Kigali, Rwanda
Kigali, Rwanda

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Rulisa S.,University of Kigali | Rulisa S.,Center for Infection and Immunity Amsterdam | Kaligirwa N.,Rwanda Biomedical Center | Agaba S.,Rwanda Biomedical Center | And 4 more authors.
Malaria Journal | Year: 2012

Background: The World Health Organization presently recommends Artemisinin-based combination therapy (ACT)as first-line therapy for uncomplicated P. falciparum malaria. Many malaria-endemic countries, including Rwanda, have adopted these treatment guidelines. The Artemisinin derivative Artemether, in combination with lumefantrine, is currently used in Rwanda for malaria during the second and third trimesters of pregnancy. Safety data on the use of ACT in pregnancy are still limited though and more data are needed. Methods: In this pharmacovigilance study, the exposed group (pregnant women with malaria given artemetherlumefantrine), and a matched non-exposed group (pregnant women without malaria and no exposure to artemether-lumefantrine) were followed until delivery. Data were collected at public health centres all over Rwanda during acute malaria, routine antenatal visits, after hospital delivery or within 48 hours after home delivery. Information gathered from patients included routine antenatal and peri-partum data, pregnancy outcomes (abortions, stillbirths, at term delivery), congenital malformations and other adverse events through history taking and physical examination of both mothers and newborns. Results: The outcomes for the total sample of 2,050 women were for the treatment (n = 1,072) and control groups (n = 978) respectively: abortions: 1.3% and 0.4%; peri-natal mortality 3.7% and 2.8%; stillbirth 2.9% and 2.4%; neonatal death [less than or equal to]7 days after birth 0.5% and 0.4%; premature delivery 0.7% and 0.3%; congenital malformations 0.3% and 0.3%. A total of 129 obstetric adverse events in 127 subjects were reported (7.3% in the treatment group, 5.0% in the control group). In a multivariate regression model, obstetric complications were more frequent in the treatment group (OR (95% CI): 1.38 (0.95, 2.01)), and in primigravidae (OR (95% CI) 2.65 (1.71, 4.12) and at higher age (OR per year: 1.05 (1.01-1.09). Conclusions: There were no specific safety concerns related to artemether-lumefantrine treatment for uncomplicated falciparum malaria in pregnancy. However, more obstetric complications were observed in the treatment group. These increased occurrence of complications could, however, be caused by the malaria episoDe itself, but further assessment is required. © 2012 Rulisa et al.; licensee BioMed Central Ltd.


Ngabo F.,Free University of Colombia | Tate J.E.,Centers for Disease Control and Prevention | Gatera M.,Rwanda Biomedical Center | Rugambwa C.,World Health Organization | And 7 more authors.
The Lancet Global Health | Year: 2016

Background: In May, 2012, Rwanda became the first low-income African country to introduce pentavalent rotavirus vaccine into its routine national immunisation programme. Although the potential health benefits of rotavirus vaccination are huge in low-income African countries that account for more than half the global deaths from rotavirus, concerns remain about the performance of oral rotavirus vaccines in these challenging settings. Methods: We conducted a time-series analysis to examine trends in admissions to hospital for non-bloody diarrhoea in children younger than 5 years in Rwanda between Jan 1, 2009, and Dec 31, 2014, using monthly discharge data from the Health Management Information System. Additionally, we reviewed the registries in the paediatric wards at six hospitals from 2009 to 2014 and abstracted the number of total admissions and admissions for diarrhoea in children younger than 5 years by admission month and age group. We studied trends in admissions specific to rotavirus at one hospital that had undertaken active rotavirus surveillance from 2011 to 2014. We assessed changes in rotavirus epidemiology by use of data from eight active surveillance hospitals. Findings: Compared with the 2009-11 prevaccine baseline, hospital admissions for non-bloody diarrhoea captured by the Health Management Information System fell by 17-29% from a pre-vaccine median of 4051 to 2881 in 2013 and 3371 in 2014, admissions for acute gastroenteritis captured in paediatric ward registries decreased by 48-49%, and admissions specific to rotavirus captured by active surveillance fell by 61-70%. The greatest effect was recorded in children age-eligible to be vaccinated, but we noted a decrease in the proportion of children with diarrhoea testing positive for rotavirus in almost every age group. Interpretation: The number of admissions to hospital for diarrhoea and rotavirus in Rwanda fell substantially after rotavirus vaccine implementation, including among older children age-ineligible for vaccination, suggesting indirect protection through reduced transmission of rotavirus. These data highlight the benefits of routine vaccination against rotavirus in low-income settings. Funding: Gavi, the Vaccine Alliance and the Government of Rwanda. © 2016 World Health Organization.


Pevzner E.S.,Centers for Disease Control and Prevention | Vandebriel G.,Columbia International University | Lowrance D.W.,Centers for Disease Control and Prevention | Gasana M.,Rwanda Biomedical Center | Finlay A.,Centers for Disease Control and Prevention
BMC Public Health | Year: 2011

Background: In 2005, Rwanda drafted a national TB/HIV policy and began scaling-up collaborative TB/HIV activities. Prior to the scale-up, we evaluated existing TB/HIV practices, possible barriers to policy and programmatic implementation, and patient treatment outcomes. We then used our evaluation data as a baseline for evaluating the national scale-up of collaborative TB/HIV activities from 2005 through 2009. Methods. Our baseline evaluation included a cross-sectional evaluation of 23/161 TB clinics. We conducted structured interviews with patients and clinic staff and reviewed TB registers and patient records to assess HIV testing practices, provision of HIV care and treatment for people with TB that tested positive for HIV, and patients' TB treatment outcomes. Following our baseline evaluation, we used nationally representative TB/HIV surveillance data to monitor the scale-up of collaborative TB/HIV activities. Results: Of 207 patients interviewed, 76% were offered HIV testing, 99% accepted, and 49% reported positive test results. Of 40 staff interviewed, 68% reported offering HIV testing to 50% of patients. From 2005-2009, scaled-up TB/HIV activities resulted in increased HIV testing of patients with TB (69% to 97%) and provision of cotrimoxazole (15% to 92%) and antiretroviral therapy (13% to 49%) for patients with TB disease and HIV infection (TB/HIV). The risk of death among patients with TB/HIV relative to patients with TB not infected with HIV declined from 2005 (RR = 6.1, 95%CI 2.6, 14.0) to 2007 (RR = 1.8, 95%CI 1.68, 1.94). Conclusions: Our baseline evaluation highlighted that staff and patients were receptive to HIV testing. However, expanded access to testing, care, and treatment was needed based on the proportion of patients with TB having unknown HIV status and the high rate of HIV infection and poorer TB treatment outcomes for patients with TB/HIV. Following our evaluation, scale-up of TB/HIV services resulted in almost all patients with TB knowing their HIV status. Scale-up also resulted in dramatic increases in the uptake of lifesaving HIV care and treatment coinciding with a decline in the risk of death among patients with TB/HIV. © 2011 Pevzner et al; licensee BioMed Central Ltd.


El-Sadr W.M.,Columbia University | Holmes C.B.,Office of U.S. Global AIDS Coordinator | Mugyenyi P.,Joint Clinical Research Center | Thirumurthy H.,University of North Carolina at Chapel Hill | And 11 more authors.
Journal of Acquired Immune Deficiency Syndromes | Year: 2012

Since its inception in 2003, the US President's Emergency Plan for AIDS Relief (PEPFAR) has been an important driving force behind the global scale-up of HIV care and treatment services, particularly in expansion of access to antiretroviral therapy. Despite initial concerns about cost and feasibility, PEPFAR overcame challenges by leveraging and coordinating with other funders, by working in partnership with the most affected countries, by supporting local ownership, by using a public health approach, by supporting task-shifting strategies, and by paying attention to health systems strengthening. As of September 2011, PEPFAR directly supported initiation of antiretroviral therapy for 3.9 million people and provided care and support for nearly 13 million people. Benefits in terms of prevention of morbidity and mortality have been reaped by those receiving the services, with evidence of societal benefits beyond the anticipated clinical benefits. However, much remains to be accomplished to achieve universal access, to enhance the quality of programs, to ensure retention of patients in care, and to continue to strengthen health systems. Copyright © 2012 by Lippincott Williams & Wilkins.


Binagwaho A.,Ministry of Health | Wagner C.M.,Harvard University | Gatera M.,Rwanda Biomedical Center | Karema C.,Rwanda Biomedical Center | And 2 more authors.
Bulletin of the World Health Organization | Year: 2012

Problem Virtually all women who have cervical cancer are infected with the human papillomavirus (HPV). Of the 275 000 women who die from cervical cancer every year, 88% live in developing countries. Two vaccines against the HPV have been approved. However, vaccine implementation in low-income countries tends to lag behind implementation in high-income countries by 15 to 20 years. Approach In 2011, Rwanda's Ministry of Health partnered with Merck to offer the Gardasil HPV vaccine to all girls of appropriate age. The Ministry formed a "public-private community partnership" to ensure effective and equitable delivery. Local setting Thanks to a strong national focus on health systems strengthening, more than 90% of all Rwandan infants aged 12-23 months receive all basic immunizations recommended by the World Health Organization. Relevant changes In 2011, Rwanda's HPV vaccination programme achieved 93.23% coverage after the first three-dose course of vaccination among girls in grade six. This was made possible through school-based vaccination and community involvement in identifying girls absent from or not enrolled in school. A nationwide sensitization campaign preceded delivery of the first dose. Lessons learnt Through a series of innovative partnerships, Rwanda reduced the historical two-decade gap in vaccine introduction between high- and low-income countries to just five years. High coverage rates were achieved due to a delivery strategy that built on Rwanda's strong vaccination system and human resources framework. Following the GAVI Alliance's decision to begin financing HPV vaccination, Rwanda's example should motivate other countries to explore universal HPV vaccine coverage, although implementation must be tailored to the local context.


McNairy M.L.,Columbia University | McNairy M.L.,New York Medical College | Lamb M.R.,Columbia University | Carter R.J.,Columbia University | And 7 more authors.
Journal of Acquired Immune Deficiency Syndromes | Year: 2013

Background: Retention of children in HIV care is essential for prevention of disease progression and mortality. Methods: Retrospective cohort of children (aged 0 to <15 years) initiating antiretroviral treatment (ART) at health facilities in Kenya, Mozambique, Rwanda, and Tanzania, from January 2005 to June 2011. Retention was defined as the proportion of children known to be alive and attending care at their initiation facility; lost to follow-up (LTF) was defined as no clinic visit for more than 6 months. Cumulative incidence of ascertained survival and retention after ART initiation was estimated through 24 months using Kaplan-Meier methods. Factors associated with LTF and death were assessed using Cox proportional hazard modeling. Results: A total of 17,712 children initiated ART at 192 facilities: median age was 4.6 years [interquartile ratio (IQR), 1.9-8.3], median CD4 percent was 15% (IQR, 10-20) for children younger than 5 years and 265 cells per microliter (IQR, 111-461) for children aged 5 years or older. At 12 and 24 months, 80% and 72% of children were retained with 16% and 22% LTF and 5% and 7% known deaths, respectively. Retention ranged from 71% to 95% at 12 months and from 62% to 93% at 24 months across countries, respectively, and was lowest for children younger than 1 year (51% at 24 months). LTF and death were highest in children younger than 1 year and children with advanced disease. Conclusions: Retention was lowest in young children and differed across country programs. Young children and those with advanced disease are at highest risk for LTF and death. Further evaluation of patient- and program-level factors is needed to improve health outcomes. Copyright © 2012 by Lippincott Williams and Wilkins.


News Article | November 16, 2016
Site: www.nature.com

Rwanda has made major public-health strides since the country's genocide against the Tutsi people ended in June 1994, but declines in foreign aid now threaten that progress. Donors such as the US President’s Emergency Plan for AIDS Relief and the Global Fund to Fight AIDS, Tuberculosis and Malaria have reduced assistance to Rwanda by 40% over the past three years, jeopardizing advances in a country seen as a development success story. The situation will be hotly discussed at the annual meeting of The World Academy of Sciences in Kigali on 14–17 November. “If the decline in funding continues, there are a lot of things to lose rather than to gain,” says Sabin Nsanzimana, who manages initiatives on HIV and other blood-borne diseases at the Rwanda Biomedical Center in Kigali, which runs the country’s health programmes. The declining foreign aid is part of two broader trends in development: redirecting money to countries that have the highest number of sick people, and urging developing countries to fund more of their own development work. The former has reduced aid to Rwanda, a small country that has slashed the incidence of diseases such as HIV. Like many other developing nations, Rwanda doesn’t have the resources to move money from priority areas such as education into health, says Nsanzimana, citing a study by Anna Vassall, an epidemiologist at the London School of Hygiene & Tropical Medicine1. Vassall estimates that even if sub-Saharan African nations more than triple their spending on HIV in the next five years, most could only raise half the money they need to meet the goal set by the Joint United Nations Programme on HIV/AIDS of ending the epidemic's global threat by 2030. Fredrick Kateera, director of research for the Rwanda office of the non-profit organization Partners in Health, says that funding cuts could imperil the research that is needed to fight diseases such as malaria in Rwanda and elsewhere. “Setting up surveillance systems costs just as much money as just giving out drugs and bed nets,” Kateera says. Rwanda has long been seen as a prime example of how science can aid development. After the genocide in 1994, Rwanda's President Paul Kagame invested in building roads, high-speed Internet access and applying science to local problems. The country slashed maternal and infant deaths, new HIV infections, AIDS deaths and mother-to-child HIV transmission2. Kagame has also used his authority to ensure that science conducted by local and foreign scientists promotes domestic development. In 2012, the country’s ministry of health published guidelines compelling all foreign research projects to strengthen Rwandan research capacity, such as training its scientists or building infrastructure. Rwandan researchers routinely appear as first and last authors on studies conducted in the country, in contrast to other African nations where native researchers often don’t benefit from foreign collaborations. “You can’t just be a global health researcher who drops in, gets some data, publishes it with your name as first author and never comes back,” says epidemiologist Edward Mills of the Institute for Health Metrics and Evaluation in Seattle, Washington, and an adjunct professor at the University of Rwanda in Kigali. Staff at clinics and ministries who fail in their roles to meet stringent health targets can also be reassigned or sacked. In July, for instance, Kagame removed Agnès Binagwaho from her post as minister of health. The highly regarded paediatrician earned the US$100,000 Roux Prize for using data to improve public health in April 2015, but was let go after malaria cases in the country quadrupled to 2 million between 2012 and 2015. Human-rights groups have chafed at Kagame’s authoritarian tendencies, but he has kept corruption low in Rwanda compared with other sub-Saharan African nations. This made the country a favourite of donors for much of the 2000s. But that shifted after 2013, when organizations such as the US Institute of Medicine questioned donors’ generosity towards Rwanda compared to nations with much higher HIV burdens — such as Swaziland. In response, donors recalibrated; in 2014, for instance, the Global Fund to Fight AIDS, Tuberculosis and Malaria began using a new formula that allocated funding in part according to a country’s burden of disease. In June, the fund said that it had reworked its formula again in response to protests from countries such as Rwanda that it punished them for their success. Still, Rwandan researchers are feeling the pinch. “The willingness to do research is there, but many institutions are lacking funding,” says physician and molecular biologist Etienne Karita, who is country director for Projet San Francisco, an HIV-prevention programme in Kigali. Despite the funding constraints and bureaucratic restrictions, Rwandan researchers who train abroad often return to their home nation, attracted by the prospect of playing their part in rebuilding. Kateera, for instance, earned his medical degree in Uganda, where universities have partnerships with prestigious institutions in Europe, the United States and Asia. Tiny Rwanda, with one-third the population and one-ninth the area of Uganda, doesn’t have that same wealth of opportunities. But Kateera feels that he can make more of a difference in Rwanda: “You can make a big impact and measure it much more easily here compared to in a larger country,” he says. He and other researchers hope that donors will hear their case, and make sure that this impact continues.


Hakizimana E.,Rwanda Biomedical Center | Hakizimana E.,Wageningen University | Cyubahiro B.,Rwanda Biomedical Center | Rukundo A.,Rwanda Biomedical Center | And 6 more authors.
Malaria Journal | Year: 2014

Background: To validate assumptions about the length of the distribution-replacement cycle for long-lasting insecticidal nets (LLINs) in Rwanda, the Malaria and other Parasitic Diseases Division, Rwanda Ministry of Health, used World Health Organization methods to independently confirm the three-year LLIN serviceable life span recommendation of WHO. Methods. Approximately 3,000 coded LLINs, distributed as part of a national campaign, were monitored in six sites, by means of six-monthly visits to selected houses. Two indicators, survivorship/attrition, a measure of the number of nets remaining, and fabric integrity, the proportion of remaining nets in either 'good', 'serviceable' or 'needs replacement' condition, based on holes in the net material, were tracked. To validate the assumption that the intervention would remain effective for three years, LLIN coverage, calculated using either survivorship, or integrity, by removing nets in the 'needs replacement' category from the survivorship total, was compared with the predicted proportion of nets remaining, derived from a net loss model, that assumes an LLIN serviceable life of three years. Results: After two years, there was close agreement between estimated LLIN survivorship at all sites, 75% (range 64-84%), and the predicted proportion of nets remaining, 75%. However, when integrity was considered, observed survivorship at all sites, declined to 42% (range 10-54%). Conclusions: More than half, 58%, of the LLINs fell into the 'needs replacement' category after two years. While these nets were counted for survivorship, they were judged to be of little-to-no benefit to a user. Therefore, when integrity was taken into account, survivorship was significantly lower than predicted, suggesting that net serviceable life was actually closer to two, rather than three years, and, by extension, that the impact of the intervention during year three of the LLIN distribution-replacement cycle could be well below that seen in years one and two. © 2014 Hakizimana et al.; licensee BioMed Central Ltd.


Binagwaho A.,Ministry of Health of Rwanda | Ngabo F.,Ministry of Health of Rwanda | Wagner C.M.,Global Health Delivery Partnership | Mugeni C.,Ministry of Health of Rwanda | And 3 more authors.
Bulletin of the World Health Organization | Year: 2013

Problem Although it is highly preventable and treatable, cervical cancer is the most common and most deadly cancer among women in Rwanda. Approach By mobilizing a diverse coalition of partnerships, Rwanda became the first country in Africa to develop and implement a national strategic plan for cervical cancer prevention, screening and treatment. Local setting Rwanda - a small, landlocked nation in East Africa with a population of 10.4 million - is well positioned to tackle a number of "high-burden" noncommunicable diseases. The country's integrated response to infectious diseases has resulted in steep declines in premature mortality over the past decade. Relevant changes In 2011-2012, Rwanda vaccinated 227 246 girls with all three doses of the human papillomavirus (HPV) vaccine. Among eligible girls, three-dose coverage rates of 93.2% and 96.6% were achieved in 2011 and 2012, respectively. The country has also initiated nationwide screening and treatment programmes that are based on visual inspection of the cervix with acetic acid, testing for HPV DNA, cryotherapy, the loop electrosurgical excision procedure and various advanced treatment options. Lessons learnt Low-income countries should begin to address cervical cancer by integrating prevention, screening and treatment into routine women's health services. This requires political will, cross-sectoral collaboration and planning, innovative partnerships and robust monitoring and evaluation. With external support and adequate planning, high nationwide coverage rates for HPV vaccination and screening for cervical cancer can be achieved within a few years.


Lamb M.R.,Columbia University | Fayorsey R.,Columbia University | Nuwagaba-Biribonwoha H.,Columbia University | Viola V.,Columbia University | And 4 more authors.
AIDS | Year: 2014

OBJECTIVES:: To compare pre and post-ART attrition between youth (15-24 years) and other patients in HIV care, and to investigate factors associated with attrition among youth. DESIGN:: Cohort study utilizing routinely collected patient-level data from 160 HIV clinics in Kenya, Mozambique, Tanzania, and Rwanda. METHODS:: Patients at least 10 years of age enrolling in HIV care between 01/05 and 09/10 were included. Attrition (loss to follow-up or death 1 year after enrollment or ART initiation) was compared between youth and other patients using multivariate competing risk (pre-ART) and traditional (post-ART) Cox proportional hazards methods accounting for within-clinic correlation. Among youth, patient-level and clinic-level factors associated with attrition were similarly assessed. RESULTS:: A total of 312S335 patients at least 10 years of age enrolled in HIV care; 147S936 (47%) initiated ART, 17% enrolling in care and 10% initiating ART were youth. Attrition before and after ART initiation was substantially higher among youth compared with other age groups. Among youth, nonpregnant women experienced lower pre-ART attrition than men [sub-division hazard ratioS=S0.90, 95% confidence interval (CI): 0.86-0.94], while both pregnant [adjusted hazard ratio (AHR)S=S0.85, 95% CI: 0.74-0.97] and nonpregnant (AHRS=S0.79, 95% CI: 0.73-0.86) female youth experienced lower post-ART attrition than men. Youth attending clinics providing sexual and reproductive health services including condoms (AHRS=S0.47, 95% CI: 0.32-0.70) and clinics offering adolescent support groups (AHRS=S0.73, 95% CI: 0.52-1.0) experienced significantly lower attrition after ART initiation. CONCLUSION:: Youth experienced substantially higher attrition before and after ART initiation compared with younger adolescents and older adults. Adolescent-friendly services were associated with reduced attrition among youth, particularly after ART initiation. © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins.

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