantage de l’effort
national pour mieux se protéger du VIH et accéder aux soins. Pour envisager cet
objectif, la direction de HI Rwanda a estimé qu’il était avant toute chose nécessaire
d’être exemplaire en interne avant de prétendre être une organisation de référence
dans la lutte contre le VIH en faveur des personnes handicapées.


Les objectifs de l’intervention/projet :
L’objectif de l’intervention est double :
   1. Mettre en place une politique de lutte contre le VIH/SIDA sur le lieu du travail
       afin de permettre aux membres du personnel de se prévenir de la maladie, de
       connaître son statut sérologique et le cas échéant, de se faire soigner.
   2. Encourager chaque membre du personnel à jouer un rôle actif dans la lutte
       contre la pandémie aussi bien dans sa vie personnelle que dans sa vie
       collective.


Description de projet/intervention et caractéristiques des bénéficiaires :
L’intervention a consisté à mettre en place une politique de lutte contre le VIH/SIDA
sur le lieu de travail au bénéfice des collaborateurs de Handicap International Rwanda
et de leurs familles (conjoint(e) et enfants). Cette politique vise à promouvoir la
prévention, le dépistage et la prise en charge des membres du personnel infectés ou
affectés par le VIH ainsi qu’à faire en sorte que chaque membre du personnel soit en
mesure de jouer un rôle actif dans la lutte contre la pandémie dans ses différents
milieux de vie. Cette intervention s’est réalisée sur des fonds propres de l’association.




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Réalisations/Etat d’avancement (des activités) :
L’intervention s’est échelonnée de fin 2005 à fin 2006.
   1. Réalisation d’un questionnaire de connaissance sur le VIH administré à
       chaque membre du personnel (octobre 2005);
   2. Dépouillement des questionnaires et analyse du niveau de connaissances du
       personnel;
   3. Organisation de sept (7) réunions du personnel en vue de parfaire les
       connaissances du personnel à propos du VIH et de partager les représentations
       que les uns et les autres se font de la maladie de manière à ce que tous
       deviennent des « agents sensibilisateurs » efficaces dans leurs différents
       milieux de vie (novembre et décembre 2005);
   4. Deux opérations de dépistage volontaire des membres du              personnel en
       organisant le déplacement des personnes à l’ARBEF : 85% du personnel a
       accepté de se faire dépister (janvier 2006);
   5. Mise en place d’un « Comité du personnel VIH » chargé d’élaborer la
       politique de lutte contre le VIH sur le lieu de travail – élaboration d’un
       document – mise à disposition d’une enveloppe de 1,4 millions Frw (février –
       juin 2006);
   6. Mise en place de groupes de parole regroupant les membres du personnel afin
       d’échanger à propos du VIH (2006);
   7. Distribution de moustiquaires imprégnées aux familles du personnel
       (décembre 2006).


Conclusion/Leçons apprises : Il est apparu qu’il n’est pas aisé de parler de sexualité
et d’évoquer publiquement le VIH et ce, même si les bénéficiaires de l’intervention
sont tous des membres du personnel de Handicap International (toutes professions
confondues). Pour obtenir des résultats durables, il faut prendre le temps de se réunir,
de se parler et de « respecter le rythme » des participants.




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II-D-4. Programme d’accompagnement des personnes vivant avec le
VIH et les orphelins rejetés

Auteur: Mukankaka Valérie
Fonction et adresse de l’auteur : Représentante PAMASOR RWANDA;
Tél. : 08753555
E-mail :m.pamasor@yahoo.fr

Localisation géographique du projet: Kicukiro /MVK

Contexte/Problématique: PAMASOR RWANDA est une Organisation                       Non
Gouvernemental Local Sans but lucratif qui a vu le jour en 1992 dans un contexte où
les malades du SIDA étaient rejetés, abandonnés par leur famille et n’avaient pas
encore accès aux ARV. PAMASOR s’est donné comme objectif d’accompagner
dignement les malades du SIDA, leur apporter une assistance morale et matérielle
pour leur permettre de faire face aux problèmes liés à leur maladie ainsi que
l’encadrement des enfants orphelins et vulnérables du SIDA. Cette assistance passe à
travers les associations des PVVIH.


Réalisations
   •   Création et suivi des activités génératrices de revenus pour les PVVIH.
   •   Facilitation de l’accès aux structures de prise en charge médicale aux PVVIH.
   •   Scolarisation et éducation aux comportements, droits et devoirs sociaux des
       enfants orphelins en général et en particulier les orphelins du SIDA;
   •   Création de l’Ecole Saint Jacob section maternelle et primaire pour les OVCs
       et la population environnante;
   •   Recherche et suivi des familles d’accueil des enfants orphelins du SIDA;
   •   Création du Centre Village d’enfants pour ceux qui n’ont pas encore de
       famille d’accueil avec un projet de Biogaz pour l’obtention de l’énergie à
       moindre coût, du lait de vache et un jardin potager pour assurer la bonne
       nutrition des enfants.
   •   Visites à domicile des PVVIH pour fournir un appui psychosocial, se rendre
       compte de leur véritable problème et les aider à trouver la solution à ces
       problèmes.
   •   Création d’un dispensaire la MADONNE offrant des services de VCT pour la
       communauté en général et les familles des PVVIH en particulier.



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Conclusions/Leçons apprises
L’assistance apportée par PAMASOR aux PVVIH a permis de faire renaître en eux
un espoir de vie, de s’épanouir, de continuer à travailler pour leur famille et de vivre
positivement avec le VIH/SIDA. PAMASOR a appris que les deux piliers majeurs
pour arriver à cela consistent à fournir à la fois l’appui socio-économique et un appui
psychosocial permanent.
Une fois que le ménage se stabilise dans sa vie, ceci permet une bonne adhésion à la
prise en charge médicale du VIH.
La confiance née de cette intervention devrait être mise à profit pour l’instauration
d’un service de VCT en faveur de la communauté de nos bénéficiaires.




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II-D-5. Exposition des objets d’art produits par les femmes
vulnérables et les orphelins et autres enfants vulnérables

Auteur: FEMMES VULNERABLES ET OVCs

Fonction et adresse de l’auteur : Bénéficiaires des projets réalisés au sein du
« Village of Hope ».

Localisation géographique: Secteur Kinyinya, Cellule Gacuriro, District GASABO

Contexte/problématique: Le génocide qu’a connu le Rwanda a fait beaucoup de
morts et les gens sont devenus responsables prématurément. En plus du génocide,
s’ajoute la pandémie du VIH/SIDA qui ravage le monde avec une forte vitesse dans
les pays en développement où se trouve le Rwanda et par conséquent empire la
situation des personnes touchées par les conséquences. Avec tous ces problèmes que
rencontrent ces gens, il a fallu penser à des stratégies pour essayer de réparer ces
cœurs déchirés par cet événement tragique et des personnes infectées et affectées par
ce fléau. Parmi les entrepreneurs de bonne volonté qui ont manifesté l’intérêt de
contribuer   à   la   reconstruction    du    pays    figurent   les   organisations   non
gouvernementales entre autre le « Rwanda Women’s Network ». C’est dans ce cadre
que cette organisation a pris le devant pour initier des projets et programmes visant à
améliorer des conditions socio-économiques des plus démunis et défavorisés à savoir
les femmes et les enfants.


Objectifs de l’intervention/projet
-Promouvoir la pérennité des programmes menés dans le « Village of Hope » par la
mise sur pied des activités génératrices des revenus;
-Accroître le revenu des bénéficiaires par la vente des produits finis;
-Créer l’esprit d’entraide mutuelle, de créativité et d’initiative;
-Promouvoir l’appropriation et le sens responsabilité parmi les bénéficiaires.




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Description du projet/intervention et caractéristiques des bénéficiaires :
L’intervention a commencé en 1998 et se situe dans le cadre du programme
d’autofinancement mis sur pied dans le cadre de faire participer les personnes qui
reçoivent différents services offerts par le centre. Elle aide aussi aux bénéficiaires à
s’approprier des interventions car se sont les mêmes individus qui choisissent ce
qu’ils doivent faire et comment le faire.
Les activités de ce programme tournent autour du renforcement des capacités socio
économiques par l’apprentissage des métiers, l‘éducation et la mobilisation. Primo
les bénéficiaires sont les femmes vulnérables rescapées dont la majorité est composée
des femmes violées pendant le génocide et veuves et qui, par conséquent, ont été
infectées par le VIH/SIDA. Les autres femmes vulnérables sont aussi intégrées dans
le programme. Secundo, l’intervention rassemble les OVCs issus de ces familles
parmi eux un petit nombre d’enfants sont infectés par le VIH/SIDA ainsi que les
autres qui sont intéressés par le travail qui se fait au sein du centre. Le critère commun
des bénéficiaires est la vulnérabilité se présentant sous différentes formes.


Réalisations:
   1) 29 OVCs ont déjà bénéficié de la formation en couture et broderie qu’ils
       produisent pour la vente;
   2) 38 OVCs ont produit des cartes postales;
   3) 25 femmes fabriquent des perles;
   4) 15 femmes tissent des tricots;
   5) 106 fabriquent les couvre –lits et les nappes de tables en fils;
   6) Les OVCs forment une troupe de danse pour générer des revenus et ainsi
       donner le message de lutte contre le VIH-SIDA à travers les chansons, danses
       etc
   7) Les femmes se rencontrent au sein du centre pour produire et discuter d’autres
       problèmes de la vie et essayer de trouver des solutions possibles.


Conclusion/Leçons apprises
Comme leçon à partager, le travail collectif ouvre une voie à la réconciliation et
l’unité. Il permet l’esprit de responsabilité par la répartition des tâches de tout un
chacun au sein du groupe. Il véhicule enfin le message de franche collaboration et de
bien gérer la chose publique par le fait qu’il est fait par les bénéficiaires et pour les


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bénéficiaires. Comme message principal, il est nécessaire de créer de telles espaces
pour que les femmes et les enfants vulnérables puissent contribuer au développement
par la résolution des problèmes qui les entourent. Cette idée se manifeste par la
volonté de multiplier ces centres dans tous les coins du pays. Aujourd’hui, « Rwanda
Women’s Network » compte 4 centres (Kagugu, Nyamirambo, Bugesera et Huye).
Contraintes : On citera comme contrainte majeure le manque de moyens suffisants
pour servir tous ceux qui sollicitent nos services avec la qualité souhaitée.




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II-D-6. Le suivi des enfants et adolescents affectés et/ou infectés par le
VIH/SIDA au sien de UYISENGA N’IMANZI.

Author : UYISENGA N’IMANZI

Contexte

Le programme de lutte contre le VIH/SIDA au sein de UYISENGA N’IMANZI s’est
focalisé sur les enfants chefs de ménage affectés et/ou infectés par le VIH/ SIDA
depuis la création de l’organisation en 2002. Depuis lors, il figure parmi les
intervenants oeuvrant dans les domaines de prise en charge psychosociale,
économique et de prévention.


UYISENGA N’IMANZI assure le suivi de 2462 enfants, dont 90% d’adolescents, le
groupe cible le plus important au Rwanda au niveau des dix districts du Pays.


UYISENGA N’IMANZI s’occupe non seulement des conséquences personnelles,
familiales, sociales et économiques découlant du diagnostic d’infection par le VIH
mais aussi de la stigmatisation sociale que ce diagnostic entraîne, d’autant plus que
UYISENGA N’IMANZI intervient dans des populations vivant dans des conditions
de vie difficiles. Elle s’occupe des enfants orphelins chefs de ménage.


Résultats
   •   Un groupe rassemblant une trentaine d’enfants chaque mois. Les objectifs
       principaux de ce groupe sont l’expression des émotions, le travail sur les
       représentations familiales, apporter une aide à l’intégration de l’information
       reçue récemment sur le VIH/SIDA, le diagnostic, l’abstinence, la fidélité,
       l’usage du condom, le changement de comportement, etc.
   •   25 groupes sont formés dans les dix districts du pays. Au sein de ces groupes
       se trouvent ceux qui vivent avec le VIH/SIDA et ceux qui ne sont pas
       infectés.
   •   C’est à travers ces groupes que toutes les activités sont organisées à savoir la
       prise en charge à domicile, le dépistage etc. UYISENGA N’IMANZI envisage
       d’atteindre le développement intégral de la personne, c’est-à-dire le
       développement qui implique l'amélioration et le progrès des conditions
       économiques, sociales, culturelles. C’est dans ce sens que UYISENGA


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    N’IMANZI travaille d’arrache-pied pour que les besoins de base comme
    l'accès à l'éducation, aux services de santé et de sécurité sociale, à
    l'alimentation, au logement soient mis à la disposition des enfants.
•   Il y a aussi l’organisation des événements culturels et sportifs dans le cadre de
    la cohésion sociale, la lutte contre la stigmatisation, la guérison sociale et
    communautaire.
•   Ces groupes de soutien ne sont pas statiques. Ils se développent et se changent
    en coopératives dans le cadre des activités génératrices de revenu, en clubs
    antisida, certains étant jeunes forment les troupes de danse et de théâtres tandis
    que les autres forment les équipes sportives;
•   Nous assurons aussi un suivi individuel.




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II-D-7. Accompagnement psychosocial et éducation alternative pour
enfants infectés et affectés par le VIH

Auteur : Maria Goretti Mukanzigiye, Coordinatrice de CIESPD
CIESPD (Chrisitian Initiative of Education for Sustainable Peace and Development)

Localisation géographique du programme : Districts de Kicukiro, Gasabo.


Justification
Dans notre pays, le nombre d’orphelins et autres enfants vulnérables est très élevé
comparativement aux autres pays africains, il s’élève à 3.200.000. Les chefs de
ménages sont plus de 50.000, et ce nombre reste croissant à cause du VIH/SIDA.
Quelques orphelins du Sida et du génocide qui ne sont pas assistés dans leurs besoins
socio-économiques ou psychosociaux se cherchent les voies de sortie : ils deviennent
prostituées, mendiants, voleurs, enfants de la rue etc.
Ce programme vise le développement holistique et la prévention du Sida chez les
orphelins et autres enfants vulnérables.


Description des activites de 2006
   •   Education: 120 enfants/jeunes ont été assistés pour leur éducation secondaire.
   •   La formation de 40 CARE GIVERS pour accompagner et faire le plaidoyer en
       faveur de 1200 enfants/jeunes affectés/infectés par le VIH/SIDA. Ces 40
       volontaires que nous appelons « AMIS, DEFENSEURS DES ENFANTS » ont été
       formés et sensibilisés sur :
          (1) les droits de l’enfant, (2) la protection des droits de l’enfant dans le droit
          rwandais, (3) les besoins psychosociaux des orphelins et autres enfants
          vulnérables affectés/infectés par le VIH/SIDA, (4) comment sensibiliser les
          parents vivant avec le VIH/SIDA pour qu’ils puissent informer leurs enfants
          sur la situation de leur vie et leur constituer une boîte des souvenirs, (5) le rôle
          de la communauté et l’Eglise dans l’accompagnement psychosocial des
          orphelins et autres enfants vulnérables, (6) les cas d’études des autres pays
          d’Afrique et d’Asie sur l’accompagnement psychosocial en faveur des OEV
          affectés/infectés par le VIH/SIDA, (7) les techniques de médiation, (8) les
          techniques de plaidoyer en faveur des OEV, (9) la sensibilisation sur la santé
          de la reproduction et la lutte contre le SIDA, (9) la participation des enfants,


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           (10) Comment créer les CARE GROUPES pour assister les OEV affectés et
           infectés par le VHI/SIDA.
       •   L’orchestre des jeunes des OEV : ils ont été assistés pour améliorer leurs
           talents en musique et danse. Ceci les a aidés non seulement pour devenir les
           professionnels en musique et danse mais aussi réduire le problème de
           discrimination et de sous-estimation pour ces OEV.
       •   Plaidoyer en faveur des OEV pour l’accès à l’éducation : CIESPD a servi
           d’exemple en introduisant le programme de l’éducation alternative du niveau
           secondaire, pour faciliter l’accès à l’éducation des OEV qui ne peuvent pas
           étudier dans le système éducatif formel comme les autres enfants. L’accès à
           l’éducation pour les OEV affectés/infectés est considéré comme la clé pour
           leur accès au bien être socio-économique. Nous élevons la voix en faveur de
           sans « voix » pour qu’ils aient l’accès à l’éducation.
       •   La sensibilisation des Eglises sur les droits des enfants et les besoins
           psychosociaux des orphelins affectés/infectés par le VIH/SIDA: c’est dans
           le but de chercher et encourager les personnes/parents qui peuvent se donner
           la peine d’accueillir ou tout simplement d’accompagner les OEV. Plus ils ne
           sont pas accompagnés plus ils sont exposés au fléau du Sida. Là où les parents
           biologiques ne sont plus, les parents adoptifs peuvent assister, éduquer et
           accompagner les OEV.


Leçons apprises et conclusion
Tout enfant affecté/infecté par le VIH/SIDA a besoin d’un accompagnateur et de l’accès à
l’éducation. La communauté peut faire l’accompagnement psychosocial             si elle est
sensibilisée/formée.   L’accès à l’éducation est la seule clé au développement socio-
économique pour tous les enfants y compris les OEV affectés/infectés par le VIH/SIDA.
C’est leur droit fondamental, chaque adulte devrait tout faire pour aider les OEV à
accéder et terminer leur éducation suivant les capacités et la potentialité de tout enfant.
Non seulement les OEV ont besoin d’avoir accès à l’éducation primaire et secondaire ou
à la formation professionnelle, mais aussi d ‘une assistance matérielle pour se sentir à
l’aise au banc de l’école.




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II-D-8. Role de l’Umbrella des Confessions Religieuses dans le
renforcement des activités de lutte contre le VIH/SIDA des
confessions religieuses et les FBOS.
Auteur : NGARUKIYE Stanis et BIGABO Félix
         Tel : 08304030
         E-mail : tostan2000@yahoo.fr ou felbig@yahoo.fr

Localisation : RCLS-Rwanda /District de Gasabo

Contexte/problématique
L’umbrella     des confessions religieuses est un réseau                  des confessions
religieuses engagées dans la lutte contre le VIH/SIDA au Rwanda, créée en
2003, sous l’appui      de la CNLS. Ce        réseau   a pour mission        d’harmoniser,
renforcer et promouvoir tous les programmes de lutte contre le VIH/SIDA
dans toutes les confessions religieuses. Avant l’existence de ce réseau, les
églises/mosquées en général, et en particulier les leaders religieux n’étaient pas
impliqués      dans     les activités    de lutte contre le SIDA. Ce dernier était
considéré comme un défi des agents de la santé, et mêmes certains fidèles
disaient que la pandémie du VIH/SIDA ne concerne pas les fidèles (chrétiens
ou musulmans). La          coordination du RCLS-Rwanda organise souvent des
réunions et ateliers d’échange dans le cadre de renforcer les activités de lutte
contre le SIDA menées par les confessions religieuses.


Réalisations
La coordination       de l’Umbrella     des   confessions   religieuses    a organisé   des
conférences nationales     des confessions religieuses visant à obtenir l’implication
totale des leaders religieux dans la lutte contre la pandémie du VIH/SIDA. En
2004, il y a eu organisation de la 3ème conférence nationale              sur le « rôle des
confessions religieuses dans la réduction des nouvelles infections du VIH/SIDA
et dans la prise en charge des ses conséquences », cette conférence avait réuni
plus de 160 leaders religieux du pays, et plus de 20 autres qui représentaient
leurs organisations internationales. Cette année,           du 12 au 13 Février, la
Coordination de l’Umbrella des confessions religieuses en partenariat avec le
PSI, a organisé la 4ème conférence annuelle des leaders religieux sur « le rôle
des institutions religieuses dans la mise en œuvre des politiques du planning



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familial   et de la prévention du VIH/SIDA », plus de 300 leaders et acteurs
religieux ont participé dans cette conférence.
Dans le cadre d’échange d’expériences de bonnes pratiques en matière des
activités de lutte contre le VIH/SIDA : deux ateliers d’échange et de suivi des
Confessions religieuses ont eu lieu à Kigali, respectivement au mois d’août et
décembre 2006,         auxquels        plus    de     50   représentants    des      organisations
communautaires à base religieuse ont participé.


Conclusion /Leçons apprises : A l’issue de                 ces conférences        nationales     et
ateliers   d’échange      sur    les   activités      du   VIH/SIDA,       presque    toutes    les
confessions religieuses membres du RC LS-Rwanda, ont commencé à intégrer le
programme du VIH/SIDA dans leurs activités. Il y a eu mise en place                             des
services de prise en charge sociale et spirituelle des PVVIH+, campagnes de
mobilisation   des     fidèles    religieux,    les    échanges    d’expérience       entre     les
organisations communautaires à base religieuse amènent                       ces dernières à
améliorer leurs actions de lutte contre le VIH/SIDA. Les leaders religieux se
sont engagés à multiplier d’efforts dans les activités de lutte contre le SIDA,
soutenir les stratégies visant à renforcer le pouvoir des femmes et filles                     dans
la lutte contre le SIDA et les ISTs.




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II-D-9. Renforcement des mesures de prévention du VIH/SIDA
par la prise en charge scolaire et l’apprentissage des métiers
chez les jeunes

Auteur : Pasteur NSABIMANA Jonas
Fonction et adresse de l’auteur : Président de l’Association, Tél : 08613483.
E-mail: pastjonask@yahoo.fr
Localisation géographique : Province de l’Est, District de Ngoma , Secteur de
Remera, Cellule Nyamagana


Contexte
La pandémie du VIH/SIDA constitue un handicap             pour le développement
communautaire. L’ACDIA était soucieux des enfants en âge scolaire tellement
nombreux des secteurs Remera et Kibungo, qui sont infectés et ou affectés
par le VIH/SIDA et qui ne pouvaient pas aller à l’école. Pour pallier à ce
problème, d’une part les enfants en âge scolaire pouvaient être réintégrés à
l’école et d’autre part, ceux en âge avancé, pouvaient bénéficier des formations
professionnelles. C’est ainsi que     l’ACDIA a initié ce       sous-projet   afin
d’atténuer l’impact du SIDA par la prise en charge scolaire des enfants de
l’école primaire et promouvoir      l’enseignement des métiers en faveur des
enfants orphelins chefs de ménage affectés par le VIH/SIDA.


Réalisations
Concernant l’action scolaire, 200 enfants infectés et affectés ont bénéficié du
matériel scolaire et des frais de scolarité.   200 enfants ont été sensibilisés à
respecter l’hygiène corporel et ont reçu       du matériel hygiénique (savons de
lessives, vaselines).
Ces enfants ont aussi bénéficié des uniformes et des chaussures.
Concernant     la formation professionnelle, l’association dispose d’un atelier de
couture ayant 11 machines à      coudre. 20 enfants infectés et affectés par le
VIH/SIDA ont suivi une formation en coupe couture. Pour le renforcement des
capacités économiques, 150 chèvres ont été offertes à 150 familles des enfants
infectés et affectés par le VIH/SIDA.




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Conclusion/Leçons apprises
Les   200 enfants qui ont bénéficié de l’assistance scolaire, continuent leurs
études dans les différentes écoles primaires de deux secteurs du District de
Ngoma . Grâce à l’activité de couture, 20 enfants formés en coupe-couture
parviennent à gagner des marchés pour leurs produits et          ainsi gagnent de
l’argent. Grâce au revenu de l’élevage des chèvres, 150 familles qui en ont
bénéficié parviennent à trouver de l’argent et engrais organiques pour la culture .




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II-D-10. Care for OVC and PLWHA
Author: Sebukire Jerôme

Title and adress: CHAMP/CRS COORDINATOR
Operational area of the projet: IN 20 DISTRICTS COVERED BY CHAMP

Project/intervention description and characteristics of beneficiaries: OVC AND
PLWHA

Achievements/progress of (activities) and conclusion/learned lessons:
The HIV/AIDS pandemic came to add to the already heavy burden of genocide and
war in Rwanda. With 1,260,000 Orphans and Vulnerable Children including 101,000
child-headed households, Rwandans urgently needed assistance in ensuring that these
future generations are well cared for and have access to basic services such as
nutrition, education, health care etc.
This will be achieved through capacity building of communities, families and orphans
to respond to the needs of OVCs and their families; CRS also works with faith-based
and community based partners in sustaining their capacity to deliver high quality
services to OVCs. During the past two years, the project has reduced the real number
of Rwandan children who would remain vulnerable, by enrolling 10,000 children
aged between 8 and 18 into primary and secondary schools and ensuring their medical
care.

As a member of the Consortium led by CHF – International to implement the four-
year USAID - Funded CHAMP, CRS is responsible for supporting OVCs and Home-
Based Palliative Care in the twenty districts covered by CHAMP : Bugesera,
Gakenke, Gasabo, Gatsibo, Gicumbi, Kamonyi, Karongi, Kicukiro, Muhanga,
Ngororero, Nyabihu, Nyagatare, Nyamagabe, Nyaruguru, Nyarugenge, Rubavu,
Ruhango, Rulindo, Rutsiro and Rwamagana as follows:


           •   8,003 OVC in primary school
           •   1,086 under 5 years
           •   714 in secondary school
           •   197 Child-Headed Households




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CRS works in partnership with the National and Diocesan Caritas staff for support
   and monitoring of OVCs in primary and secondary schools by organizing psycho
   support camps during vacation, home-based palliative care to PLWHA, nutrition
   care for OVCs affected or infected with HIV/AIDS and socio-economic
   strenghtening for local communities to ensure sustainability of services to OVCs
   and PLWHA. This project has contributed to the decrease of the number of
   children exposed to bad behaviours, to the street and to poor health conditions.
In collaboration with the FOSA, ASP and volunteers in each parish have ensured the
follow-up of the households’ beneficiaries of the health scheme « Mutuelles de
Santé »: some dioceses assisted for the family photographs to be inserted in the
adhesion booklets, each household received their booklet and sick people got medical
care without problems.
Families were trainied on seeking care and the advantages of being a member of the
health insurance.
After the purchase made in Kigali, a three-month stock of SOSOMA was distributed
to the 5 dioceses. SOSOMA was distributed to households with OVCs infected, OVC
showing signs of malnutrition and CHH.
Volunteers and ASP from each parish ensured the distribution of the ration of each
OVC. Each OVC’s family receives 7 kgs per month. This quantity contributed to the
other indirect beneficiaries inside the households as well, reaching 1398 households
served.
After receiving the training of trainers on SILC (saving and lending methodology),
the 6 diocesan agents trained the 17 ASPs on SILC methodology and its
implementation in the community group.
Discussions have been made with the local authorities about the methodology. The
issues of safety for the money-holder had been discussed and some local authorities
were reluctant about the methodology.
In Rwamagana and Kibungo, caregivers have been integrated in SILC groups. In
Kigali, SILC groups have been set up, with parents or mentors of OVC but also their
neighbors. General rules discussed and adopted such as the amount of contribution to
be given by each member of the group and the frequency of meetings. For example,
they meet once a month and give contribution varying between 500 and 1000
Rwandan francs.



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CRS and CHF continued to support and built the capacity of Caritas. Program
manager from CRS organized weekly programming meetings in order to ensure
follow-up of Caritas implementation and to coordinate technical assistance to be
provided to the field.


CRS and Caritas M&E officers took part in the second session of M&E training
organized by CHAMP at CHF headquarters. They participated also in the second
training organized in Musanze District related to the use of the new CHAMP
database.
CRS and Caritas participated also in the BCC workshop organized in Kibuye,
« Centre Bethanie » related to the integration of CHAMP topics in « Urunana »
broadcasted serials.
In order to ensure the quality of its partnership, CRS organized a workshop
regrouping his partners including Caritas Rwanda. CHAMP was used as a good
reference for transparent and well-defined partnership among all CRS projects.
Meanwhile, CRS organized a second workshop with all its four HIV/AIDS related
projects including CHAMP in order to enhance its shared vision and its HIV/AIDS
continuum of care and support strategies to the most vulnerable in Rwanda.
Linkages between CHAMP as a community-based program and AIDS Relief as a
clinical-based project was discussed and an action plan to start was identified in
Northern Province (Bungwe, Rushaki and Muhura health centers).


CRS, following the family-based approach, trained the 250 volunteers during the
previous quarter to assist the OVC but also provide palliative care to their infected
parents.
During this quarter, each volunteer received a home-based care kit (see annex: content
of the HBC Kit) and a bicycle. Each of them signs a contract in order to ensure proper
use of the bicycle. They were formally introduced to the local authorities, the FOSA
and the community.


Each volunteer made home visits to PLWHA and in total they provided care and
support to 726 households.




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Caritas identified new volunteers in new parishes to replace those of Kibungo Diocese
which were removed from the program. (The new USAID intervention zone). There
are four new parishes in Kigali ((Ste Famille, St Pierre Cyahafi, Masaka and
Rwankuba) and 3 parishes in Kabgayi Diocese (Kivumu, Nyarusange, and Gihara).
As said earlier, each ASP contacted the FOSA where OVC and their families receive
care. The list of OVC and all of the household members where shared with the FOSA
to ensure the provision of services under the health insurance (mutuelles de santé).


Linkages with local authorities during the distribution ceremony of the home-based-
care kits and the bicycles to volunteers and during the holiday camps. Authorities
participated not only through formal speech during the opening ceremony but also
played an active role as a facilitator of the holiday camp. For CRS/Caritas, such
participation shows the level of collaboration and linkages with the community.
Each Diocese submitted CHAMP beneficiary lists to local authorities.


CRS/Caritas developed and finalized its M&E handbook including all the forms and
the M&E system applied to the different levels from the community to national
Caritas. These M&E tools was shared and discussed with diocesan teams in order to
include their feed-back and inputs. The next steps are the sharing with CHF and
CHAMP partners.
   •   Master register;
   •   Identification Form of a beneciary;
   •   Individual form;
   •   Work visits in parishes;
   •   Control form of community volunteer/caregiver;
   •   Control of lists to make sure there is no duplication. All the lists from each
       Diocese are being compiled in Excel. So, the verification is easier.


In order to assess the achievements of the program, a joint-field trip was done with the
CRS country representative and Caritas team leader in Kigali, meetings and
discussions with OVC, family and community were done using the work plan as a
checklist.




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II-D-11. The provision of social and economic support to people
living with HIV and their families
Author: Bruce NIZEYE, PIH POSER COORDINATOR, Inshuti Mu Buzima,
Rwinkwavu, Rwanda.

Operational area of the project: Inshuti Mu Buzima (PIH in Rwanda) with its
POSER program is currently working in two public district hospitals (Rwinkwavu and
Kirehe hospitals) and four health centers (Mulindi, Rukira, Rusumo and Nyaburuye),
with a collective catchment area of 425,000 people.

Program description and characteristics of beneficiaries: The US-based NGO
Partners In Health (PIH), in partnership with the Rwandan Ministry of Health,
launched an integrated HIV and primary care program in two rural health districts.
Between June 2005 and February 2007, through POSER, our target population
includes HIV patients enrolled on ART (2,000 by the end of 2006; 3,000 by the end of
2007), thousands more HIV-positive patients whose health status we are monitoring,
AIDS orphans and vulnerable children, and other HIV-affected households. In 2006,
POSER reached an estimated number of 4,800-5,000 beneficiaries. In 2007 our goal
is to reach more than 10,000 beneficiaries.


Context: In December 2005, PIH inaugurated the Program on Social and Economic
Rights (POSER) in Rwanda which was modeled after our successful approach to HIV
and patient care in Haiti. Through this program, we have learned a great deal from
this inaugural year of programming as we have adapted our POSER model to the
specific needs and context of the communities we serve in Rwanda.        This program
covers several categories, including Health and Social Services, Pediatric, Nutrition,
Hospice/Housing, and Capacity Building. These are seven main POSER program
areas in Rwanda.


Objectives of the program: The Program on Social and Economic Rights – the goal
of which is to meet the basic needs of HIV patients, their families, and other HIV-
affected households. Within 20 years of experience in the prevention and treatment of
HIV in one of the world’s poorest countries, PIH recognizes the inextricable link
between HIV and poverty. Therefore, the provision of social and economic support to
people living with HIV and their families is a crucial step in stemming the tide of the
HIV pandemic. – services that both improve HIV patient adherence to treatment and


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help to break the cycle of poverty that leads to disease and ill health in resource-poor
settings.


Achievements/Progress of activities:
1)      Housing for HIV patients
Towards the end of 2005 and over the last year, PIH has built homes for 55 HIV-
positive patients from across our six sites. Other 300 patients have received support
in the form of roofing or siding materials to bolster their existing homes.
2)      Support for schooling for HIV-affected children
In the last year, PIH has initiated school-wide prevention education and voluntary
counseling and testing for HIV as well as training on dental care, personal hygiene,
and safe water use, at primary schools in the Rwinkwavu area. Through this effort,
we are reaching more than 10,000 children. We are working with 10 schools to
provide uniforms, books, notebooks, pens, and school lunches to 2,000 children in
need. We are also paying school fees for HIV-affected students at secondary schools
(which charge enrollment fees). We paid school fees for 300 students in 2006 and
will expand to 600 students in 2007.
3)      Infant formula for HIV-positive mothers
PIH currently has 735 HIV-positive mothers and 747 infants enrolled in our
prevention of mother-to-child transmission program (PMTCT) program, which
includes clinical monitoring, treatment for mothers, and prophylactic ART to prevent
vertical transmission to newborns.
4)      Specialized medical services for HIV patients
On occasion, our patients need specialized tests or care that we are not equipped to
provide at Rwinkwavu or Kirehe hospitals, and we must transfer them to Kigali.
Through POSER, we ensure transportation costs to transfer patients to Kigali and fees
for medical services costs.
5)      Vocational training for HIV patients
In 2006, PIH began a construction workshop at Rwinkwavu hospital. This program
serves two purposes – to provide a workshop where we can build much of the basic
furniture needed in our clinics far more cost-effectively than purchasing them, and to
provide vocational training for patients and others in the community. In 2006-2007,
the program will continue to bring in trainees in groups of 10-15 to participate in six
months of vocational training in carpentry, welding, sewing, art work and masonry.


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24 first tainees finished their 6 months training in those domains in January 2007.
6)     Micro-grants/loans for associations of people living with HIV/AIDS
In 2006, in the first year of this initiative, PIH has already made 20 grants in the
Rwinkwavu area and 20 in Kirehe area, totaling 40 grants.           In 2007 we have
anticipated by making 100 grants, as we expand the program to our five other sites.
7)     Payment of medical insurance fees (mutuelles) for HIV patients
PIH has agreed to pay the mutuelles (1000 Rwandan francs per individual per year, or
US$5) for our most impoverished HIV patients. We anticipate paying such fees for
38,000 patients in 2007, whose 12% (6,000) will be HIV patients.


Conclusion/learned lessons: The services offered through the POSER program have
an immediate and great impact on the health outcomes of HIV patients and the well-
being of HIV-affected families and households. Most obviously, patients who have
adequate food, housing, and support are better able to adhere to treatment and avoid
debilitating AIDS-related infections. They are more likely to remain in their homes
and communities rather than being cared for in clinic settings, thus lessening the
social isolation of HIV/AIDS and offering an example of positive living to combat the
stigma surrounding the disease, which in turn encourages others to get tested. The
program offers children from households impacted by HIV the chance to have access
to education and better plan their life prospects.      Providing HIV patients with
vocational training empowers them to put their lives on track by obtaining
employment and sufficient income. We hope through expanding POSER services and
developing additional partnerships we will expand our social support programs in the
areas of agriculture, microfinance, water, etc to maximize the long term impact these
programs have on families.




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II-D-12. Rwanda’s National HIV & AIDS-related Digital Library
(RNHDL); progress during 2006.

Authors: Scialfa, Tom (Tulane University), Bagorozi Ndimurukundo, Mike (Tulane
University), Afrika Fulgence (CNLS), Alice Mukaneza (TRAC)
Organization responsible: Tulane University, CNLS, TRAC.

Context: Gray literature is that which is produced on all levels of government,
business and industry in print and electronic formats, not controlled by commercial
publishers (GreyNet 1999).       Most of the “evidence” that is needed to make
geographically-specific, evidence-based decisions is in the form of gray literature; this
is particularly true for low income countries. Rwanda-specific, HIV & AIDS-related
gray literature is, for the most part, neither available nor accessible. In Rwanda,
trained human resources with good technical writing, research and analytic skills are
scarcer than in any other African country due to the lingering demographic impact of
the genocide making it even more difficult to promote a culture that embraces – rather
than fearing – evidence-based decision making.


Objectives of the RNHDL:
   1. To collect, archive and organize Rwanda-specific, HIV & AIDS-related, full
       text gray literature and resources in a searchable national, digital library;
   2. To facilitated access to - and promote the use of – the RNHDL;
   3. To improve the usability of the RNHDL holdings thereby increasing the
       probability that it will be used for (better) evidence-based decision-making;
   4. To help the CNLS continually improve its’ annual research exchange
       conference & provide needed inventories to better coordinate programs,
       research & reporting;
   5. To reinforce technical report writing, analytic and research capacity of
       Rwandans;


Description of intervention: Rwanda’s National HIV & AIDS Digital Library
(RNHDL) is a collaborative initiative between the CNLS, TRAC the MOH’s division
of plan and Tulane University. This RNHDL assembles full-text resources that cover




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the entire range of resource types4 relative to its’ multi-sector response to HIV &
AIDS. Its’ focus is on Rwanda-specific, gray literature. Development of this digital
library is a continuous, iterative process: done within the context of the 5S Digital
Library framework and what is known about document & user-interface usability.
However, it goes beyond this by turning the library into a proactive capacity-building
intervention by systematically applying the usability criteria that we developed to
resources obtained. Resources that satisfy the usability criteria move from the non-
verified to the verified collections (thereby affirming to users that these are more
usable). The people that apply the criteria to the resources improve their technical
writing and analytic skills. By sending feedback on the results of applying these
criteria to the authors - and requesting revisions by the authors and authoring
institutions - they too increase their technical writing and analytic skills. The library
also indexes its’ holdings for browsing by (1) title (2) resource “type” (3) “sectors”
implicated (4) organization producing the resource.                                     Because of the diversity of
“types” of resources that the library holds the targeted user audience are all literate
people interested in HIV & AIDS in Rwanda with access to the internet. Searches can
be made within the title, abstract, table of contents, full text or within specific meta
data elements.


Achievements: Library creation began in late 2005 but it was really in early 2006
when progress accelerated and by December 31st, 2006 we had:
• Developed the libraries resource collection tools and procedures;
• Revised & expanded usability criteria & restructured the Greenstone Libraries
     database (see RNHDL JointTechnicalRptModificaitons2Organization FINAL
     July06.pdf);
• Conducted 1st phase inventorying and resource collection; there are now > 370
     resources               from             Rwanda                 available              in           the            RNHDL
     http://www.cnls.gov.rw/digitallibrary.php;
• Trained the CNLS, TRAC, Tulane team in database maintenance & using the
     criteria;




4
    This refers to the type of media that is available in the RNHDL, it could be a document, a poster, map, audiovisual material, etc



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• Begun reviewing all abstracts that were disseminated by the CNLS’ in 2005 and
 2006 during the 1st and 2nd annual Rwandan HIV & AIDS research exchange
 conference.


Lessons learned: Collecting resources is slow and requires much patience.
Designing and configuring Greenstone digital library software proved to be more
challenging than we had anticipated (but it’s free). It took many revisions to the
usability criteria to render the results of its use sufficiently consistent between users.
The RNHDL’s resources are insuffient and consequently (a) usability criteria have
been used on only a few documents meaning nearly all remain in the {non-verified}
collections. People who are not familiar with the subject matter can still apply the
usability criteria if training is provided. In early 2007, we will promote and increase
the use of the RNHDL, seek additional resources and begin the 2nd round of resource
collection.




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II-E. POLITIQUE ET MISE EN ŒUVRE DES
      PROGRAMMES




                                       221
II-E-1. Building capacity in health human resources – the
NURSPH’S Executive MPH Program

Author: Laura J. Haas, MBA, PhD
Title and address: Deputy Director, Support to the Rwanda SPH Project; Payson
Center for International Development; 300 Hébert Hall, Tulane University; New
Orleans, LA 70118

Geographic location of the project: NURSPH, Kigali, Rwanda


Project description and target group characteristics: The purpose of the Executive
MPH program is to equip experienced health officers with the necessary
competencies for improved planning, managing, and assessing of health services to be
provided to the people of Rwanda. At the end of the MPH program, a graduate will be
able to function as a public health specialist or manager of health services in
accordance with international standards. He/she will be expected to be a leader in
improving health status, overseeing clinical health care delivery, and promoting health
and preventing disease. The MPH program extends over a period of two academic
years and consists of eight learning modules, six of which include fieldwork
assignments, and the development and defense of a thesis as requirements for the
award of the degree. Disciplinary areas include epidemiology; biostatistics;
demography; social, behavioral and management sciences; economics; and
environmental sciences. Traditionally, recruits were selected from among directors of
health districts and directors of hospitals, focusing on district level leadership. More
recent intakes have seen an expansion of MOH candidates and include several from
the central level in addition to private students, primarily from the NGO sector. The
MPH program has also been successful in attracting candidates from neighboring
countries with several graduates from Democratic Republic of the Congo.
Context: As Rwanda faces important human resource constraints in the health sector
in the aftermath of the genocide; Tulane University developed, in conjunction with
the Ministry of Education (MOE), the National University of Rwanda (NUR), and the
Ministry of Health (MOH); a model workforce development strategy for
strengthening and mobilizing the higher education infrastructure in support of societal
reform. This strategic alliance is based upon the belief that Schools of Public Health
(SPH) are critical institutions in promoting rapid transitions from crisis to sustainable


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development. These Schools are the key agents of social change within the health
sector as they are commonly responsible for providing both in-service as well as
graduate education to the leadership of the health sector. More specifically, Tulane
has assisted the MOE/NUR to develop a new School of Public Health that emphasizes
strengthening the mid-level technical and managerial levels within the health sector.
As part of this capacity development activity, Tulane and NURSPH launched an in-
service Executive MPH degree program as a direct response to these capacity needs.


Program objectives: Equip health professionals with the required knowledge for
planning, management and evaluation of health services in order to improve the
health of the Rwandan population.


Specific Objectives: Upon completion of the Executive MPH program, students
should be able to:
1) Promote health and prevent disease.
2) Direct clinical health care delivery.
3) Supervise health services and manage health personnel.
4) Provide leadership to improve public health.


Achievements: Of the 46 students who have begun the Executive program, 37% have
been awarded the MPH degree while the remainder have completed all coursework
requirements and continue to progress towards completion of the required thesis.
Women have participated in all three intakes and their participation has increased
from 10% in the first year of the program to 30% in the latter two intakes. The fourth
MPH intake began in January 2007.


Conclusion/Lessons learned: The arrival of the NURSPH to Kigali has dramatically
increased the MPH program’s visibility and facilitated access to potential students.
Demand for the School’s training programs continues to increase and outstrips its
current capacity to satisfy demand in terms of adequate facilities and qualified faculty.
Efforts will continue to expand the NURSPH’s capacity to deliver quality education
and training via more innovative training formats and the transformation of its
curricula into distance formats to meet this high demand.



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II-E-2. APPROCHE MOBILE POUR LE TRAITEMENT AUX
ARVS PAR LES MEDECINS DE L’HOPITAL DE DISTRICT

Auteurs: Laetitia Gahimbaza, M.D., Gerard Ngendahimana, M.D., Chantal
Ndikubwimana, Stephanie Marion-Landais, MPH

Fonction et adresse: Laetitia Gahimbaza, M.D., ART Team Leader, The Capacity
Project, Kigali, Rwanda ; Gerard Ngendahimana, M.D., Deputy Director, The
Capacity Project, Kigali, Rwanda ; Chantal Ndikubwimana, Nursing ART Advisor,
The Capacity Project, Kigali, Rwanda ; Stephanie Marion-Landais, MPH, Program
Officer, The Capacity Project, Kigali, Rwanda

Localisation géographique du projet: Rulindo, Gicumbi, Nyagatare, Gatsibo,
Kayonza et Rwamagana

Contexte
Le Projet IntraHealth International/ Capacity appuie les activités de lutte contre le
VIH/SIDA dans 5 districts du Rwanda. Dans un contexte où seuls les médecins sont
autorisés à prescrire les ARVs, il appuie les activités de traitement du VIH/SIDA par
les ARVs dans 8 formations sanitaires, dont 7 sont des centres de santé sans
médecins et avec un personnel infirmier insuffisant.


Objectifs du projet
Pour une bonne intégration de ce nouveau service ART et le développement des
compétences locales, ce sont les médecins de l’Hôpital de District qui font des
descentes dans les Centres de Santé pour prescrire les ARVs et assurer le suivi des
patients enrôlés et une meilleure prise en charge des autres patients.


Description du projet et caractéristiques des bénéficiaires
L’Hôpital de District disponibilise un médecin qui va prester toute la journée dans les
centres de santé, une fois par semaine. Le projet supporte les frais de location de la
voiture et le per diem du médecin, les frais de communication entre le médecin, le
titulaire du centre de santé et le Directeur de l’Hôpital de District. Il supporte aussi les
frais de déplacement et le per diem pour les visites à domicile et les références et
contre-références des patients sous ARVs. Ainsi, l’infirmier qui se trouve sur le site
joue un plus grand rôle dans la prise en charge des patients VIH/SIDA et peut
demander un avis médical en cas de difficultés, aussi bien pour les patients VIH/SIDA
que pour les autres cas compliqués pour lui. Ces médecins sont aussi en contact par



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téléphone avec un médecin du projet expérimenté dans le traitement aux ARVs pour
avis éventuels.


Réalisations
L’Hôpital de District s’implique directement dans le programme. Quand le médecin
est là, il ne s’occupe pas seulement des personnes sous traitement ARV, il voit aussi
les autres malades qui nécessitent une consultation par un médecin et donne son avis
pour les personnes hospitalisées. C’est une occasion pour lui de former et superviser
l’équipe soignante du centre de santé. Avec cette approche, l’ouverture d’autres sites
sera facile et moins coûteuse. Le service de traitement étant bien intégré dans les
autres services, il sera plus facile de les céder au district à la fin du Projet.
L’implication des médecins de l’hôpital de district dans le traitement et le suivi des
patients sous traitement ARV permet une intégration du service et contribue à
améliorer la qualité des soins dans les centres de santé périphériques.




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II-E-3. La communauté s’implique et les résultats suivent

Auteurs: Emile Sempabwa, Community Participation, Communication & Field
Coordination Team Leader, Twubakane/IntraHealth International; Jean Marie
Sinari, Community Health Coordinator, Twubakane

Localisation géographique du projet:
Activités au niveau central, et dans 12 districts avec une population de 3,2 millions
(Kigali : Gasabo, Kicukiro et Nyarugenge ; Est : Kayonza, Kirehe, Ngoma,
Rwamagana ; Sud : Kamonyi, Muhanga, Nyamagabe, Nyaruguru, Ruhango)

Contexte/Problématique
Le secteur étant l’unité de base pour tout le développement global du District, il
compte en général un ou deux centres de santé (CS). Chaque CS a un comité de santé
qui s’occupe de sa gestion financière. Mais, selon les études, ce comité s’intéresse peu
au rôle de liaison avec les membres de la communauté pour identifier les problèmes
de santé importants. Pour combler cette lacune, le Ministère de la Santé, en étroite
collaboration avec ses partenaires dont le Programme « Twubakane » de
Décentralisation et de Santé, a mis sur pied des stratégies d’implication
communautaire dont celle du PAQ pour la définition et l’amélioration de la qualité
des services offerts dans les formations sanitaires de base.


But : Impliquer pleinement les communautés dans la résolution des problèmes de
santé pour une meilleure santé et un développement durable.


Description de projet/interventions et caractéristiques des bénéficiaires : (en
cours en 2006). Le Programme « Twubakane » de Décentralisation et de Santé, géré
par IntraHealth International, a pour but d’accroître l’accès, la qualité et l’utilisation
des services de santé familiale au niveau des formations sanitaires et des
communautés. Le Partenariat pour l’amélioration de la Qualité (PAQ) est un
partenariat entre les formations sanitaires et les communautés qu’elles servent.
L’approche PAQ explore et comble tous les liens manquants à une meilleure
participation communautaire car, regroupant tous les partenaires de la vie du secteur
dans laquelle la formation sanitaire est implanté, elle ramène chacun des acteurs
communautaires à la conscientisation, la responsabilisation, l’appropriation, la
compréhension et la planification commune pour la résolution des problèmes


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conjointement identifiés. Le PAQ contribue donc à améliorer l’accès, la qualité,
et l’utilisation continue des services de santé.


Objectifs de l’intervention
1) impliquer les autorités locales, les leaders d’opinions, la société civile, les
organisations locales et toute personne physique ou morale influente de la
communauté, dans la mobilisation de cette dernière pour la gestion de leurs services et
problèmes de santé; 2) contribuer à l’amélioration de la qualité des soins offerts par
les centres de santé et les hôpitaux.


Réalisations
Le Programme Twubakane a aidé les autorités des districts, des secteurs et des
formations sanitaires à établir des équipes PAQ dans 78 centres de santé. D’ici mi
2007, il y aura 134 équipes PAQ dans les 12 districts couverts par Twubakane. Grâce
à ces équipes PAQ, qui se réunissent régulièrement, la qualité des services offerts
dans les services de santé est perçue communément par les prestataires et les
représentants de la communauté. Les problèmes identifiés sont résolus à temps, par
niveau de responsabilité et avec le concours de chaque organe représenté dans les
équipes PAQ y compris les comités des mutuelles, les églises, les agents de santé
communautaires et les organes élus. En effet, chaque équipe PAQ a pu identifier les
solutions aux problèmes de santé y compris ceux liés à la non utilisation du planning
familial, les problèmes rencontrés par les personnes vivant avec le VIH qui n’ont pas
toujours accès aux services ARV, la non utilisation du service de CDV, et les
problèmes généraux liés à l’hygiène du CS ainsi que le mauvais accueil. Les équipes
PAQ contribuent ensuite à la résolution des problèmes, notamment par une meilleure
utilisation de la PF en faisant la sensibilisation, (un CS est passé de 8,8% à 15% en
moins de 5 mois), un plaidoyer avec les autorités du district pour les services ARV,
une meilleure hygiène par la construction des latrines et réparation des sources d’eau,
et un meilleur accueil grâce au dialogue avec les prestataires.


Conclusion/Leçons apprises
Grâce aux équipes PAQ, la responsabilisation et la collaboration entre leaders/acteurs
communautaires et prestataires deviennent effectives avec une planification conjointe
pour résoudre les problèmes identifiés, et ainsi, une amélioration consécutive des


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indicateurs de santé. L’approche PAQ est donc indispensable pour une résolution
durable des problèmes d’accès, qualité et utilisation des services de santé par
l’implication des communautés concernées.




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II-E-4. Les actions de la démarche de plaidoyer ayant permis
l’inclusion des personnes handicapées dans la lutte contre le
VIH/SIDA au Rwanda
Auteur : Marc Vaernewyck
Fonction et adresse de l’auteur : Directeur de Programme de Handicap
International Rwanda, BP 747 Kigali – mvaernewyck@hi.org.rw – mob. 00250 0830
3203

Localisation géographique du projet : Rwanda - Kigali

Contexte/problématique : Au Rwanda, on considère à tort que les personnes
handicapées sont inactives sur le plan sexuel et sont moins exposées aux risques de
violences sexuelles et de viol par rapport aux personnes valides. Des études menées
auprès de jeunes gens handicapés au Rwanda ont permis de découvrir que la plupart
d’entre eux étaient informés de l’existence de l’épidémie du VIH/SIDA, mais que
leurs connaissances sur sa prévention et sa transmission étaient médiocres. Au sein de
la société rwandaise, on considère que les personnes handicapées n’ont pas d’activité
sexuelle, ou du moins que leur activité est moins active que celle des personnes sans
handicap. Par conséquent, la majorité des personnes croient que les rapports sexuels
avec une personne handicapée comportent moins de risques. Dans certaines régions
du Rwanda, une croyance répandue veut qu’avoir des rapports sexuels avec une
personne handicapée porte chance. Par ailleurs, ces études soulignent que les
personnes handicapées sont particulièrement vulnérables à cause de leur pauvreté, de
la difficulté qu’elles ont à nouer des relations stables et le fait que la plupart d’entre
elles, les filles et les femmes en particulier, sont exposées au risque d’assujettissement
sexuel ou de violences sexuelles. Les personnes handicapées sont sujettes à un
fardeau double en ce qui concerne le VIH/SIDA, à savoir un risque croissant
d’infection et un accès réduit à la prévention et aux soins.


Les objectifs de l’intervention/projet : L’intervention a consisté à planifier des
actions de plaidoyer de manière à convaincre la CNLS à prendre des mesures face au
problème et à rectifier sa stratégie de lutte contre le VIH/SIDA afin d’inclure les
personnes handicapées comme un groupe à risques à part entière nécessitant d’être
pris en compte dans les différents programmes de lutte contre le VIH.




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Description du projet/intervention et caractéristiques des bénéficiaires : Les
personnes handicapées n’étaient pas prises en compte comme groupe à risque dans le
« Cadre Stratégique National de Lutte contre le SIDA 2002-2006 ». L’intervention
initiée par Handicap International, fin 2005 et début 2006, en concertation avec le
mouvement des personnes handicapées rwandais, a consisté à réaliser une démarche
de plaidoyer vis-à-vis de la CNLS afin que celle-ci corrige cet oubli.   Fin 2006, le
Plan Stratégique National Multisectoriel de Lutte contre le VIH/SIDA 2005-2009
inclut la population en situation de handicap dans les groupes à risques et l’Umbrella
des Associations de Personnes Handicapées luttant contre le Sida (UAPHLS) est
opérationnelle grâce à l’appui de la CNLS. Cette intervention a été réalisée sur des
fonds propres de HI.
Réalisations/Etat d’avancement (des activités) : Les différentes actions de
plaidoyer ont été les suivantes :
1.     Rassembler l’information sur la problématique du VIH et du Handicap. Il a
ainsi été possible de découvrir sur Internet une étude récente réalisée par l’ONG
« Save the Children » intitulée « Double Fardeau », Dr Aisha Yousafzi et Karen
Edwards du Centre for International Child Health (1994) et de prendre toute la mesure
du problème. Rassembler également les données statistiques disponibles afin de
quantifier la problématique (novembre 2005).
2.     « Prendre la parole et faire le plaidoyer» lors du Séminaire participatif
(décembre 2005) organisé par la CNLS visant à prendre les avis des acteurs afin
d’élaborer le futur Plan Stratégique.
3.     Remercier et confirmer le plaidoyer par un courrier consigné par la Fédération
des Associations et des Centres pour Handicapés du Rwanda (FACHR) et par les
principales associations nationales de personnes handicapées accompagnés d’un
mémo et adressé au Secrétaire Exécutif de la CNLS (janvier 2006).
4.     Se réunir avec le Secrétaire Exécutif de la CNLS et la FACHR pour chercher
les meilleurs moyens d’inclure les personnes handicapées dans les programmes de
lutte contre le VIH (avril 2006). Le Secrétaire Exécutif a proposé la création d’une
Umbrella des Associations de Personnes Handicapées Luttant contre le SIDA
(UAPHLS)




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Conclusion/Leçons apprises : Le plaidoyer en faveur d’une cause doit impliquer les
principaux intéressés et s’appuyer sur des données fiables et convaincantes (études et
statistiques).




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II-E-5. Le renforcement de l’adhésion aux services de santé par les
agents de santé communautaires
Auteurs : Mukandanga Odette1, Sowaf Ubarijoro2, Marthe Mukaminega3, Jeroen
van’t Pad Bosh3, Jaques Rutabagaya2, Nancy Fitch4

Fonction et adresse de l’auteur: 1Senior Technical Officer PMTCT/VCT/OI,
Technical Advisor2, Senior Technical Advisor3, Country Director4
Elizabeth Glaser Pediatric AIDS Foundation-RWANDA

Localisation géographique du projet: Notre programme dessert 8 districts
administratifs dont Nyarugenge, Gasabo, Kicukiro, Rwamagana, Gatsibo, Gakenke,
Burera, et Musanze spécialement dans les Centres santé de Kabusunzu, Butamwa,
Jali, Masaka, Rubungo, Gikomero, Nyagasambu, Nzige, Rubona, Gituza,
Nyagahanga, Ngarama, Kabere, Mataba, Kinyababa et Dispensaire Muhima.

Problématique : Les services de santé sont supposés être implantés dans un milieu
où ils viennent apporter des solutions aux problèmes de santé qui handicapent le bien
être en général (morbidité et mortalité) en particulier de la population dans une zone
bien définie. Le Service de CDV/PTME /ARVs existent, mais l’utilisation de ces
services est toujours inférieure :
   •   L’effectif des personnes VIH+ qui arrivent dans la prise en charge (ARVs)
       reste toujours bas;
   •   Le taux d’accouchement des femmes positives faible diminue l’utilisation
       efficace du service PTME;
   •   Le manque de suivi des enfants exposés diminue le nombre des enfants testés;
   •   Les grossesses répétées observées chez les femmes infectées ;
   •   Le manque des connaissances sur comment et quand adhérer aux services
       ARVs.
Cependant, l’accès et l’utilisation de ces     services   continue à être un défi qui
préoccupe le Ministre de la santé et surtout les Partenaires car les services y relatifs
disponibles au niveau des FOSA semblent ne pas être suffisamment utilisé.


Objectifs spécifiques
1. Informer les agents de santé communautaire sur le VIH/SIDA et d’autres IST
ainsi que sur les activités de prise en charge disponibles aux FOSA et dans la
communauté.



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2. Enseigner les animateurs de santé comment encourager les PVVIH à vivre
positivement avec le VIH/SIDA ;
3. Aider les animateurs de santé à faire le suivi dans la communauté et assurer
l’orientation et l’adhésion des PVVIH aux services            appropriés (CDV, PTME,
ARVs. PF, soins palliatifs, nutrition etc);
4. Faire comprendre        aux animateurs de santé que la confidentialité est         très
importante en général et en particulier pour les PVVIH;
5. Enseigner les animateurs de santé sur la planification de leurs activités, le suivi et
l’évaluation pour connaître l’évolution de leur travail;
6. Donner les connaissances de base sur le counselling (surtout du couple et enfants),
soins palliatifs, nutrition et le Planning Familial.


Description de l’intervention et caractéristiques des bénéficiaires :         EGAPF en
s’appuyant sur le programme des Agents de Santé Communautaire                 existant, a
développé une approche plus efficace d’impliquer la Communauté dans
l’amélioration de l’accès et l’utilisation des services des hôpitaux et/ou centre de santé
à travers les agents de santé communautaire (adhésion aux services sanitaires). Les
agents de Santé Communautaire (animateurs de santé, accompagnatrices) reçoivent
une formation approfondie de 5 jours sur la pandémie du VIH/SIDA; en mettant
l’accent sur la personne infectée et affectée par le VIH en général et sur le suivi et la
prise en charge de l’enfant exposé en particulier.
La nouveauté de cette approche est qu’au cours de cette formation, ils apprennent
comment faire une planification y compris le suivi et l’évaluation de leurs activités
qui facilitera la réalisation de leurs objectifs.


Etat d’avancement des activités:
-Programme proposé, discuté avec le MINISANTE;
-Animateurs de santé et accompagnatrices identifiés;
-Développement des outils de gestion du programme;
-Formation des formateurs au niveau des différents districts appuyés par EGPAF (4
par district);
-Formation des animateurs de santé et accompagnatrices a chaque site (21);
-Le programme des agents de santé communautaires est fonctionnel;
-Appui technique et financier pour la mise en œuvre de ce programme.


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Conclusion:
Avec les agents de santé communautaire:
   •   Participation communautaire en matière du VIH/SIDA;
   •   Le programme est durable;
   •   L’adhérence aux services rendus aux PVVIH sera améliorée;
   •   Les personnes qui ont été perdus de vue (PTME, CDV, ARV) seraient réduits.




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II-E-6. Expérience d’avsi dans la prise en charge psychosociale des
enfants infectés par le VIH/SIDA

Auteurs : Daniella Kayitesi; responsable de la santé, Rachel Nyiracumi ; chargée de
la Santé des OVCs. AVSI BP : 3185, Kigali, Rwanda. E-mail : kigali@avsi.org

Localisation géographique : District de Kamonyi, Ruhango, Nyanza et Gatsibo.


Contexte : des milliers d’enfants séropositifs voient leur monde s’effondrer à cause
de cette pandémie. Quand ils perdent leurs parents, ils n’ont ni protection ni espoir
pour l’avenir.
Vu la situation socio-économique de ces enfants, leur accès au traitement s’avère
impossible sans appui extérieur. Ces enfants sont souvent victimes des
discriminations et se heurtent à des obstacles innombrables.
Soucieux d’améliorer l’état de santé de ces enfants, un paquet complet d’interventions
est donné pour leur assurer l’espoir pour l’avenir.


Objectif de l’intervention/projet : Garantir aux enfants infectés un paquet complet
des services de prise en charge psycho sanitaire.


Description du projet:/intervention et caractère des bénéficiaires :
Cette intervention est en faveur de 34 enfants séropositifs sous le traitement ARV ;
ces enfants sont répartis sur les 4 districts. Certains sont des orphelins de deux parents
qui vivent dans des familles d’accueil, d’autres sont dans des familles des enfants
chefs de ménage et d’autres des orphelins d’un seul parent. L’intervention ne se limite
pas seulement à l’enfant mais également à toute sa famille. Dans la plupart des cas on
trouve plus d’un seul enfant infecté dans une famille.


Réalisation/état d’avancement des activités : Ce projet était en cours en 2006.
Les soins de santé sont garantis pour chaque famille des enfants infectés à travers le
payement de la mutuelle de santé.
Pour les personnes infectées de chaque ménage les soins non couverts par les
mutuelles de santé sont payés ainsi que d’autres facilités comme le transport, la
restauration et le logement.




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Pour les personnes sous le traitement en ARV qui doivent faire un voyage pour
prendre le traitement au cas où les services compétents sont éloignés de sa résidence,
les mêmes facilités de transport, de restauration et de logement leur sont assurées.
Comme l’infection à VIH compromet le statut nutritionnel des ces enfants et que les
infections opportunistes rendent encore leur santé plus déplorable, un appui
nutritionnel est accordé à tous les ménages ayant un enfant infecté.
Des jardins potagers sont mis à leur disposition pour améliorer leur état nutritionnel,
des tuteurs de ces enfants sont regroupés dans une association pour le jardin potager
avec les mamans des autres enfants mal nourri pris en charge par AVSI dans chaque
district concerné. Ces associations sont appuyées matériellement et techniquement par
AVSI et bénéficient des semences, du matériel agricole et des formations relatives à la
nutrition, la santé en général, l’hygiène etc.
Des visites de suivi aux domiciles de ces enfants sont effectuées par le personnel
social au moins une fois par mois.
Des associations génératrices de revenue sont mises en place pour les tuteurs de ces
enfants pour les aider à améliorer leur niveau de vie.


Conclusion/Leçons apprises: Les soins complets pour les enfants infectés ont
sensiblement diminué par rapport à leur situation de vulnérabilité. La santé de leur
ménage s’est améliorée et grâce aux associations, ces enfants ont réintégrés
socialement.




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II-E-7. Groupes de soutien pour enfants séropositifs: participation
active des enfants dans leur maladie

Auteurs : Jeannine Uwera1, Jeanne d'Arc Nyirajyambere2, Joséphine
Mukamuganga3, Claire Gazille4, Janet Alonso5, Johan van Griensven6 pour le projet
VIH MSF-OCB, Kigali-Rwanda
1
 MSF-OCB, psychologue; 2MSF-OCB, responsable formation et communication;
3
 MSF-OCB,        responsable IEC et communication 2003-2006; 4MSF-OCB,
coordinatrice projet VIH 2006; 5MSF-OCB, MD, coordinatrice médical, 6 MSF-OCB,
MD, responsable de documentation, projet VIH, Kigali-Rwanda.

Localisation: Centre de santé Kinyinya et Kimironko

Problématique
Les enfants ont le droit de connaître la vérité sur leur statut sérologique. Ils
comprennent quand les adultes essayent de leur cacher quelque chose de grave grâce à
leur sensibilité. Des groupes de soutien pour enfants ont été mis en place, appuyés par
MSF. Le but des groupes est de créer un environnement où les enfants peuvent
s'exprimer et développer une attitude de vie positive (vis-à-vis du VIH), entourés par
d'autres enfants aussi atteints par le VIH.


Réalisations
Aider les enfants à comprendre ce qui se passe dans leur vie, les aider à accepter les
vérités difficiles, c'est commencer par leur raconter la vérité sur le VIH/SIDA. Durant
les sessions sur le CDV pour enfants, le statut est relevé individuellement. Ensuite, la
participation à un groupe de soutien est proposée à chaque enfant dépisté VIH-positif,
à partir de l'âge de 7 ans.          Dans une ambiance sécurisante, préservant la
confidentialité, les sujets proposés par les enfants sont abordés avec beaucoup
d'attention dans un espace qu'ils méritent:
       VIH (quoi, pourquoi et comment ?)
       la vie et la mort
       le changement physiologique du corps humain et vie sexuelle,
       discrimination, comment la famille perçoit un enfant séropositif.
Les enfants ne s'expriment pas seulement à travers la parole, mais aussi à travers des
jeux, des dessins, des contes…etc.




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Les groupes se réunissent une fois par mois (deux fois par mois pendant les vacances)
et sont encadrés par une assistante sociale, avec l'appui d'une psychologue.
Actuellement 94 enfants participent dans 3 groupes avec un groupe spécial pour les
enfants plus âgés (12-18 ans).


Leçons apprises et conclusion
Les groupes de soutien peuvent augmenter l'acceptation du VIH et le bien-être
psychosocial de l'enfant. Il est donc important que chaque enfant puisse bénéficier de
la participation à un groupe de soutien. Un des défis du programme est le manque de
ressources financières pourv intégrer d’autres enfants séropositifs.




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II-E-8. Multi-sectoral partnerships to improve community-based
HIV/AIDS services in Rwanda

Authors: CHF International-Rwanda / CHAMP
Geographic location of program: 20 Districts in Rwanda


Objectives/issues of program:        The Community HIV/AIDS Mobilization Program
(CHAMP) is a four-year PEPFAR-funded multi-sectoral partnership model consisting of 6
international partners and 9 local Rwandan organizations. These national partners in turn
link with 997 community-based organizations (CBO) at the grassroots level maximizing
the program’s geographical coverage.
CHAMP has three main objectives:
1.) To mobilize and strengthen the capacity of Rwandan organizations in providing a
continuum of community-based HIV/AIDS services;
2.) To improve and expand the continuum of HIV/AIDS community-based services
throughout Rwanda; and
3.) To build and strengthen linkages and referral systems between community-based and
clinical service providers.


Description of activities: CHAMP focuses on six main areas of intervention: capacity
building, linkages, palliative care, orphans and vulnerable children (OVC), behavior
change communication and monitoring and evaluation.


Lessons learned:
•   Through this model the program was able to rapidly scale up geographically and reach
    needy individuals in remote areas throughout the country, with individuals served
    reaching unexpected levels.
•   The model strengthens linkages between community-based services and decentralized
    health systems and structures to provide comprehensive and holistic services.
•   The transfer of skills in cascade easily flows vertically and horizontally for maximal
    impact and sustainability.
•   Building upon Rwandan government strategies and systems, especially at the
    decentralized level helps harmonize tools nationwide, and paves the way for
    sustainability.



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Conclusion: After one year of implementation, the program covers two-thirds of the
country and has reached 17,000 OVC and 15,000 PLWHA with essential community-
based care and support services, including economic and psychosocial support. In addition,
more than 13,000 individuals have been reached with HIV prevention messages. Close to
5,000 community volunteers have been trained to provide quality services. The partnership
model enhances program ownership by beneficiaries and community leaders, and
maximizes potential for sustainability.




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II-E-9. Reducing missed opportunities for early identification and
care or referral of HIV-exposed and infected infants and children
through integrating an HIV component into IMCI strategy in
Rwanda.
Author : Yameogo Mathias

Title and adress of the author : Conseiller technique en Santé Maternelle,
Néonatale et Infantile, BASICS, Ministère de la Santé, Kigali, Rwanda

Co-authors :
Field Nger Mary Lyn, BASICS, Washington DC, USA; Ilibagiza Denise, chargée du
bureau de Lutte contre les Maladies de l’Enfant, Ministère de la Santé, Kigali,
Rwanda ; Ekpo Gloria, BASICS, Washington DC, USA

Context/Issue: In Rwanda, significant efforts are being made by the government and
its partners to increase the number of children accessing pediatric care and treatment
services. Between 2005 and 2006, childhood access to antiretrovirals improved by
200%, and bringing the number of children being treated to 1,443. Although the
number of health facilities providing antiretrovirals to children is on the rise, health
professionals and communities are not prepared to identify and refer infants and
children who need care and treatment early in the course of their HIV disease. This
ultimately results in numerous missed opportunities for identifying and treating HIV-
exposed children in the formal health sector, or even providing a basic care package
through community workers and NGOs.
Established by WHO in 1995, the Integrated Management of Childhood Illnesses
(IMCI) strategy has been implemented in a considerable number of African countries,
including Rwanda. The goal of IMCI is to reduce under-5 mortality by addressing its
five primary causes: acute respiratory infections, diarrhea, malaria, measles, and
malnutrition. Given the increasing importance of HIV as a contributor to morbidity in
children, it is necessary to integrate HIV into the IMCI strategy as a way to reduce
missed opportunities and contribute to improvements in the early identification of
HIV-exposed and infected children who need care.


Achievemnts: With technical assistance from USAID’s BASICS project and other
child survival partners in 2006, the Rwandan Ministry of Health developed a process
for integrating HIV into the national IMCI strategy, based on WHO’s work in this
area. This comprised the incorporation of information from four sources into WHO’s



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IMCI materials. These included the HIV training modules used nationally in Rwanda,
the guide for care of HIV-infected children, the guide for PMTCT, and WHO’s
complementary module on ICMI-HIV.
The plan is that all sick children under the age of five be seen by trained providers in
health facilities and systematically assessed for the five primary causes listed above
and HIV exposure. The children are then classified according to the assessment
results, care and treatment (if needed) are provided according to the established
algorithm, mothers are given counseling on HIV infection and related problems, and
necessary follow-up is planned.
Between July 2006 and February 2007, a total of 73 Rwandan service providers
covering a target population of 86,300 children under the age of five were trained in
IMCI-HIV. Using their experience from the field, participants contributed to
improving training materials during the first training course. A post-training follow-
up plan is currently underway, which will help better clarify results obtained in the
field.


Conclusion/Learned lessons:       The trainees’ acquisition of skills in IMCI was
considered to be excellent. For example, during the clinical practice, an average of
95% of the cases of sick children—for all causes, including HIV—were managed
correctly by the participants, according to the instructions they received. The
implementation of IMCI in Rwanda provides an excellent opportunity for the
integration of HIV into child health and reducing missed opportunities for early
identification and care or referral of HIV-exposed and infected infants and children.




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II-E-10. Defining and integrating nursing competencies in
HIV/AIDS, Gender and Family Planning in A1 Nursing and
Midwifery Programs
Author: Josephine Mukakalisa, Viviane Mukakarara, RN, Stephanie Marion-Landais,
MPH, Gerard Ngendahimana, M.D.

Title and Adress: Josephine Mukakalisa, Nursing Education Associate, The Capacity
Project, Kigali, Rwanda ; Viviane Mukakarara, RN, Nursing Education Team Leader,
The Capacity Project, Kigali, Rwanda ; Stephanie Marion-Landais, MPH, Program
Officer, The Capacity Project, Kigali, Rwanda; Gerard Ngendahimana, M.D., Deputy
Director, The Capacity Project, Kigali, Rwanda

Geographic location of the Project: Rwamagana École des Sciences Infirmières,
Kibungo Ecole des Sciences Infirmières, Nyagatare Ecole des Sciences Infirmières,
Byumba Ecole des Sciences Infirmières, et Kabgayi Ecole des Sciences Infirmières



Context/the issue of the project: Rwanda’s HIV prevalence has been estimated at a
rising 7.3% in urban areas and at 2.2% in the rural areas. The involvement of the
Rwandan government and the availability of funding from various donors have fueled
the diversification of HIV interventions and the increase of care and treatment
programs for PLWHA in Rwanda. Although HIV programs have multiplied, nursing
personnel is not always well prepared to take on care and treatment of PLWHA.


Project objectives: Encouraged by the minister’s 2003 directives which described the
accessibility of CT, treatment, and other services, and the government’s desire to
integrate other programs such as family planning and gender into nursing education,
the new lessons have quickly been integrated. In addition, with the country’s reform
of nursing and midwifery training programs, the concurrent elaboration on the A1
curricula provided a convenient opportunity to integrate the new A1 curricula in
HIV/AIDS, family planning, and gender. The competencies are as follows:
    1. HIV/AIDS prevention and treatment;
    2. Family Planning;
    3. Gender.




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Project description and target group characteristics:
In February 2005, in collaboration with IntraHealth, the Minister of Health organized
a needs assessment for the HIV/AIDS curricula in the 5 A1 nursing and midwifery
schools. This assessment showed that the HIV/AIDS, family planning, and gender
content have not been properly integrated into the curricula of the 5 nursing and
midwifery programs. The next steps included identification of nursing competencies
in HIV/AIDS.


Achievements: As Rwanda has been greatly affected by the brain drain, there are
very few existing trained personnel in nursing, particularly HIV/AIDS care and
treatment. This posed a challenge for finding the appropriate number of staff to train
the A1 nursing and midwifery students. In addition, there was a lack of up-to-date
reference documents which the trainers could use as teaching materials. Every A1
nursing and midwifery student should receive rigorous theoretical training which
integrates core competencies on HIV/AIDS, family planning and gender.           Once
trained on these competencies, nurses quickly integrate their knowledge into practice
during their hospital practicums and, once matriculated, will be prepared to provide
quality care and treatment for patients.




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II-E-11. Le succès de l’intégration des services: exemple des
consultations prénatales focalisées.

Auteurs : Dr. Defa Wane, Cheffe d’Equipe de la Qualité des Services et de la Santé
Communautaire, Twubakane ; Daphrose Nyirasafali, Coordinatrice de la Santé
Reproductive/ Planification Familiale, Twubakane ; Dr. Pascal Musoni,
Coordinateur de la lutte contre le Paludisme, Twubakane

Localisation géographique du projet:
Niveau central et dans 12 districts (Kigali : Gasabo, Kicukiro et Nyarugenge ; Est :
Kayonza, Kirehe, Ngoma, Rwamagana ; Sud : Kamonyi, Muhanga, Nyamagabe,
Nyaruguru, Ruhango)

Contexte/Problématique : L’intégration des services, définie comme « l’offre
proactive d’un paquet de services de santé à un même bénéficiaire, dans une même
formation sanitaire et au même moment » permet d’accroitre l’accès aux soins, la
qualité et l’utilisation des services, de réduire les occasions manquées, de maximiser
l’utilisation des ressources du client et du système de santé. A contrario, les approches
verticales sont plus coûteuses et moins bénéfiques pour les patients, les prestataires,
les formations sanitaires et les programmes. Au Rwanda, les statistiques montrent que
la population enregistre de bons accès à certains services : ainsi, 94% des femmes
enceintes font au moins une visite prénatale au cours de leur grossesse bien que
tardivement.   Cependant, malgré cet accès, la plupart des services préventifs et
curatifs sont sous utilisés. Pour améliorer cette situation, le système de santé doit
donc maximiser l’opportunité présentée par chaque visite effectuée dans une
formation sanitaire.


Objectifs de l’intervention/projet : Le but du projet est d’accroître l’accès, la qualité
et l’utilisation des services de santé familiale au niveau des formations sanitaires et
des communautés en renforçant les capacités des autorités locales et des
communautés. Pour ce faire, la stratégie privilégiée est celle de l’intégration des
services dont cette présentation démontre l’impact positif à travers l’exemple des
consultations prénatales (CPN) focalisées offrant aux femmes enceintes plusieurs
services simultanés comprenant le traitement présomptif intermittent du paludisme
(TPI) et la prévention de la transmission du VIH de la mère à l’enfant (PTME).


Description du projet/intervention et caractéristiques des bénéficiaires (en cours
en 2006) : Le Programme « Twubakane » de Décentralisation et de Santé, géré par


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IntraHealth International, appuie le Gouvernement du Rwanda au niveau central et
dans 12 districts du pays pour relever les défis relatifs aux besoins de la population en
matière de santé. Ainsi, il collabore étroitement avec le Ministère de la Santé et
d’autres partenaires pour assurer une programmation intégrée et une standardisation
des normes et protocoles de santé, des outils de formation et de supervision. Dans les
12 districts couverts, le Programme appuie la formation des prestataires basée sur les
compétences, la supervision formative et le renforcement des capacités des formations
sanitaires et des autorités locales pour assurer une meilleure prestation de services.


Réalisations/Etat d’avancement (des activités) : Le Programme Twubakane, en
collaboration avec le Ministère de la Santé, les formations sanitaires, et d’autres
partenaires, a élaboré/révisé des modules de formation intégrés, assuré la formation
des prestataires et appuyé leur supervision formative. Ainsi, en fin 2005, plus de 800
prestataires (dont 250 dans la zone couverte par Twubakane) ont été formés en CPN
focalisée puis des supervisions formatives ont été menées, augmentant les taux de
couverture pour la CPN et le TPI. En effet, selon une enquête conduite par l’OMS, en
juin 2006, 85% des femmes enceintes au Rwanda avaient reçu une dose de TPI contre
0,3 % en 2005 selon l’EDS; alors que 62% des femmes au niveau national et 69% des
femmes dans la zone Twubakane avaient reçu les deux doses de TPI conseillées
pendant la grossesse.


Conclusion/Leçons apprises: En intégrant un paquet de services dans la CPN
focalisée et en améliorant la qualité de tout le paquet prénatal, y compris le TPI et
l’offre des moustiquaires imprégnées gratuites, les chiffres suggèrent qu’on a réussi à
encourager les femmes enceintes à venir plus tôt et plus souvent à la consultation
prénatale. Les femmes enceintes qui viennent tôt à la CPN ont également la chance de
participer plus tôt à la PTME. Des leçons ont été apprises aussi sur les enjeux de
l’intégration : la nécessaire collaboration entre plusieurs départements et programmes
du Ministère de la Santé, alors que les ressources des bailleurs de fonds sont souvent
ciblées sur un programme ou un volet, et le besoin d’avoir davantage de prestataires
polyvalents dans les centres de santé pour pouvoir offrir tous les services tous les
jours.




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II-E-12. Involving PLWHA associations to promote adherence to
Antiretroviral Treatment

Author: Laetitia Gahimbaza, M.D., Gerard Ngendahimana, M.D., Chantal
Ndikubwimana, Stephanie Marion-Landais, MPH

Title and Adress: Laetitia Gahimbaza, M.D., ART Team Leader, The Capacity
Project, Kigali, Rwanda ; Gerard Ngendahimana, M.D., Deputy Director, The
Capacity Project, Kigali, Rwanda ; Chantal Ndikubwimana, Nursing ART Advisor,
The Capacity Project, Kigali, Rwanda ; Stephanie Marion-Landais, MPH, Program
Officer, The Capacity Project, Kigali, Rwanda.

Geographical location of the project: Rulindo, Gicumbi, Nyagatare, Gatsibo,
Kayonza and Rwamagana Districts

Contexte/issues of the project: Since October 2005, the Capacity Project in
Kigali/ Rwanda has supported antiretroviral treatment (ART) services in 8 Rwanda
rural health facilities. Nurses or social workers at the local health facility organize
monthly home visits for PLWHA in order to promote and ensure adherence to
treatment. However, the shortage of human resources in the health facilities poses a
challenge, as does the increasing number of clients, and the poor road conditions. To
overcome these challenges, The Capacity Project has organized monthly meetings for
People Living with HIV/AIDS at each of the 8 Capacity-supported treatment sites.


Objectives of the intervention/project: In addition to adherence, the association
leader mediates discussions on hygiene, family planning, HIV family testing,
nutrition, opportunistic infections, malaria, tuberculosis, health insurance, gender and
income-generating activities. The PLWHA members are encouraged to share their
personal experiences and best practices among members of the group. If the number
of PLWHA is too large for one group (more than 10-12 people), the members are
separated in smaller groups according to neighborhood or social group (e.g., mothers,
widows, bachelors). When one member is found to have an adherence issue, he is
counseled by his fellow group members, and if necessary, the members can plan
home visits to provide follow-up.


Description of the project/intervention and characteristics of beneficiaries: Each
client included in the ART program is encouraged to join a PLWHA association.
Associations convene at the health facility on a monthly basis and the transport fees



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for each member is covered by the Capacity Project. One nurse or social worker from
the health facility leads the meeting using behavior change communication materials.


Achievements/Progress (of activities): As of 2007, the PLWHA association program
has been launched for 28 groups and has reached 3,077 PLWHA.                    PLWHA
association members who assist health staff by completing client home visits also
provide reports to the health facility, thereby simplifying the follow-up for that client.
Accordingly, with this information the health facility director obtains a better
knowledge of the clients who may need special care. Since the launch of Capacity-
supported ART programs in 2005, the patient follow-up rate has held strong at 100%.
The integration of HIV into the other provided services has also been simplified, as
the PLWHA are helping in the sensitization for voluntary testing in their local
communities. Linking the health facilities and PLWHA associations is a direct
approach to promote adherence and integrate HIV in other care programs. PLWHA
associations ensure ART adherence and alleviate gaps in human resources at the local
level. The organization of PLWHA associations should be recommended at the
community level.




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II-E-13. Psychosocial support as a key to successful scaling up of
HAART in children

Authors: Jeannine Uwera1, Jeanne d'Arc Nyirajyambere2, Joséphine Mukamuganga3,
Claire Gazille4, Janet Alonso 5, Johan van Griensven6 for the MSF-OCB HIV project,
Kigali-Rwanda
1
 MSF-OCB, psychologist; 2MSF-OCB, responsible of training and communication;
3
 MSF-OCB, responsible of IEC and communication 2003-2006; 4MSF-OCB, field
coordinator HIV project 2006; 5MSF-OCB, MD, medical coordinator; 6MSF-OCB,
MD, responsible of documentation, HIV project, Kigali-Rwanda.

Localisation: Kinyinya and Kimironko Health centres


Background: Scaling-up of HAART for children has proven to be challenging at the
national and international level. In the MSF-supported ARV program in Kimironko
and Kinyinya health centres, close to 300 children ≤ 15 years - constituting 10.6 % of
the total ARV cohort - have been started on HAART, with highly satisfactory
outcomes. We feel that a strong focus on psychosocial issues for PLWHA in general
and for children in particular from the start of the program has been a key factor for
the successful scaling up of the paediatric HIV/ARV program.


Strategies and results: Raising awareness on the issue of HIV testing of children
through discussion groups for adults with HIV: From the start, discussion groups were
organised for all PLWHA and for women attending the PMTCT program in
particular. These discussion groups demonstrated that only when the parent/caretaker
has accepted his/her HIV-status, there is an openness to discuss testing of the
children, creating an active demand of parents to have their children tested.


Building confidence: training of health care staff on child-specific issues of HIV:
Several barriers exist for the medical staff to test children, mainly resulting from a
'fear of the result'. Through formal training sessions and discussions, medical staff
progressively felt more convinced and confident with testing of children of HIV-
positive adults. A consensus was reached to disclose the HIV status to children from
the age of 7 years on. Practical training on disclosure to children was provided on site
in the health centres; a specific tool for explaining HIV to children was introduced. A
separate day for testing of children was organised (in Kinyinya) and is planned in


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Kimironko: this ensures that enough time is available to every child and facilitates on-
site training of health care staff in counselling of children.


Individual disclosure to child-caretaker: Individual disclosure to the child-caretaker
ensures that every child is adequately informed and its questions and concerns are
specifically addressed. The relationship child-parent is considered, exploring a way
for the child and the parent to communicate on HIV. By increasing the well-being of
both child and caretaker, the follow-up in the program and adherence on HAART is
facilitated.


Children support groups: The aim of these groups is to create an environment where
the children can express themselves, raise their questions and worries and develop a
positive attitude towards life and as such increases the acceptance of HIV and the
psychosocial well-being of the children.


Lessons learned for successful scaling-up of paediatric HAART:
By addressing parents through discussion groups and at the same time ensuring
confidence for the medical staff in addressing the issue of HIV in children, a high
number of children have been tested and followed up in our cohort.            Adequate
disclosure of the HIV status to both child and caretaker is the key issue for a
successful paediatric HIV program and practical training on counselling of children is
essential. Children support groups can play an important role.




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II-E-14. « SAFETSTOP » : Une stratégie innovatrice pour cibler les
communautés à très haut risque le long des axes routiers

Auteur : Protais Ndabamenye


Fonction et Adresse de l’auteur : Associate Director, Coordinateur du Projet
ROADS dans les pays Francophones, Afrique de l’Est. Family Health International,
Immeuble de la Caritas Kigali, B.P : 3149, Tel : 250 0830 06 36, email :
protaisn@fhgirw.org


Localisation géographique du projet: Ville de Kigali (Secteur Gikondo, Gatenga et
Gatsata), District de Rusizi (Secteur Kamembe et Mururu), District de Gicumbi
(secteur Cyumba, Rubaya et Kaniga)


Contexte/Problématique : Un rapport publié en 2005 5 par le projet de renforcement
du contrôle des IST/VIH au Kenya et en Uganda indique que dans les pays de
l’Afrique de l’Est, la prévalence du VIH/SIDA est 2 fois plus élevée dans les sites
d’arrêt des camionneurs par rapport à l’ensemble du pays. Le même rapport parle
également que plus de 60% de camionneurs passent moins de 40 nuits par an dans
leur domicile; qu’ils ont en moyenne 2.3 partenaires sexuels, que 62% ont rapporté
avoir eu des rapports sexuels avec un partenaire occasionnel (40% au Rwanda6) et que
plus de 80% sont mariés (70% au Rwanda7). Le même rapport indique que 80% des
femmes à faibles revenus sur les axes routiers s’engagent dans les rapports sexuels
pour subvenir à leurs besoins primaires. Les évaluations formatives de base conduites
sur les axes routiers ont montré que les services offerts dans ces communautés –bars,
restaurants, logements, VIH/SIDA (aux frontières et sur les sites de transit) sont
souvent de très faible qualité et que la pauvreté est un facteur de risque important
particulièrement pour des femmes et enfants vulnérables plus âgées. Cette situation a
motivé l’USAID à développer un programme régional de lutte contre le VIH/SIDA le
long des axes routiers du corridor nord dont le Rwanda fait parti.




5
  Annual figures from Kenya and Uganda, Univ of Nairobi/Univ of Manitoba Strengthening STD/HIV Control Project 2005
6
  BSS auprès des camionneurs, Family Health International, 2000
7
  BSS auprès des camionneurs, Family Health International, 2000



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Objectifs de l’intervention/projet ; Les objectifs régionaux de ce programme sont
les suivants :
    1. Augmenter l’accès des populations mobiles et les communautés le long du
        corridor de transport aux services de prévention, de soins, de traitement et
        d’appui psycho social;
    2. Identifier les problèmes techniques qui surviennent et partager les meilleures
        pratiques;
    3. Expérimenter de nouvelles innovations/stratégies à travers des programmes
        pilotes;


Description de projet/intervention et caractéristiques des bénéficiaires : ROADS
est un projet régional qui a été développé et financé par USAID/EAC et mis en œuvre
par Family Health International (FHI) pour développer des stratégies innovatrices de
lutte contre le VIH/SIDA qui ciblent les communautés à très haut risque de contracter
le VIH el long des axes routiers. Ces communautés comprennent notamment des
camionneurs, des femmes à faibles revenus y compris les prostituées, des hommes en
uniformes (dont les militaires, les policiers, les douaniers), des commerçants et des
travailleurs présents sur le site, des jeunes scolarisés et non scolarisés, des enfants
vulnérables et des PVVIH. Dans la mise en œuvre de l’intervention, FHI/ROADS
identifie un site dans le pays sur un axe routier où un grand nombre de camionneurs
passe la nuit et entre en relation avec la communauté locale. Une intervention est
exécutée sous le concept de « Safe T Stop » où le système de « Cluster model » est
utilisé. Le programme existe au Rwanda depuis 2005 et a commencé avec les
camionneurs et leurs épouses sous le financement direct de la mission USAID
Rwanda. Depuis août 2006, l’intervention est sous la coordination du programme
régional basé à Naïrobi. Les activités couvertes sont en rapport avec la prévention et
l’amélioration de l’accès aux services VIH/SIDA (CDV, prise en charge, OVC, AGR)
en faveur des camionneurs, des femmes à faible revenu, des jeunes, des (PVVIH et les
OVCs COP7). Prochainement, la lutte contre la pauvreté par la création de l’emploi
en faveur des femmes et les OVCs à faibles revenus sera entreprise sous le concept de
« Lifework » comme stratégie de prévention de l’infection au VIH.


Réalisations/Etat d’avancement (des activités) : Au niveau régional : (i) 28 Sites
identifiés au Burundi, Djibouti, RDC, Kenya, Rwanda, Sud du Soudan, Tanzanie et


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Uganda, (ii) Evaluations participatives conduites dans les même pays, (iii) Activités
lancées dans 19 sites: Djibouti (2), Kenya (3), Rwanda (3), Sud du Soudan (7),
Tanzanie (2) et Uganda (2), (iv) Plus d’un million de population touchée.
Au Rwanda, trois sites sont ciblés : Ville de Kigali (au tour de Magerwa et Gatsata),
Rusizi (Mururu et Kamembe) et Gatuna, 130 personnes dont 90 P.E de l’association
des chauffeurs des poids lourds au Rwanda et 40 animatrices dont 10 SW de
l’AEC/Duhugurane ont été formées. Jusque fin janvier 2007, ce groupe a ciblé 16,
990 personnes avec les messages de prévention du VIH, 2.365 personnes dont 490
femmes ont été référés au services de CDV et traitement des OIs et 202 aux services
de traitement des IST. En plus, 48.875 condoms ont été distribués à travers les points
de distribution mis en place par les partenaires. Le programme a également eu un
impact sur le dialogue entre les partenaires sur le VIH et leur vulnérabilité au VIH. En
effet, 2.163 personnes dont 515 femmes ont rapporté avoir engagé les discussions sur
le VIH avec leurs conjoints. Depuis août 2006, FHI ROADS a effectué deux
évaluations participatives rapides, une sur la relation entre la consommation de
l’alcool et le VIH/SIDA et une autre dans les trois sites pour compléter le paquet des
services offerts selon le concept Safe T Stop. Après la présentation des résultats aux
différents membres de la communauté et l’identification des priorités, les différentes
associations par groupes cibles se sont mis ensembles (Cluster model) pour planifier
l’intervention. Elles ont également choisi une association qui va coordonner les
activités et gérer les fonds et ils ont constitué un comité de gestion où chaque
association est représentée.


Conclusions/Leçons apprises : Les membres des bénéficiaires et les autorités
administratives de base ont été impliqués dans tout le processus de développement de
l’intervention depuis l’évaluation formative jusqu’à la définition des activités à faire y
compris la budgétisation. Ce processus a été fort apprécié aussi bien par les
bénéficiaires que par les autorités administratives de base et les umbrellas, car le
programme répond aux besoins réels des bénéficiaires tels que exprimés par eux
mêmes.


Le système de Cluster est très innovateur. Avec ce système, on amène même les
petites associations à la prise de décision de l’intervention et du processus de suivi. En



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plus, on a la chance de mieux assurer une couverture plus large du groupe cible et
mieux assurer une gestion saine des fonds.


Le fait que l’intervention doit être exécutée sur une zone assez limitée et par les
organisations communautaires locales, la faible capacité des organisations constitue
un défi majeur à l’atteinte des résultats escomptés dans les délais prévus.




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II-E-15. The role of accompagnateurs in delivery of Antiretroviral
Therapy in rural Rwanda

Authors: Kamanzi C1, Nshunguyabahizi M1, Walker K1, Harerimana M1, Epino H1,
Stulac S1, Rich M1,2,3
Title and Adress:      Nurse, Head of ID Clinic
                       Partners In Health
                       Nyamugali Health Center, Kirehe District

Other author affiliations:
   1. Partners In Health, Boston, MA, USA, and Inshuti Mu Buzima, Rwinkwavu,
      Rwanda.
   2. Department of Social Medicine, Harvard Medical School, Boston, MA, USA.
   3. Division of Social Medicine and Health Inequalities, Brigham and Women's
       Hospital, Boston, MA, USA.

Geographical location of project: Kayonza, Kirehe, Ngoma Districts

Context: The treatment of patients with antiretroviral therapy (ART) in rural
resource-poor settings is challenging. Well trained medical professionals are scarce
and frequent visits to health centers may be difficult for patients who are ill and live
far from a clinic. One solution that addresses these difficulties is the employment of
accompagnateurs, or community health workers, in follow-up of patients on ART.


Project objectives: Accompagnateurs are employed by PIH to accompany patients on
ARV therapy (and with other chronic diseases) in order to provide support to the
patient and to observe the daily taking of medication. The goal is that patients will
have high levels of adherence to their regimens and that any problems, whether
medical or social, will be quickly identified and addressed.


Project   description    and    target   group    characteristics:    The   model    of
accompagnateurs as a cornerstone of ART scale-up has been implemented
successfully in rural Rwanda in a collaborative program between the US based NGO
Partners In Health and the Rwandan Ministry of Health. Accompagnateurs receive
training in: HIV prevention and treatment, recognition of opportunistic infections and
adverse effects of ARVs, and adherence techniques. They must live near the patient,
be considered outstanding community members, and not be a first degree relative.
Their responsibilities include daily patient visits, referral of patients with
complications to the health center, and participation in monthly trainings.



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Accompagnateurs receive regular compensation with food baskets or cash incentive
equivalents and are supervised by infectious disease clinic nurses and accompagnateur
leaders.


Achievements: Between June 2005 and December 2006, 1938 patients were enrolled
on ART in 3 rural districts in Rwanda and received daily support from 758
accompagnateurs.    The accompagnateurs also increased the utilization of health
services and speed of ART scale-up by participating in active case finding and contact
tracing within their communities.


Conclusion/Lessons learned: By training and employing community members to
accompany patients receiving ART, it is possible to scale-up rapidly and achieve high
rates of patient retention. The training and compensation of accompagnateurs
improves their own quality of life and allows them to educate others in the community
at large.




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II-E-16. UNE PRISE EN CHARGE INTEGREE DES PVVIH SUR
LES SITES SANS PROGRAMME ARV : LE PAQUET DE BASE
D’EGPAF

Auteurs: Sowaf UBARIJORO1, Jeroen van’t Pad Bosch2, Mukandanga Odette3,
Marthe Mukaminega4, Jaques Rutabaga5 Nancy Fitch 6

Fonctions et adresse des auteurs : MD, Technical Advisor1 MD, DHTM, DPH
Senior Technical Advisor2 Bc PH, Senior Technical Officer PMTCT/VCT/OI3 MD,
MMed (Ped), MSc, Senior Technical Advisor4 MD, Technical Advisor5       MD,
                6
Country Director
Elizabeth Glaser Pediatric AIDS Foundation-RWANDA

Localisation géographique: CS Gikomero, District de Gasabo, Ville de Kigali



Problématique
Les services PTME et CDV sont actuellement disponibles dans beaucoup de FOSA
du pays (256 sur environ 424, début 2007). Cependant, la prise en charge des PVVIH
n’étant pas généralement disponibles au niveau de la majorité de ces FOSA. Pour
cette raison, les patients sont transférés vers des FOSA avec un programme ARV, qui
parfois sont loin de leur domicile. Il s’en suit qu’un grand nombre de PVVIH testés
sont perdus de vue et ne sont pas pris en charge ou arrivent trop tard dans les sites
ARV. Le but du ‘Paquet de Base’ développé par EGPAF est de rendre ces FOSA
capables d’offrir une prise en charge globale de qualité aux PVVIH jusqu’au moment
opportun de transfert vers les sites avec un programme ARV, et ainsi diminuer le
nombre de PVVIH non prises en charge après le test.


Réalisations
Le Paquet de Base comprend le renforcement des activités de CDV/PTME,
l’instauration d’un suivi clinique et immunologique, du soutien communautaire, d’un
appui nutritionnel et d’un système de référence et contre référence. L’implantation du
Paquet de Base comprend le soutien aux sites dans le recrutement et la formation du
personnel, l’adaptation des infrastructures, un canevas détaillé d’organisation des
services de prise en charge intégré et de suivi intensif et régulier. Les infirmiers sont
formés à déterminer les stades cliniques (selon l’OMS), l’interprétation du taux des
CD4, et le diagnostic et le traitement des infections opportunistes. Les sites emploient
un agent de liaison des activités communautaires qui coordonne une équipe des


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animateurs de santé. Chaque site reçoit un Point focal de lien des Programmes qui
assure la connexion entre les services VIH et les autres services médicaux.
Ce modèle est en cours d’initiation au CS Gikomero, mais il est prévu de l’étendre
aux autres sites EGPAF où le programme ARV n’est pas encore disponible.


Conclusion
Il est possible de disponibiliser même aux sites à ressources limitées, un paquet
d’activités permettant de suivre les patients jusqu’au moment du début des ARV.
Même si l’implémentation de ce Paquet de Base n’est qu’à son début, nous sommes
convaincus que cette approche intégrée et d’appui intensif peut améliorer le
continuum de soins pour les personnes vivant avec le VIH et les enfants exposés.




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II-E-17. Prise en charge psycho-medico sociale au centre médico-
social de Biryogo

Auteur : Aurore Prats Hermandez et Mukamurara Bellancille
Tél : 573413, cmsbilyogo@yahoo.fr
Localisation géographique : District Nyarugenge, Secteur Nyarugenge




Contexte
Depuis 1989, les habitants de la population environnante du CMS Biryogo,
ont commencé à fréquenter le programme de prévention du VIH/SIDA du
centre. Ces personnes étaient volontairement soumises au test du VIH/SIDA et
un nombre considérable d’entre elles étaient trouvées séropositives. La plupart
des   personnes   qui   ont   été   trouvées   séropositives,   étaient des personnes
vulnérables dont la situation socioéconomique était précaire. C’est ainsi qu’un
programme    d’assistance à ces personnes nécessiteuses a été mis en place. Le
Centre médico social de Biryogo a commencé à faire le suivi de ces PVVIH.
L’approche utilisée par les agents sociaux est l’ accueil, l’écoute, l’orientation
et visite à domicile, pour connaître la situation socioéconomique des familles
des personnes trouvées séropositives. Les PVVIH qui étaient identifiées étaient
invités à participer mensuellement dans des réunions des séropositives afin de
pouvoir les amener à vivre positivement et échanger les expériences. Des visites
des malades referrés dans des hôpitaux (CHUK, maternité de Muhima, Centre
psychiatrique de Ndera, Hopital Kibagabaga) sont souvent réalisées.


Réalisations en 2006
339 visites à domicile ont été effectuées dont 192 SSS (Service social SIDA),
et 192 pour les PVVIH au stade des ARV.
-Soins médicaux pour 1738 PVVIH
-Accès au mutuel de santé : 2146
-Réhabiliation nutritionnelle : 1024 (PVVIH, T.B,)
-Assistance alimentaire PTME : 184
-Hébergement maison Dusangire : 102 (une maison transitoire de récupération)
-Aides d’urgence : 12 (les PVVIH les plus nécessiteux)



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-Frais funéraires : 3
-Loyer : 57 PVVIH
-Allocation aux orphelins : 47
-La scolarisation : 272 (maternelle, primaire et secondaires)


Conclusion/Leçons apprises
Grâce aux mutueles de santé, le nombre de maladies et le taux de cas de décès
ont diminué. Les enfants scolarisés et assistés poursuivent leurs études. Grâce
à l’assistance alimentaire, les PVVIH ont repris la force et sont capables de
s’autofinancer.




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II-E-18. Impact Of Introducing Hiv Clinical Services On Delivery Of
Other Non-Hiv Care In Primary Health Centers In Rwanda.

Authors: Jessica Price, PhD, Evode Micomyiza, Venuste N., Jean Paul Tchupo, PhD

Context
In recent years thousands of patients in Rwanda have benefited from new clinical
services in HIV, which have become available as a result of increased donor funding
earmarked to support these services. This has, however, raised concerns that vertical
and disproportionate funding favoring HIV may produce a negative effect on the
delivery of other non-HIV primary health care. Specifically, some have speculated
that non-HIV services delivery may decline as newly introduced, donor-funded
project-driven HIV care is afforded more health worker attention and time. To
ascertain the impact of introducing basic HIV care on non-HIV service delivery, we
compared the quantity of non-HIV services delivered before and after the
introduction of basic HIV care.

Methodology

Basic HIV care = a minimum package of HIV services including counseling and
testing (C&T), prevention of mother-to-child transmission (PMTCT), and preventive
therapy with cotrimoxazole (PT).
Non-HIV service delivery = (i) non-HIV lab tests performed; patient consultations
(out patients); hospitalizations; (ii) ANC services (1st trimester, 2nd trimester, 7-8
months, and nine consultations; all 4 recommended consultations completed; syphilis
screening conducted); (iii) deliveries at the FOSA; (iv) family planning uptake; and
(v) services for children (child vaccinations completed, children treated for
malnourishment, children brought for growth monitoring). Data on non-HIV services
delivered were derived from monthly FOSA reports submitted to the district.
Prior to the introduction of basic HIV care = Time 1: The six-month period prior to
the first client tested at the FOSA for HIV, whether in the context of C&T or PMTCT.
After the introduction basic HIV care = Time 2: December 2005-May 2006, at which
time all selected FOSAs had at least 6 months experience offering the basic HIV care
package.
The Sample: 30 selected FOSAs (9 public, 21 officially recognized) constitute a
convenience sample according to the following inclusion and exclusion criteria:


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Inclusion criteria                        Exclusion criteria
   FHI partner, for ease of data             Hospitals
   collection                                Less than six months experience
   Primary health center                     implementing basic HIV care
   At least six full months of experience    FOSAs implementing a partial
   implementing the basic HIV care           package of basic HIV care, e.g., C&T
   package                                   only

Analyses: Using SPSS for data management and analysis, we compared mean
numbers of non-HIV services delivered/FOSA/month from Time 1 (prior to
introduction of HIV services) and Time 2 (after introduction of HIV services) periods.
On variables that met the normality assumption, we used the Paired-Samples T Test;
on variables that did not meet the normality assumption, we used the Wilcoxon
Signed-Ranks Test. In total, we analyzed data on 29 non-HIV services delivered.
Multivariate analyses were used to test for effects of number of months of experience
with performance-based financing (PBF), number of months with health insurance
(mutuelles de santé), and number of months of offering basic HIV care.


Principle results
In all non-HIV service areas except hospitalizations, significant increases in the
quantity of non-HIV services were observed after the introduction of basic HIV care.
In 18 of the 29 non-HIV service delivery indicators measured, the mean number of
services delivered/FOSA/month were significantly greater (p≤.05) in Time 2
compared to Time 1. In 11 non-HIV service indicators, no significant changes were
observed. No decreases in the quantity of non-HIV services were observed from
Time 1 to Time 2. The most consistent increases were observed in ANC services,
maternity services, and family planning uptake. Regression analyses indicated that
number of months experience with PBF and health insurance (mutuelles de santé)
were not important predictors of increases in non-HIV services; the number of months
experience offering HIV basic care was by far the most important predictor of
increases in the quantity of non-HIV services delivered.


Conclusions
These findings clearly illustrate that adding HIV services to the primary health care
service mix does not necessarily negatively impact the quantity of non-HIV services,
as feared by some. In contrast, these data suggest that enhancing health center



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capacity in HIV increases service delivery generally. The sample, however, is not
representative; we therefore suggest that a similar study be conducted in other FOSAs
to determine if these findings at FHI-supported sites apply elsewhere. Finally, we
recommend a companion study be completed to examine the impact of HIV service
introduction on the quality of care generally.




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II-E-19 Le renforcement de l’adhésion aux services de santé par les
agents de santé communautaires.

Auteurs : Mukandanga Odette1, Sowaf Ubarijoro2, Marthe Mukaminega3, Jeroen
van’t Pad Bosh3, Jaques Rutabagaya2, Nancy Fitch4
Fonction et Adresse de l’auteur: 1Senior Technical Officer PMTCT/VCT/OI,
Technical Advisor2, Senior Technical Advisor3, Country Director4
Elizabeth Glaser Pediatric AIDS Foundation-RWANDA


Localisation Géographique du Projet: Notre programme dessert 8 Districts administratifs dont
Nyarugenge, Gasabo, Kicukiro, Rwamagana, Gastibo, Gakenke, Burera,et Musanze spécialement dans
les Centres santé de Kabusunzu , Cor‘Num,Butamwa , Jali, Masaka, Rubungo, Gikomero,
Nyagasambu, Nzige, Rubona,Gituza , Nyagahanga, Ngarama, Kabere, Mataba, Kinyababa et
Dispensaire Muhima



Problématique : Les services de santé suppose être implanter dans un milieu ou ils
viennent apporte de solutions aux problèmes de santé qui handicapent le bien être en
général (morbidité et mortalité) en particuliers de la population dans une zone bien
définie. Le Service de VCT/PMTCT /ARVs existent, mais l’utilisation de ces services
est toujours inférieure :
    •   L’effectif de personnes VIH+ qui arrive dans la prise en charge (ARVs)
        reste toujours bas
    •   le taux d’accouchement des femmes positives faible diminue l’utilisation
        efficace de service PMTCT ;
    •   le manque de suivis des enfants exposés dimunie les nombre des enfants
        testés ;les grossesses répétées observées chez les femmes infectées ;
    •   manque des connaissances sur comment et quand adhérer aux services
        ARVs.
Cependant, l’accès et l’utilisation de ces services continue à être une lacune qui
préoccupe le Ministre de la santé et surtout les Partenaires car les services en rapport,
disponibles au niveau des FOSA semblent ne pas suffisamment utiliser


Objectifs spécifiques
1. Informer les agents de santé communautaire sur le VIH/SIDA et autres IST et sur
les activités de prise en charge disponibles aux FOSA et dans la communauté.


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2. Enseigner les animateurs de santé comment encourager les PVVIH à vivre
positivement avec le VIH/SIDA ;
3. Aider les animateurs de santé à faire le suivi dans la communauté et assurer la
l’orientation et l’adhésion des PVVIH aux services appropriés (VCT, PMTCT,
ARVs. PF, soins palliatifs, nutrition,…)
4. Faire comprendre aux animateurs de santé que la confidentialité est très
importante en générale et en particulier pour les PVVIH. ;
5. Enseigner les animateurs de santé sur la planification de ses activités, le suivi et
l’évaluation à son niveau pour connaître l’évolution de son travail ;
6. Donner les connaissances de base sur le counselling (surtout du Couple et
enfants), soins palliatifs, nutrition, PF,


Description de l’intervention et caractéristiques des bénéficiaires : EGAPF en
s’appuyant sur le programme des Agents de Santé Communautaire existant, a
développé une approche plus efficace d’impliquer la Communauté dans
l’amélioration de l’accès et l’utilisation des services des hôpitaux et/ou centre de santé
via agents de santé communautaires (adhésion aux services sanitaires). Les agents de
Santé Communautaires (animateurs de santé, accompagnatrices) reçoivent une
formation approfondie de 5 jours sur la pendemie du VIH/SIDA; en mettant l’accent
sur la personne infectée et affectée par le VIH en général et sur le suivi et la prise en
charge de l’enfant exposé en particulier.
Du nouveau dans cette approche ; au cours cette formation, ils apprennent comment
faire une planification y compris le suivi et l’évaluation de leurs activités qui
facilitera l’atteinte de leurs objectifs.


Etat d’avancement des activités:
Programme proposé, discuté avec le MINISANTE
Animateurs de santé et accompagnatrices identifiés
Développement des outils de gestion du programme
Formation des formateurs au niveau des différents districts appuyés par EGPAF (4 par
district)
Formation des animateurs de santé et accompagnatrices a chaque site (21)
Le programme des agents de santé communautaires est fonctionnel



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Appui technique et financier pour la mise en œuvre de ce programme


Conclusion:
Avec les agents de santé communautaires:
   •   Participation communautaire en matière du VIH/SIDA
   •   le programme est perein
   •   l’adhérence aux services rendus aux PVVIH serait améliorée
   •   Les perdus de vue (PTME, VCT, ARV) seraient réduits




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II-E-20 Harmonizing the Children and AIDS response in Rwanda.
Authors: 1Binagwaho, 2A, Muita J, 3Spring K.
Affiliations: 1Executive Secretary, CNLS, 2Head, HIV/AIDS Programme UNICEF
Rwanda, 3M&E Adviser, UNAIDS, Rwanda

Context:    In Rwanda the fight against HIV /AIDS is coordinated evaluate and
monitor by the CNLS by means of a National strategic Framework developed through
a participatory process. The country demonstrates a positive response overall in
indicators for survival and well-being, the multiplicity of responses to the epidemic
and level of external financing. For children HIV and AIDS response was reviewed
during the mid term revue (2004). The CNLS with the partners developed a strategy
focusing on children, for coordination, resource mobilization and M&E because the
children were found to be less than that of adults.


Approach and target group characteristics: The CNLS and UNICEF in 2005
undertook a survey to assess the situation of children and AIDS, the level of response
and to identify the partners involved. This included desk review, interviews of
HIV/AIDS partners and in-depth study of 15 communities based and 15 facility based
services. The results demonstrated that less than 1% of HIV+ children in need of
ARVs were on treatment, PMTCT services were available in 50%, many
interventions on primary prevention addressing EABC but behaviour change was still
slow among young people, and the policy and National plan of Action on Orphans
and Vulnerable Children was in place but few children received comprehensive care.
Also that Rwanda had a large number of partners in the HIV/AIDS arena (more than
700 associations of PLWHA). Strategic planning for children and AIDS,
coordination, advocacy and monitoring and evaluation of the progress were
recommended. The results were presented at the 1st National conference on children
and AIDS 2005 and formed the basis for development of an Action Plan to be
monitored over one year. Four areas of programming the Children and AIDS response
were identified: PMTCT, Paediatric treatment, Primary prevention for young people
and Protection care and support. The CNLS and partners agreed on four working lead
by a Government institutions and co-chaired by one of the partners and a steering
committee to coordinate the joint plan implementation-co-chaired by CNLS and
UNICEF.



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Achievements:
Children and AIDS steering committee was created and four working groups put in
place:
   I.      Paediatric Treatment and Care
   II.     Primary Prevention among youths
   III.    Protection Care and Support of OVC
   IV.     PMTCT
The coordination structure above was very effective in monitoring the response to
children and AIDS in 2006. A follow-up assessment was undertaken in October 2006
and a second national conference with high quality presentations, participation of
children and international presence was organized. The second assessment
documented progress in all the areas of children and AIDS and identified further
action. The outcome of the 2nd conference is a plan of action for 2007 which will be
reviewed at the 3rd conference in 2007.


Conclusion/Lessons learned: Establishing results-based partnerships for children
provided a platform for advocacy and heightened response to a specific national
concern. Brining all partners on board accelerate the solution




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II-E-21 Sharing Knowledge for Action to Support Vulnerable
Children (Joint Learning Initiative in Children and AIDS)

Authors : Binagwaho, A.1, Bell, P.2, Deshmukh, M.3, de Waal, A.4, Foster, G.5, Kim,
J.6, Mamdani, M.7, Mungherera, L.8, Richter, L.9, Wakhweya, A.10
1
    National HIV/AIDS Control Commission, 2Carter Centre, 3CARE, 4Social Science
Research Council, 5FACT, 6FXB Centre for Health and Human Rights, 7REPOA,
8
    Mamas Club, 9Human Sciences Research Council, 10Family Health International


Context:
Because all over the world Children are found to be less included in program than that
of adults, an initiative was launched in London, in 2006 to provide to the world
solutions to correct that. So far we know that families and communities provide the
biggest part of the care and support for children affected by HIV/AIDS. Improved
mechanisms are needed to share best practices on how external agencies can support
family and community response and deliver services to children when traditional
care-giving mechanisms fail. The Joint Learning Initiative on Children and
HIV/AIDS (JLICA) proposes solutions to this challenge, particularly for sub-Saharan
Africa.


Approach:
JLICA offers a new model of partnership for knowledge-sharing on children and
HIV/AIDS programs and policies. JLICA analytic work is done by 4 thematic
Learning Groups, which focus on: strengthening families; strengthening community
and civil society response; expanding access to essential services; and informing
social and economic policies. Each group includes researchers, implementers,
universities, policy experts and advocates. JLICA research comprises literature
reviews, policy analyses and program case studies and experimental researches.
JLICA innovates by applying a multidimensional and multi-disciplinary model of
child wellbeing to policy and implementation options for children affected by
HIV/AIDS. JLICA's network structure provides an innovative dissemination
mechanism for best practices.




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Achievements:
JLICA brings evidence that effectively protecting vulnerable children requires
integrated program strategies linking effectives policies, adapted health care,
education and comprehensive social protection. The Initiative is based on practice-
models for bundling key children services in resource-constrained, high-HIV-
prevalence settings. A challenge for JLICA is to disseminate context-sensitive models
for scaling up integrated services. In Rwanda, JLICA fosters knowledge-sharing by
working with Government, public institutions and civil society in a Learning
Collaborative for programs focus on access to prevention care and treatment.
Collaborative members continuously review the policies and implementation practices
as part of a national expansion of integrated health and social protection services for
children affected by HIV/AIDS, using a community-based delivery model. Partners in
the Learning Collaborative include governmental and non-governmental agencies,
researchers, community-based groups and international organizations. The
Collaborative works to strengthen knowledge-sharing as program scale-up proceeds.


Conclusion/Lessons learned:
Linking policies, health care, education and social protection and HIV prevention in
an integrated, nationally-driven program improves outcomes for vulnerable children.
Wrap-around service packages for vulnerable children can and should be
implemented under community leadership in resource-constrained settings with the
support of development partners. A multi-disciplinary network model is an effective
way to generate and share best practice recommendations in this area. A Learning
Collaborative involving government, non-governmental and community actors works
to promote shared learning among policymakers and implementers serving children
affected by HIV/AIDS.




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II-E-22 Advancing the Children and AIDS agenda: Lessons from the
Rwandan Paediatric conference on HIV and AIDS
Authors: 1Dr Agnes Binagwaho , 2 Dr Jane Muita, 3 Kate Spring, 2Silvia Chiarucci
Affiliations: 1CNLS Rwanda, 2UNICEF Rwanda, 3UNAIDS, Rwanda

Context: Rwanda has made progress towards achieving MDG 6 and has advocated
for increasing the commitments of resources. In 2004 the National AIDS Control
Commission (CNLS) and its partners acknowledged that children were not included
in programs in the same scale as adults when the fight against HIV and AIDS is
concern; children were representing less than 1% of patients on ART treatment
(TRAC 2005) and only 0.2% of orphans and vulnerable children (OVC) were
receiving some free external support to meet their basic needs (RDHS 2005). To
respond to this, CNLS launched an advocacy process through Annual National
Conferences on Children and AIDS.


Approach: To respond to that situation an Annual National Conferences was created
to provide a forum for discussion and consensus on the current situation of children at
national and international level. Led by CNLS, the conferences are planned, organised
and followed-up through the full involvement and participation of national
institutions, development partners and local and international researchers and
practitioners. To date, Rwanda has organised two conferences preceded by a research
to assess of achievement and result in recommendations given the previous year. Each
year CNLS and the partners in the fight against HIV and AIDS make a plan of action
with targets for the next year. Meaningful participation of children and youth and
patronage at the highest level of the State is assured.


Achievements:
To date: 1) mobilisation of leaders at all level in favour of the children affected or
infected by HIV and AIDS. 2) scale up plans for PMTCT and Paediatric HIV and
AIDS treatment, care and support are in place 3) paediatric ART services have been
scaled up tremendously, with 30% of HIV+ children requiring ARV actually on ART;
4) a minimum package of services has been developed to provide adequate support to
OVC and adopted at national level for scaling up; 5) A family approach to increase
uptake and follow-up of HIV+ women and their children; 6) Primary prevention


                                                                                   271
especially among young people is increasingly addressed and is being linked with
sexual reproductive health 7) HIV prevention has been mainstreamed in the EDPRS.


Conclusion/Lessons learned: There are significant gains in using evidence based
advocacy to design interventions and guide the coordination of interventions. The
inputs to the conference include data on achievements and gaps, interventions
documented as best practices both local and international and forums to reinforce
partnerships between the different actors. The theme changes every year; 2005 theme
was “Join us in mobilizing extra ordinary action for treatment, care and support of
children affected and infected by HIV/AIDS while 2006 was “A Family Approach ”
and in 2007 it will be “Role of the decentralization in care and treatment of children
affected by HIV.” . This case of Rwanda demonstrates that Annual National
Conferences if locally owned and steered can provide the vital momentum necessary
to advance the agenda of Children and AIDS.




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II-E-23. Enhanced paediatric HIV/AIDS care and treatment through
increased HIV testing services

Authors: 1.Dr Binagwaho, A; 2 Dr Asiimwe, A; 3.Hakizimana, E; 4. Nyaruhirira, I
1
  Executive Secretary, CNLS; 2Director of Treatment and Research AIDS Centre;
3
  Technical advisor in HIV and Health integration CNLS; 4Minister of State in Charge
of HIV and AIDS and other diseases

Context:
Rwanda go for universal access of children for HIV and AID care and treatment by
availing HIV testing services to all children exposed to HIV or presenting AIDS
related symptoms.
Children are accessing HIV and AIDS care and treatment late in the course of the
disease because parents and caregivers delay to test them.
Statistics from health centres show that the number of children in the treatment
programs does not increase proportionately to that of the adults.


Among the children born to HIV+ mothers in 2005 and 2006 only 58.5% and 74.8%
respectively were tested for HIV while the intention was to test all those born to HIV+
mothers in the PMTCT program. Although the rate of testing is high compared to
other sub-Saharan countries and our paediatric treatment program is considered
exemplary we are not satisfied because even mothers who receive PMTCT services or
those on ARV treatment do not all test their children for HIV. The estimated number
of children in need of ART by the end of 2006 was 7000 but only 41% was attained.
Therefore we need to review our approach.


Approach:
In 2005 we worked with our developmental partners to identify obstacles. The
discussion identified the following:
       Parents’ auto stigma makes them feel responsible for the HIV status of their
       children
       Fear of healthcare professionals who do not know when and how to prescribe
       ARV
       Fear of healthcare professionals to disclose result to children




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          Caregivers do not know that it is the children’s right to be tested if they are
          exposed to HIV or if they have any HIV symptom


In a participatory process we conceive the following strategies were put in place to
accelerate HIV testing for children:
   I.        A Ministerial instruction granting free VCT in public and affiliated health
             facilities
   II.       Training of health workers on HIV testing for children and family
             counselling and ART
   III.      Free VCT for all children all health facilities in the country
   IV.       Mobilising partners to ensure universal paediatric ART
   V.        A Ministerial instruction for systematic VCT for malnourished children.
   VI.       Counselling HIV+ parents to test their children
   VII.      Mobilising community leaders and people living with HIV and AIDS to
             sensitize HIV+ parents to test their children


Achievements
Children have no voice and for them the fight against HIV and AIDS remains a
challenge and while fighting this epidemic we discover unexpected obstacles. In this
case we realized that children were not included in the program despite the political
will to do so. To solve that all partners agreed to work together


Recommendations
To find a better way to implement programs for children multiple approaches are
needed to trace children born to HIV+ mothers. We should be innovative and learn
while implementing. Good collaboration and coordination of all stakeholders and a
quick review of problems associated with protocols and programs were some of the
basic principles for success in managing change.




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II-E-24. Partnership to improve service delivery at district level
Authors: 1Binagwaho, A; Spring K2 ; 3Fulgence, A; 4Semukanya, A
1
  Executive Secretary, CNLS; 2M&E Adviser, UNAIDS, Rwanda; 3Director, CNLS
4
  Deputy Executive Secretary, CNLS.

Context:

To improve efficiency in service delivery in all sectors for the communities and
individual level the decentralized system had been changed to bring decision making
and implementation at district level. This has resulted in increased activities at the
district and community for all issues and among them for the HIV response. Activities
undertaken and financed at the community level include income-generating activities,
capacity-building (training), technical assistance, planning, coordination and M&E.

Approach:
To assess the real impact of the HIV/AIDS infection and it’s response at the
community level, the CNLS organized field visits with development partners and
district managers throughout all 30 districts. The objective was to assess the situation,
identify the bottlenecks for implementation and coordination and to seek solutions.
Three times a quarter joint supervisory field mission of joint teams comprising
representatives of National and District AIDS Control Commissions (CNLS, CDLS);
national and international agencies operating at district level and members of the civil
society are organized in two phases. We started by assessing the situation and
sensitization of district leaders to ensure integration of all partner activities in district
plans. Six moths later and based on a monthly assessment of activities at district level,
using a checklist jointly prepared by partners (National Institutions, Development
Partners and Implementers Partners).

Achievements, Challenges and recommendations
Participants in the first field visits have had first-hand exposure to implementation
challenges at the district and community level. The problems identified include:
CDLS activities need to be reflected in the district plans; joint action need to
strengthened for efficiency; all implementing partners to ensure that their plans are
reflected in district plans; partners should have joint planning sessions so that
stakeholders (beneficiaries and local administration) points of view are taken into
account; the process of decentralization of service delivery needs to be accelerated in


                                                                                        275
health institutions, and to included people living with HIV. Finally, it was noted that
CNLS and partners could continue to build capacities of staff to be more operational
at the level of District Committees in the areas of planning, monitoring and evaluation
of projects, and in coordination of the response at the district and community level.


Conclusion:
Decentralization is timely, given the focus on getting more and better results with
available resources for the AIDS response. The informative reports have indicated
some few changes in working modalities which will improve the utilisation of
resources, both human and financial and will improve the performance at the district
level.




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II-E-25. Planing, monitoring and reporting in the context of
decentralization: lessons from Rwanda “CNLS Mapping” Data Base

Japhet Taratibu*, Robert Banamwana*, Fulgence Africa*, R .Amina*, Therese
Bishagara**, Scott Moreland*** Dr. Agnes Binagwaho*

*CNLS, Kigali, Rwanda, **Constella Futures/MEASURE Evaluation, Kigali, Rwanda, *** Constella
Futures/MEASURE Evaluation, Chapel Hill, NC, USA


Context:
The policy in the fight against HIV and AIDS in Rwanda is strengthening
decentralization of coordination of HIV and AIDS response at the District level. Each
Districts has an the same types of member District in they AIDS Control Committee,
representing key departments and the strong leaders of the civil society, including
people living with AIDS.
While a national level M&E system was developed to monitor and evaluate the HIV
and AIDS strategic plan, no tools were in place to capture plans and reporting on
progress at the District. With the decentralisation the CNLS needed to gather
information on the implementing agencies in the District, what they do, intervention
target groups, amount of, and sources of funding.


Approach:
The CNLS created a decentralized data base system that tracks budget, services
providers, their action plans, and progress in implementation. Base-line information
and data for the data base of the district was collected and entered into the database.
Program implementers and one CDLS staff were trained in the data base and
monitoring and evaluation principles. The data base allows entering of annual action
plan and reports, using a unique format. This simplify reporting, and planning and the
template use is linked, in the same data base, with quarterly reporting form which has
additional of only two columns showing the number of beneficiaries actually served,
and the amount of funds spent.


The District aggregates this information into the District data base. The system will in
the future include a GIS component for geographic assessment of activities. To allow
transmission of data to CNLS, modems are use through IT tools. We installed cell
phone technology in each district to transmit data by an internet web-based.



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Achievements and Challenges:
The MEASURE Evaluation Project and the National M&E technical Committee
provided technical and financial assistance, including the training of CNLS staff in
database development. The CNLS district level data base was developed entirely by
local CNLS staff, and continues to maintain it.
A regular baseline survey is conducted to capture implementing organizations’
activities, geographical coverage, and plans of action, budgets, and CNLS
certifications for the new implementers. The survey provides for improvement in data
collection, use of data in coordination, informing planning, monitoring and evaluating
of HIV and AIDS programmes. A module on OVCs was included in 2006 survey, and
in the data base.


Key Recommendations:
Most countries are developing monitoring and evaluation systems either in response
to donor need (e.g. PEPFAR, MAP, Global Fund, and UNGASS) or identified local
needs. The Rwanda CNLS, with support of MEASURE Evaluation has demonstrated
that locally the development of a unique systems is possible, cost effective and viable.




                                                                                    278
II-E-26 The World AIDS Day: an opportunity for national
mobilization

Authors: Dr A. BINAGWAHO, M. KAMUKUNZI, J. P. AYINGOMA. , F. AFRICA


Context
Year after Year, the CNLS, in collaboration with all partners and administrative
authorities organizes a two months national mobilization campaign in the context of
the World AIDS Day.
The topic of the campaign is determined based on national reality, but still related to
the internationally already set theme for the World AIDS Day. In 2006 the national
theme for the campaign emphasized: “The responsibility of the family in the fight
against AIDS”, drawn from the international theme.
The theme was chosen based on results of the 2005 Demographic and Health Survey
(DHS). According to DHS results, 75% of Rwandans do not know yet their HIV
status; 238 VCT sites and 223 PMTCT sites have been created but only 68% of
women who go to health facilities for PMTCT access the services. As 71.8% of
women deliver their babies at home, PMTCT service is offered to only 28.2% of
women in need of it.


Approach:
The campaign was launched at national level under the coordination of District AIDS
control Committees and implemented by umbrellas and other partners from the civil
society. Sensitization sessions focused around the national theme and was organized
within public and parastatal institutions where the majority of them had a voluntary
HIV test. For efficient coordination and positive impact the sensitization through
media and radio broadcast programs was done.according to, a media plan of each
radio station among the five with the largest coverage; Every week during the two
months    campaign, each of the five radio broadcasted one topic or two from
preestablished subthemes
To make sure a maximum number of people is reached the World AIDS Day
generally celebrated on 1st December was organized on November 25, 2006 to
coincide with the national community work, commonly known as “UMUGANDA”
held, , in each of the 2148 administrative cells of the country.



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Outcomes and challenges:
All leaders from the Top to the community level in collaboration with development
partners were mobilized to promote VCT in families. Couples were urged to attend
antenatal care services and to use PMTCT services; so as to increase, the rate of use
of PMTCT service which still remains low. The WAD campaign successfully reached
the most remote areas in the country. The result was an increase in number of people
tested for HIV in all health centres.


Key recommendations
The National AIDS Day campaign is a key and suitable moment to mobilize the
country in the fight againstHIV and AIDS. All partners, sectors and all leaders should
get involved in the campaign in a bid to reach positive impact. Efficient organization
of the campaign enables all stakeholders to refocus sensitization programmes
throughout the country.




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II-E-27. Intégration de la lutte contre le sida dans le secteur public
Auteurs : Docteur Agnès BINAGWAHO, UMWALI WA NGOGA Denise,
Institution responsable de l’étude: La CNLS


Contexte :
Le SIDA est devenu une menace terrible pour le monde du travail : il frappe le
segment le plus productif de la main d’oeuvre, réduit ses gains, accroît
considérablement les dépenses des entreprises de tous les secteurs d’activités parce
qu’il réduit la production, augmente les coûts du travail, induit une perte de
compétence et d’expérience.     Il représente en outre une menace pour les droits
fondamentaux au travail.
Les effets du VIH/SIDA sur la population active et sur l’ensemble des personnes en
âge de travailler peuvent être mesurés en termes d’impact global sur la croissance
économique et sur le développement. En causant maladies et décès parmi les
travailleurs, l’épidémie de VIH/SIDA réduit les réserves en compétences et
expérience de la population active et cette déperdition de ressources humaines menace
directement notre capacité à atteindre les objectifs de l’élimination de la pauvreté et
du développement durable.
L’impact du VIH/SIDA se fait particulièrement sentir au niveau de la population en
âge de travailler, parmi les travailleurs du secteur public, du secteur privé et de
l’économie informelle.


Approche :
Création de l’Umbrella du secteur public et mobilisation des institutions pour la
désignation d’un point focal chargé des activités qui permettent de        prévenir le
VIH/SIDA et limiter sont impact sur les employés et les institutions.
Engagement progressif des institutions étatiques et intégration de leurs activités de
lutte contre le SIDA dans leurs Plans d’actions.


Résultats:
       70 % des institutions ont un plan d’action budgétisé
       60 % des points focaux ont été formés en informatique, 72 % ont eu une
       formation sur les connaissances générales sur le        VIH, le SIDA et les



                                                                                   281
     autres IST, 80 % formés en planification et gestion des programmes, en
     communication et culture et en changement de comportement, 72 % en
     planification, suivi et évaluation des programmes de lutte contre le SIDA.
     Des VCT et des Family day ont été organisés
     37 728 condoms ont été distribués sur le lieu de travail


Recommandations
     Intégrer la lutte contre le SIDA dans les budgets ordinaires des institutions et
     dans l’EDPRS
     Préparer des Plans d’actions qui permettent la durabilité du financement
     Renforcer les VCT




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II-E-28 One UN: A Mirror Image by Partners

Authors: 1Binagwaho, A, Spring K2, Kourouma K3.
1
  Executive Secretary, CNLS 2M&E Adviser, UNAIDS,             3
                                                                  Country Coordinator,
UNAIDS, Rwanda

Location Rwanda


Context:
The UN High-level Panel Report in 2006 acknowledges that the UN delivery is
“fragmented and weak” with a “proliferation of agencies, mandates and offices” and
“excessive administration costs.” The OECD 2006 Report on the Paris Declaration in
Rwanda reported that; UN disburses 15 percent of ODA on budget and aid recorded
as disbursed by government was approximately 21 percent of UN aid schedules; of a
total 48 project implementation units (PIUs), the UN accounts for 30, and none of the
aid disbursed by the UN was programme-based, compared to 39 percent overall. 80
percent of UN technical assistance is coordinated compared to 61 percent overall. 15
percent of UN external missions were joint missions, compared to 13 percent of the
total 213 donor missions. This assessment proves the need for reform for alignment to
the national response. In December 2006 Rwanda applied for, and was selected as
one of 8 pilot countries for implementing Joint UN reform.


Approach:
A One UN in Rwanda is planned to improve the implementation for universal access
by increasing, efficiency of the UN to deliver and make the money work, support the
government to plan better and to mobilize partners and resources in the most effective
ways and integrate the UN plan in the national plan.
All UN Agencies, together with Government and development partners brainstormed
on how to operationalise the process of transformation to a “One UN” ans agreed on
outcomes for the next UN Development Assistance Framework (2008-2011


Outcomes/Challenges
A set of outcomes based on national policies and priorities, partner alignment and UN
comparative advantages in the areas of governance, health (including HIV),
education, social protection and agriculture/environment, using the EDPRS as the
overarching framework was agreed on by all partners. An Interagency Committee



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comprising 4 UN partners, 2 bilateral partners, and 4 Government agencies was
created to steer the process.
The UNDAF results matrix has been completed, and the UNDAF will be finalized by
end March 2007. This document is developed such that it is aligned with the national
response, and will form the basis for UN support to the national plan through one
budgetary framework.


Conclusion:
This initiative is promising, with participation of partners and full implementation is
hopeful but challenging. Hopeful, because the experience of the UN for AIDS
response, consolidating the Global Task Team Division of Labour, provides useful
lessons for the larger UNDAF support to the expanded “Three Ones” initiative to all
sectors of planning and development.      The Government of Rwanda has already
advanced coordination beyond AIDS, to include TB and malaria in the concept of
“Three Ones for the Big Three.” Launched in Rwanda in 2005




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II-E-29 Coordination of HIV and AIDS Research through
partnership: Experience of Rwanda

Authors: Dr Agnès BINAGWAHO1, Fulgence AFRIKA1, Richard NIYONKURU1, Dr
Anita ASIIMWE2

Affiliation: 1CNLS, 2TRAC

Key Words: Coordination, Research, HIV

Context:
The National research steering committee in the area of HIV and AIDS was created
in a bid to harmonized coordination of research. In fact ,before the creation of this
Committee, a lot of research was carried out without responding to a national need
and utilization of their results was poor. While research is very expensive, Rwanda
had neither an organ nor a mechanism that could help avoid possible duplications of
researches.


Approach:
As indicated in, the national AIDS policy was the epidemic surveillance and research
are important source of strategic information likely to guide planning and decision
making at different levels. In this regard the National AIDS control Commission has
put in place the National Research Steering Committee in the field of HIV and AIDS.
The core mission of this committee is to advise the Government in                 planning,
coordination, monitoring and evaluation of researches in the domain of HIV and
AIDS. The coordination machanism put in place by CNLS is very participatory and
involves all partners, public as well as private sector, universities and civil society.
The research committee is made up of 17 institutions involved in the fight against
HIV/AIDS. Each institution designates a knowledgeable resource person who sits on
the committee. The committee meets regulary once a month to evaluate research
projects in this field in a bid to guarantee the researches carried out are useful, usable,
used and cost effective.




Outcomes and Challenges:
A form guiding the preparation of protocols has been designed and can be accessed on
the CNLS Website: www.cnls.gov.rw


                                                                                           285
Since the inception of the committee, 45 research protocols have been evaluated and
about 85% of them were approved without major changes and the committee helped
to improve 15% of them.
The National steering committee in the field of HIV and AIDS has brought strong
synergy among actors involved in HIV and AIDS research . Presently, researches
meet the National Multisectoral Plan and other key documents.


Key Recommendations:
Coordination of research in the domain of HIV and AIDS through a multidisciplinary
committee allows not only to validate methodology, circumvent duplications and
ensure that all results are useful and usable, but also and most importantly it allows
rational use of funds and ensures stimulation of quality research and synergy among
the researchers.




                                                                                     286
II-E-30 Planning, monitoring and reporting at decentralized level in
Rwanda
Authors: Robert Banamwana*, Fulgence Africa*, Japhet Taratibu*, R .Amina*,
Thérèse Bishagara**, Dr Agnes Binagwaho*

*CNLS, Kigali, Rwanda, **Constella Futures/MEASURE Evaluation, Kigali,
Rwanda, *** Constella Futures/MEASURE Evaluation, Chapel Hill, NC, USA

Key Words: Data Flow, Decentralization, Monitoring

Context:

In 2006 a decentralization policy aimed at transferring decision making and power to
districts including the fight against AIDS was adopted by the Rwanda Government.
The former reporting system based on province was abandoned and replaced by the
one at districts level.
The data flow is based on           monitoring and evaluation system matrixes. .
Subsequently, the success of monitoring and evaluation system must have quality data
inflow collection. Quality data inflow must avoid data duplications; have a standard
format of data collection and reporting.
In an attempt to ensure effective and efficient data collection, CNLS developed a
decentralized data flow from districts to central level and vice versa.
The main objective was to avoid duplication and to endow district level authorities
with supervisory rights over all activities in the fight against AIDS carried out for the
community under their responsibility.


Approach
Concertation with all partners in the fight against HIV andAIDS was organized by
CNLS through seminars and meetings at differents levels to establish data flow. “The
National Monitoring and Evaluation Plan elaborated by CNLS with the support of
international experts, was used to facilitate debates and discussions.
The adopted data flow ensures that the implementing organizations who report
quarterly and annually, conform to the reporting format of CNLS.
Districts actions plans and reports are consolidated and sent to CNLS through « web
based technology”.




                                                                                     287
Outcomes and Challenges
In partnership with all stackholders, and the technical support of « MEASURE
EVALUATION », CNLS established an efficient data flow system tailored to meet the
administrative structures.
This has resulted in country wide synergy and harmonized planning and reporting
helping the « three ones» at central and decentralized level to be implemented.


Key recommendations
Rwandan experience shows that with good coordination committed partners,
participatory process and little help of international experts; it is possible to put in
place a lasting, efficient monitoring and evaluation system which responds to local
context.




                                                                                    288
II-E-31 Responsibility of religious leaders towards increasing
universal access to family planning and HIV prevention

Auteur(s): 1Binagwaho, A, Spring K2, Ngarukiye Stanis3, Leuschner4, S, Semukanya
A5, Nyaruhirira, I6

1
  Executive Secretary, CNLS 2Monitoring and Evaluation Adviser, UNAIDS, Rwanda
3
  National Coordinator, Umbrella of Faith Based Organizations, 4 PSI/Rwanda Country
Director , 5 Deputy Executive Secretary, CNLS, 6Minister of State for HIV/AIDS and
Other Epidemics.

Institutions Responsible of the study: Ministry of Health, CNLS, UNAIDS,
Umbrella of Faith-based Organisations, UNFPA


Context
Total fertility rate in Rwanda’s is estimated at 6.1 with a population growth of 2.6%, a
41% unmet need for family planning, and low modern contraceptive prevalence of
10%. Consequently, the population density is the highest in Africa, with high
maternal mortality (750 per 100 000), and an HIV prevalence of 3.0% in the general
population aged 15-49, and of 1.5% among youth aged 15-24 (among which 2.5%
female, .5% male, revealing underlying gender issues). It is clear that Universal
access to health services, family planning and HIV prevention is difficult to achieve if
nearly half of services are provided by faith-based organizations which are not willing
to distribute modern contraceptive methods including condoms due to religious
beliefs.


Approach
Given that faith based health facilities are not willing to implement new national
policies for Family Planning and HIV Prevention with Condoms, which in fact
constitute a barrier to universal access,, the Government has developed strategies to
open dialogues that ensure future commitment. The Ministry of Health and CNLS
have strengthened the policy environment, national strategies, action plans and
coordinating bodies to integrate family planning and HIV approaches, and to avoid
duplication, gaps, and inefficiencies across health programs.




                                                                                    289
Achievements and Challenges
Success was recorded by the Ministry of Health and CNLS which strengthened the
policy and strategy environment. In fact, these two bodies added new national policies
on Family Planning and Condoms and updated the range of strategic plans, including
The National Strategic Framework for HIV/AIDS (2006-2009), the National Multi-
sectorial Strategic Plan for HIV/AIDS (2006-2009) and The National HIV Prevention
Plan (2005-2009), and The National Strategic Guide for Behavior Change
Communications (BCC). In addition, coordinating steering committees and a network
of “umbrella” organizations of target populations ensure that these annual plans fit
within the national policy and strategy frameworks. As a result, Rwanda has made
major progress in increasing access to condoms, contraceptives, BCC and improving
the quality of reproductive health service delivery.


As Faith-based health facilities have revealed reluctance to provide reproductive
health services, the Ministry of Health and CNLS engaged Religious Leaders in a
dialogue that achieved the first signed joint declaration of religious leaders to support
Government efforts to reduce population growth and to fight HIV/AIDS.
Lessons learned
Active engagement of religious organizations is important for the success of the
national vision for universal access to health services and commodities and continued
communication between the government and religious leaders about the role of
religious institutions supporting and delivering new family planning and HIV
prevention policies must continue


Key Recommendations
Three key approaches will sustain progress towards universal access to reproductive
health services:   population sensitization with harmonization of communication
messages, service delivery improvements by all service providers, and integration of
HIV prevention with reproductive health.
.




                                                                                     290
II-E-32. Engagement du leadership dans la lutte contre le VIH et
SIDA au Rwanda

Authors: Dr A. Binagwaho, L. Mukashyaka, E. Karwera, G. Gatariki,
A. Semukanya

Affiliation : Commission Nationale de Lutte Contre le VIH et SIDA (CNLS)


Contexte
La mise en place des politiques et stratétégies de lutte contre le VIH et SIDA ne
peuvent être efficaces et durables que si elles se font dans le respect des Droits de
l’homme et les principes de la démocratie. Cela implique que la communauté à la
base soit sensibilisée, mobilisé et concertée par les leaders locaux et que tous
ensembles participent activement avec l’assistance des partenaires, aux activités de
Lutte contre le VIH et SIDA. C’est dans ce contexte que la mission de la CNLS de
coordination et de mobilisation des leaders tant au niveau central que communautaire
se trouve justifiée.


Description de l’approche
Depuis 2003, la question du VIH et SIDA a été ajouté dans l’ordre du jour de chaque
retraite annuelle du Gouvernement central. Ceci a donné naissance à la résolution 21
qui traduit l’ engagement ferme du gouvernement dans la lutte contre le VIH et
SIDA.
Ainsi la CNLS, dans le contexte de la décentralisation , a intégré les activités de lutte
contre le VIH et SIDA dans les districts. Ces activités font parti des performances à
évaluer chaque année.
Pour une plus grande efficacité et efficience, la CNLS a mis en place les activités de
suivi-évaluation qui se font par voie des descentes trimestrielles sur terrain qui
regroupent tous les leaders locaux, bénéficiaires et partenaires dans la lutte contre le
VIH et SIDA.
Ces descentes se font dans les 30 districts du pays et sont dirigées par le Maire du
district et le Secrétaire Exécutif Adjoint de la CNLS pour informer, sensibiliser,
évaluer les progrès, identifier les problèmes rencontrés et trouver dans l’immédiat des
solutions.




                                                                                     291
Réalisations
Pour évaluer l’état d’avancement et faire des ajustements nécessaires, la résolution
21 est revue chaque année.
Au niveau des districts, la CNLS a signé des protocoles d’accords avec ces
administrations décentralisées afin d’intégrer dans leurs structures des Comité de
District de Lutte contre le SIDA qui sont supervisés par les Maires.
Les descentes ont montré que les plans d’actions des districts consolident toutes les
activités de lutte contre le VIH et SIDA dans le District. Elles ont en outre revelé
l’existence de plan de district IEC/CCC, de Recherche, de Suivi et Evaluation et autre
en accord avec les plans nationaux existants. Aussi, il a été constaté l’existence des
sous-comités techniques fonctionnels dans les domaines OEV, IEC/CCC, approbation
des agréments, activités génératrices de revenues.


Recommendation:
Les leaders du niveau central ainsi que la CNLS devraient descendre le plus souvent
dans les communautés de base pour s’assurer que les bénéficiaires des activités de
lutte contre le SIDA sont satisfaits des services qui leur sont donnés.




                                                                                  292
ANNEXES




          293
                                     AGENDA
                              Thursday, March 29, 2007
8:00 – 8:30   Registration and poster viewing
8:30 – 9:00   Opening Ceremonies                                       Moderator
              Welcome note:
              • Rev. Nathan GASATURA
                  Chair of CNLS CommissionersBoard
              Opening remarks:
              • Mme Béatrice KAGOYIRE
                  Présidente Nationale du RRP+                         Dr Agnes BINAGWAHO
9:00 – 9:30
              • Dr I. NYARUHIRIRA                                      Executive Secretary – CNLS
                  Minister of State in Charge of HIV/AIDS and
                  other epidemics
              • Prof. R. MURENZI
              Minister at the President office in charge of Science,
              Technology and Scientific Research
                             Session I: Clinical Research
Moderator: Dr KEKOURA (UNAIDS Country Coordinator)
Raporteur: Dr L. MUSANGO (Director SPH-NUR)
                                                                       Kenneth Schulz, PhD,
              Invited presentation
                                                                       Vice President, Quantitative
9:30 – 9:40   Clinical Research in HIV: Future Directions and the
                                                                       Sciences, Family Health
              Need for Rigorous Randomized Trials
                                                                       International
                                                                       Dr Kayitesi Kayitenkore
              Safety and immunogenicity of the VRC recombinant         Projer San Francisco-
              multiclade HIV-1 adenoviral vector vaccine alone or      Rwanda;
9:40 – 9:50
              in combination with the VRC multiclade HIV-1 DNA         Chair of the Ethical
              plasmid vaccine in healthy African adults                committee for HIV/AIDS
                                                                       Research in Rwanda
                                                                       Eveline Guebbels, PhD,
                                                                       International Scientific
              Current developments in HIV prevention technology        Manager, Center of Poverty-
9:50-10:00
              research (PREP, microbicides, anti HSV2 methods)         related Communicable
                                                                       Disease of the University of
                                                                       Amsterdam
10:00-10:30   Discussion
10:30-11:00   Pause and poster viewing
                    Session II: Clinical Care and Treatment
Moderator: Dr E. KARITA (Director Projet San Francisco-Rwanda)
Rapporteur : Dr Laurien NYABYENDA (Président du Forum des ONG / ARBEF)
              Invited presentations:                                   Shanon Galvin, MD,
11:00-11:10   Current and emergent issues in HIV patient care: a       Ass.Professor
              global perspective                                       University of North Carolina
                                                                       Anita Asiimwe, MD, Head
                                                                       of Task Force
              Current and emergent issues in HIV patient care: a
11:10-11:20                                                            Treatment and Research on
              national perspective
                                                                       AIDS Center Plus (TRAC
                                                                       Plus)
              Secondary effects and other complications from 1st
              line ARVs: Observations on 406 adverse effects
                                                                       Innocent Turate
              necessitating drug changes in patients from two
                                                                       ARV Coordinator
11:20-11:30   health facilities in Rwanda
                                                                       FHI-Rwanda
              With Symptomatic lactic acidaemia on stavudine-
              containing ART: clinical features of 20 cases and
              risk factor assessment
Moderator: Claude SEKABARAGA, M.D (Directeur de l’Unité de Planification, Politique et
Développement des Compétences, MOH)
Raporteur: Dr Jeff HANSON (Director CDC-RWANDA)
                                                                       P. Rugimbanya
                                                                       Senior Laboratory Quality
                Evaluation of a new national quality control
11:30 – 11:40                                                          Assurance Manager
                approach, for HIV testing in Rwanda
                                                                       Laboratoire National du
                                                                       Rwanda
                Validation of WHO-recommended immunological
                                                                       J.v.Griensven
11:40 – 11:50   criteria for treatment failure – with recommendation
                                                                       MSF
                to emphasize implications for national protocol
                                                                       N. Makombe
                Evaluation d’une technique alternative automatisée
                                                                       Biotechnologist
11:50 – 12:00   à coût réduit pour la mesure de la charge virale
                                                                       Laboratoire National du
                plasmatique du VIH-1 au Rwanda
                                                                       Rwanda
                                                                       E. Karara
                Joint Supervision with TRAC Partners in HIV            Monitoring and Evaluation
12:00 – 12:10
                Programs: Major Findings                               Unit
                                                                       TRAC Plus
12:10-12:40     Discussion
12:40 – 2:00    Lunch and poster viewing
                       Session II: Clinical Care and Treatment
Moderator: John DUNLOP (Supervisory Health Officer USAID)
Raporteur: Dr Daniel NGAMIJE (Coordinateur Unité de Gestion Projets/GF/MAP)
                Invited Presentation:
                                                                       Jessica Justman
                HIV Prevention, Care and
2:00 – 2:10                                                            Director Columbia/UTAP
                Treatment in Resource-Limited Settings: Updates
                                                                       New York, US
                from Recent Clinical Trials"
                                                                       Dr. Chintu Namwinga
                Early Clinical Outcomes among Children Receiving
                                                                       PMTCT Coordinator/ Center
2:10-2:20       Antiretroviral Therapy at Primary Health Clinics in
                                                                       for Infectious Disease
                Lusaka, Zambia: Bridging Service and Research
                                                                       Research - ZAMBIA
                                                                       P. Manyika
                Implementing an Electronic Medical Record System
2:20-2:30                                                              Data Manager
                to Expand ARV Treatment in Rural Rwanda
                                                                       Partners In Health-Rwanda
                                                                       L. Bangendanye
                Utilization of Maternity Services by HIV-infected
                                                                       Senior Technical Officer and
2:30 – 2:40     Women in FHI-supported Health Centers in
                                                                       Team Leader MTCT/PT/STI
                Rwanda
                                                                       FHI-Rwanda
2:40 – 3:10     Discussion
3:10- 3: 40     Pause and poster viewing
                ART delivery and adherence in a program for            S. Stulac
                                                                       Partners In Health, Boston,
3:40-3:50       comprehensive pediatric HIV care in rural Rwanda
                                                                       MA, USA and Inshuti Mu
                Partners in Health.
                                                                       Buzima, Rwinkwavu, Rwanda
                                                                       J. Uwineza
                Espace de dialogue, une prise en charge appropriée
3:50 – 4:00                                                            Psychologue Clinicienne
                                                                       We-Act /Rwanda
                Implementing HIV/AIDS Treatment and Care               E. Ndoba
                                                                       Country Coordinator
4:00-4:10       Project among Mobile populations – The RDF             Charles R Drew
                context                                                University/Rwanda
                Implementation of the Partners In Health (PIH)         PC Niyigena
4:10-4:20       community-based model of HIV care and prevention       HIV/TB Program Coordinator
                in a rural health district in Rwanda                   Partners In Health-Rwanda




                                                                                                295
4:20-4:50   Discussion
                                                 Kate SPRING
                                                 Monitoring and Evaluation
                                                 Officer UNAIDS
4:50-5:15   Synthesis of Discussions for Day 1
                                                 Umutoni SHAKIRA
                                                 Executive Secrétary
                                                 Réseaux Rwandais des PVVIH




                                                                         296
                                   Friday, March 30, 2007
8:00 – 8:30     Participant arrival and poster viewing
                                    Session III. Prevention
Moderator: Dr Louis MUNYAKAZI (Directeur de l’Institut National des Statistiques au Rwanda)
Raporteur: Dr Jane MWITA (HIV specialist, UNICEF-Rwanda)
                                                                        Mahesh Mahalingan
                Invited Presentation:                                        UNAIDS Country
8:30 – 8:40
                Importance of research in Prevention                         Coordinator,
                                                                             LESOTHO
                                                                             Chimbwete Chiweni
                Male Circumcision and HIV prevention: From research to
8:40 – 8:50                                                                  UNAIDS Regional
                policy and action
                                                                             Support Team
                                                                             Dr. J. Byaruhanga
                Changes in HIV knowledge, sexual risk, and utilization of
                                                                             Head Epidemiology
8:50 – 9:00     VCT among youth in Rwanda: Behavioral Surveillance
                                                                             TRACPlus
                Results from 2000 – 2006
                                                                             BN. Maggwa
                Contraception – an effective and underutilized approach to
9:00 – 9:10                                                                  Directorof Research
                preventing HIV sequelae
                                                                             FHI-Kenya
                                                                             C. KAYITESI
                Changes in sexual risk behavior in sex workers in Rwanda:
                                                                             Nutritionist
9:10 – 9:20     Report of findings comparing 2000 and 2006 BSS data and
                                                                             TRACPlus
                review of implications for prevention programming
                Determinants of Condom Use among high-risk youth who         Stacy Leuschner
9:20 – 9:30     frequent hotspots in high-transmission zones”. .             Country Director
                                                                             PSI-Rwanda
9:30 – 10:00  Discussion
10:00 – 10:30 Pause and poster viewing
Moderator: Dr Anita Asiimwe (Director TRAC)
Raporteur: Dr Ruben SAHABO (Country Director COLUMBIA University/Rwanda)
                                                                          V. Mutarabayire
              Bilan de la campagne de dépistage volontaire mobile au      Coordinateur Seceteur
10:30 – 10:40
              niveau de 19 entreprises privées et paraétatiques du Rwanda Privée/
                                                                          APELAS
                                                                          R. Sahabo
              Expanding HIV Care and Treatment to Rwandan Prisons: A      Country Director
10:40 – 10:50
              Collaborative approach                                      Columbia University /
                                                                          Rwanda
                                                                          G. Ngendahimana
              Involving Men in Prevention of Mother-to-Child Transmission Deputy Director
11:50 – 12:00
              of HIV Programs in Rwanda                                   IntraHealth / Capacity-
                                                                          Rwanda
                                                                          A. Jeffrey
              Mobile VCT: An Evaluation of Innovative HIV-Testing
12:00 – 12:10                                                             Program Officer
              Approaches
                                                                          CDC-Rwanda
                                                                          JMV Nsengiyumva
              Implication du secteur prive dans la lutte contre le        Chef du Service
12:10 – 12:20
              VIH/SIDA : expérience de la Banque de Kigali                Medico-Social
                                                                          Banque de Kigali
11:20 – 12:50 Discussion
12:50 – 2:00  Lunch and poster viewing




                                                                                            297
    Session IV. Social and Economic Impact and Psycho-social Care and
                                 Support
Moderator: Dr Francois SOBELA ( Medical Officer, WHO)
Raporteur: Prof Nsanze (Dean faculty of Medecine-NUR)
                                                                               D. Pinault
              Community Learning and Action for Stimulation and                OVC and HIV/AIDS
2:00 – 2:10
              Enhancement                                                      Advisor
                                                                               CARE-RWANDA
                                                                               E. Kalisa
              Scaling up the mentorship program to address the
                                                                               Director for Technical
2:10 – 2:20   psychosocial problems of orphans and vulnerable children in
                                                                               Services
              Gikongoro
                                                                               World Vision Rwanda
                                                                               M. Baingana
              Rwanda HIV/AIDS public interest fellowship program
                                                                               Technical Advisor
2:20 – 2:30   (RHPIF); progress and achievements during its’ first 2½
                                                                               NUR/SPH Tulane -
              years
                                                                               RWANDA
              Prise en charge psychosociale des personnes vivant avec le
                                                                               S. Kazimbaya
2:30 – 2:40   VIH au niveau des centres de conseil et d’orientation de la
                                                                               Executif Secretary
              SWAAR
                                                                               SWAA RWANDA
2:40 – 3:10   Discussion
3:10-3:40     Pause and poster viewing
                           Session V: MULTI COUNTRY
Moderator: Dr Joseph WAKANA (Executive Secretary Great Lakes Initiative on AIDS-GLIA)
Raporteur: Dr Vyankandondera (Centre Hospitalo-Universitaire de Kigali)
              Invited Presentation:                                            Dr Agnes Binagwaho
3:40 – 3:50   The Multi Country Program: Current situation and                 Executive Secretary
              perspective for the future                                       CNLS
                                                                               Dr Thomas
                                                                               MACHARIA
              Pattern of Immunologicimprovement and relation to viral          Clinical Associate,
              suppression in resource- limited settings: Kenya, Uganda,        PEPFAR AIDSRelief,
3:50-4:00
              Zambia                                                           Institute of Human
                                                                               Virology (IHV),
                                                                               University of Maryland,
                                                                               Baltimore, US
                                                                               Ruth Goehle
              Implications of the CD4 count at initiation of anti-retroviral
                                                                               Country Director
              therapy on morbidity, mortality and virologic outcomes in
4:00 – 4:10                                                                    CRS/ AIDSRelief
              Rwanda – a descriptive cross-sectional review in AIDSRelief
                                                                               RWANDA
              supported health centers
Moderator: Mrs Rose GAHIRE (Vice.Chair CNLS commissioners Board)
Raporteur: Tom Scialfa (Director Tulane University)
                                                                               T. Bishagara
                                                                               President
              Assessment of nutritional support provided by faith based
4:10 – 4:20                                                                    Shining Hope for Great
              organizations (FBOs) to people affected by HIV and AIDS
                                                                               Lakes (SHGL)
                                                                               RWANDA
              Inception and implementation of the Multi Country Program
                                                                               Kanabetsho Bainame
4:20 – 4:30   on Social Science Research in the field of HIV/AIDS in
                                                                               University of Botswana
              Botswana
                                                                               Dr André Soubeiga
              Le conseil dépistage volontaire dans les formations              Socio-Antropologue
              sanitaires : une alternative contre la stigmatisation des        Maitre Assistant
4:30 – 4:40
              PVVIH ? Cas de Bobo Dioulasso et Kongoussi au Burkina            Université de
              Faso)                                                            Ouagadugu
                                                                               BURKINA FASSO



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                                                                   Prof. E. Safary Ariga
                                                                   Deputy Vice Chancellor
            Food and nutrition security among people living with
4:40-4:50                                                          of Great Lakes
            HIV/AIDS in Suba district
                                                                   University of Kisumu -
                                                                   KENYA
4:50-5:20   Discussion
                                                                   • Dr P.SHYAKA
                                                                   Clinicien Invistigateur
                                                                   AMATA
                                                                   Lux Development
5:20-5:30   Synthesis of day 2                                     • Dr Marthe
                                                                       Mukaminega
                                                                   Senior Technical
                                                                   Advisor – EGPAF

            Closing:                                               Moderator
                                                                   Mr A.Semukanya
5:30-5:40   Recommendations                                        Deputy Executive
                                                                   Secretary-CNLS
            • Dr. Damascène NTAWUKURIRYAYO
                                                                   Dr Agnes
            Minister of Health
5:30                                                               BINAGWAHO
            • Prof. Laurent NKUSI                                  Executive Secretary –
            Minister in the Prime Minister’s Office in charge of
                                                                   CNLS
            Information




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