hiv control in rwanda: lessons and challenges · dhs 2010 0.5 1.5 2.9 3.9 6.3 6.7 5.7 raihis 2013...
TRANSCRIPT
![Page 1: HIV control in Rwanda: Lessons and challenges · DHS 2010 0.5 1.5 2.9 3.9 6.3 6.7 5.7 RAIHIS 2013 0.4 1.0 2.1 4.4 5.0 7.2 6.5 PERCENT HIV PREVALENCE DHS 2005 DHS 2010 Reduction of](https://reader033.vdocuments.us/reader033/viewer/2022050213/5f5f9deb9b83d522372fa6a3/html5/thumbnails/1.jpg)
HIV control in Rwanda:
Lessons and challenges
Sabin Nsanzimana,MD Institute of HIV disease prevention& control
![Page 2: HIV control in Rwanda: Lessons and challenges · DHS 2010 0.5 1.5 2.9 3.9 6.3 6.7 5.7 RAIHIS 2013 0.4 1.0 2.1 4.4 5.0 7.2 6.5 PERCENT HIV PREVALENCE DHS 2005 DHS 2010 Reduction of](https://reader033.vdocuments.us/reader033/viewer/2022050213/5f5f9deb9b83d522372fa6a3/html5/thumbnails/2.jpg)
• Landlocked East Africa nation,
• 26,388Km2:
• ~11.5 M, highest pop.density in Africa: 416 ppl./km2
• Life expectancy at birth m/f (years, 2013): 64/67
• HIV prevalence :3%
Country Profile
A Hilly Terrain a.k.a ‘’A country of a Thousand Hills and
thousand solutions
![Page 3: HIV control in Rwanda: Lessons and challenges · DHS 2010 0.5 1.5 2.9 3.9 6.3 6.7 5.7 RAIHIS 2013 0.4 1.0 2.1 4.4 5.0 7.2 6.5 PERCENT HIV PREVALENCE DHS 2005 DHS 2010 Reduction of](https://reader033.vdocuments.us/reader033/viewer/2022050213/5f5f9deb9b83d522372fa6a3/html5/thumbnails/3.jpg)
HIV incidence (2004 to 2014) New infections reduced by 50%.
0
5000
10000
15000
20000
25000
30000
35000
197
5
197
6
197
7
197
8
197
9
198
0
198
1
198
2
198
3
198
4
198
5
198
6
198
7
198
8
198
9
199
0
199
1
199
2
199
3
199
4
199
5
199
6
199
7
199
8
199
9
200
0
200
1
200
2
200
3
200
4
200
5
200
6
200
7
200
8
200
9
201
0
201
1
201
2
201
3
201
4
201
5
201
6
201
7
201
8
201
9
Number of new HIV infections
Total PLHIV deaths*
Annual AIDS deaths
TODAY
HIV Related deaths (2014) 78% decline in overall AIDS related deaths (2004 to 2014)
New HIV infection & AIDS related deaths in Rwanda Source: UNAIDS epi spectrum & RBC annual reports
![Page 4: HIV control in Rwanda: Lessons and challenges · DHS 2010 0.5 1.5 2.9 3.9 6.3 6.7 5.7 RAIHIS 2013 0.4 1.0 2.1 4.4 5.0 7.2 6.5 PERCENT HIV PREVALENCE DHS 2005 DHS 2010 Reduction of](https://reader033.vdocuments.us/reader033/viewer/2022050213/5f5f9deb9b83d522372fa6a3/html5/thumbnails/4.jpg)
Few years ago … Saving lives with Free Treatment for HIV Infection and Tuberculosis
Kim JY, Farmer P. N Engl J Med 2006;355:645-647.
Before After
March 2003 September 2003
![Page 5: HIV control in Rwanda: Lessons and challenges · DHS 2010 0.5 1.5 2.9 3.9 6.3 6.7 5.7 RAIHIS 2013 0.4 1.0 2.1 4.4 5.0 7.2 6.5 PERCENT HIV PREVALENCE DHS 2005 DHS 2010 Reduction of](https://reader033.vdocuments.us/reader033/viewer/2022050213/5f5f9deb9b83d522372fa6a3/html5/thumbnails/5.jpg)
0
1
2
3
4
5
6
7
8
15-19 20-24 25-29 30-34 35-39 40-44 45-49
DHS 2005 0.5 1.6 2.9 5.2 4.9 6.6 4.6
DHS 2010 0.5 1.5 2.9 3.9 6.3 6.7 5.7
RAIHIS 2013 0.4 1.0 2.1 4.4 5.0 7.2 6.5
PER
CEN
T H
IV P
REV
ALE
NC
E
DHS 2005 DHS 2010
Reduction of
HIV Prevalence
among youth
Peak prevalence RAIHIS 2013
RAIHIS : Rwanda AIDS Indicators and HIV Incidence survey
![Page 6: HIV control in Rwanda: Lessons and challenges · DHS 2010 0.5 1.5 2.9 3.9 6.3 6.7 5.7 RAIHIS 2013 0.4 1.0 2.1 4.4 5.0 7.2 6.5 PERCENT HIV PREVALENCE DHS 2005 DHS 2010 Reduction of](https://reader033.vdocuments.us/reader033/viewer/2022050213/5f5f9deb9b83d522372fa6a3/html5/thumbnails/6.jpg)
HIV Prevalence
National Average: 3% Male: 2.3% Female: 3.6%
City of Kigali 7.3%
• Even in Kigali, disparity of
prevalence
• High pockets of HIV prevalence:
FSWs: 51% (BSS2010)
HIV prevalence in Rwanda is 3% , BUT…
Source: Rwanda Demography Health Survey (DHS), 2010
![Page 7: HIV control in Rwanda: Lessons and challenges · DHS 2010 0.5 1.5 2.9 3.9 6.3 6.7 5.7 RAIHIS 2013 0.4 1.0 2.1 4.4 5.0 7.2 6.5 PERCENT HIV PREVALENCE DHS 2005 DHS 2010 Reduction of](https://reader033.vdocuments.us/reader033/viewer/2022050213/5f5f9deb9b83d522372fa6a3/html5/thumbnails/7.jpg)
51% Core transmitters (Highest prevalence)
Bridging Population (Moderate prevalence)
General Population (Lowest prevalence)
FSW: HIV Core Transmitters in Rwanda
![Page 8: HIV control in Rwanda: Lessons and challenges · DHS 2010 0.5 1.5 2.9 3.9 6.3 6.7 5.7 RAIHIS 2013 0.4 1.0 2.1 4.4 5.0 7.2 6.5 PERCENT HIV PREVALENCE DHS 2005 DHS 2010 Reduction of](https://reader033.vdocuments.us/reader033/viewer/2022050213/5f5f9deb9b83d522372fa6a3/html5/thumbnails/8.jpg)
Source: RBC, HMIS 2015
Patients on ART & Patients tested HIV+
0
10000
20000
30000
40000
50000
60000
2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014
New HIV positive cases
![Page 9: HIV control in Rwanda: Lessons and challenges · DHS 2010 0.5 1.5 2.9 3.9 6.3 6.7 5.7 RAIHIS 2013 0.4 1.0 2.1 4.4 5.0 7.2 6.5 PERCENT HIV PREVALENCE DHS 2005 DHS 2010 Reduction of](https://reader033.vdocuments.us/reader033/viewer/2022050213/5f5f9deb9b83d522372fa6a3/html5/thumbnails/9.jpg)
Year over year reduction
associated with every 10%
increase in ART coverage
results into 6% incidence
reduction
Effect of ART coverage on HIV prevention
Source: S. nsanzimana, E. mills & al. abstract,feb. CROI 2015, Seattle ,USA
![Page 10: HIV control in Rwanda: Lessons and challenges · DHS 2010 0.5 1.5 2.9 3.9 6.3 6.7 5.7 RAIHIS 2013 0.4 1.0 2.1 4.4 5.0 7.2 6.5 PERCENT HIV PREVALENCE DHS 2005 DHS 2010 Reduction of](https://reader033.vdocuments.us/reader033/viewer/2022050213/5f5f9deb9b83d522372fa6a3/html5/thumbnails/10.jpg)
New infections ~ 10,000
a
Deaths:~ 5000
c All HIV Infected 210,000
b
Treatment as Prevention (TasP)
![Page 11: HIV control in Rwanda: Lessons and challenges · DHS 2010 0.5 1.5 2.9 3.9 6.3 6.7 5.7 RAIHIS 2013 0.4 1.0 2.1 4.4 5.0 7.2 6.5 PERCENT HIV PREVALENCE DHS 2005 DHS 2010 Reduction of](https://reader033.vdocuments.us/reader033/viewer/2022050213/5f5f9deb9b83d522372fa6a3/html5/thumbnails/11.jpg)
Global 90-90-90 Targets & Current Status
*McMahon et al. 2015, estimates for LMIC for intention-to-treat
![Page 12: HIV control in Rwanda: Lessons and challenges · DHS 2010 0.5 1.5 2.9 3.9 6.3 6.7 5.7 RAIHIS 2013 0.4 1.0 2.1 4.4 5.0 7.2 6.5 PERCENT HIV PREVALENCE DHS 2005 DHS 2010 Reduction of](https://reader033.vdocuments.us/reader033/viewer/2022050213/5f5f9deb9b83d522372fa6a3/html5/thumbnails/12.jpg)
Rwanda’s Progress Towards 90-90-90
208,497
1 Nsanzimana et al, The Lancet HIV feb 2015 2 Drug Resistance Monitoring in selected sites, 2013 3 HMIS , June 2015
210,000
86%
85%
82%
4%
5%
8%
0
50000
100000
150000
200000
HIV Positive people Diagnosed On ART VL suppressed
(< 40 copies /ml)
# o
f H
IV i
nfe
cte
d p
eop
le
![Page 13: HIV control in Rwanda: Lessons and challenges · DHS 2010 0.5 1.5 2.9 3.9 6.3 6.7 5.7 RAIHIS 2013 0.4 1.0 2.1 4.4 5.0 7.2 6.5 PERCENT HIV PREVALENCE DHS 2005 DHS 2010 Reduction of](https://reader033.vdocuments.us/reader033/viewer/2022050213/5f5f9deb9b83d522372fa6a3/html5/thumbnails/13.jpg)
Target coverage in HIV program
Sources: 1TracNET data on current program enrollment
90-90-90 Target of 90% of PLHIV
know their status
Under test and treat
Aim to enroll ~36,000 people on
ART, mainly from current Pre-ART
patients1
![Page 14: HIV control in Rwanda: Lessons and challenges · DHS 2010 0.5 1.5 2.9 3.9 6.3 6.7 5.7 RAIHIS 2013 0.4 1.0 2.1 4.4 5.0 7.2 6.5 PERCENT HIV PREVALENCE DHS 2005 DHS 2010 Reduction of](https://reader033.vdocuments.us/reader033/viewer/2022050213/5f5f9deb9b83d522372fa6a3/html5/thumbnails/14.jpg)
WHO recommends to treat all HIV+ What next ?
How much?
Can we afford?
How can we operationalize the new recommendations?
How can we retain patients in care (especially healthy
patients)?
How can we measure the benefits and impact?
![Page 15: HIV control in Rwanda: Lessons and challenges · DHS 2010 0.5 1.5 2.9 3.9 6.3 6.7 5.7 RAIHIS 2013 0.4 1.0 2.1 4.4 5.0 7.2 6.5 PERCENT HIV PREVALENCE DHS 2005 DHS 2010 Reduction of](https://reader033.vdocuments.us/reader033/viewer/2022050213/5f5f9deb9b83d522372fa6a3/html5/thumbnails/15.jpg)
Can Rwanda afford Test and Treat ?
What are the benefits?
![Page 16: HIV control in Rwanda: Lessons and challenges · DHS 2010 0.5 1.5 2.9 3.9 6.3 6.7 5.7 RAIHIS 2013 0.4 1.0 2.1 4.4 5.0 7.2 6.5 PERCENT HIV PREVALENCE DHS 2005 DHS 2010 Reduction of](https://reader033.vdocuments.us/reader033/viewer/2022050213/5f5f9deb9b83d522372fa6a3/html5/thumbnails/16.jpg)
-
50,000
100,000
150,000
200,000
250,000
2013Guidelines
UniversalTreatment
Patient Numbers in 2020 at 95% coverage
8%
256,522
257,842 5%
Early analysis shows in Rwanda, Test & Treat could bring an additional 8% of patients on treatment, with a 5% increase in funding need
Source: 1 Epi Estimate RBC,2014
ARVs
Lab
personel
Ind costs
![Page 17: HIV control in Rwanda: Lessons and challenges · DHS 2010 0.5 1.5 2.9 3.9 6.3 6.7 5.7 RAIHIS 2013 0.4 1.0 2.1 4.4 5.0 7.2 6.5 PERCENT HIV PREVALENCE DHS 2005 DHS 2010 Reduction of](https://reader033.vdocuments.us/reader033/viewer/2022050213/5f5f9deb9b83d522372fa6a3/html5/thumbnails/17.jpg)
Early analysis into Universal Treatment in Rwanda suggests a reduction in the number of PLHIV by 2020
2012 2013 2014 2015 2016 2017 20182019 2020 2021 2022 2023 2024 2025 2026 2027 2028 2029 2030
-
50
100
150
200
250
300
1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39 41 43 45 47 49 51 53 55 57
Tho
usa
nd
s
Epi Estimates of PLHIV under 2013 Guidelines vs Universal Treatment
2013 Guidelines 2013 Guidelines Universal Treatment Universal Treatment
Source: 1 Epi Estimates RBC,2014
![Page 18: HIV control in Rwanda: Lessons and challenges · DHS 2010 0.5 1.5 2.9 3.9 6.3 6.7 5.7 RAIHIS 2013 0.4 1.0 2.1 4.4 5.0 7.2 6.5 PERCENT HIV PREVALENCE DHS 2005 DHS 2010 Reduction of](https://reader033.vdocuments.us/reader033/viewer/2022050213/5f5f9deb9b83d522372fa6a3/html5/thumbnails/18.jpg)
By adopting Test and Treat, Rwanda may be able to avert 17,800 more infections than under the 2013 Guidelines
-
500
1,000
1,500
2,000
2,500
-
0.5
1.0
1.5
2.0
2.5
3.0
20
14
20
15
20
16
20
17
20
18
20
19
20
20
20
21
20
22
20
23
20
24
20
25
20
26
20
27
20
28
20
29
20
30
Ad
dit
ion
al In
fect
ion
s av
erte
d
Ad
dit
ion
al C
ost
of
AR
T
Mill
ion
s
Incremental Cost and Impact of Moving from 2013 Guidelines to Universal Treatment
Cost increase Infections averted
Average
additional annual
costs for ARVs
and labs
= $ 1.4 million p.a
Additional Infections Averted by Scaling Up
17,800
SAVING:
1st line ARV costs for
17,800 people
= $3.5 million a year
![Page 19: HIV control in Rwanda: Lessons and challenges · DHS 2010 0.5 1.5 2.9 3.9 6.3 6.7 5.7 RAIHIS 2013 0.4 1.0 2.1 4.4 5.0 7.2 6.5 PERCENT HIV PREVALENCE DHS 2005 DHS 2010 Reduction of](https://reader033.vdocuments.us/reader033/viewer/2022050213/5f5f9deb9b83d522372fa6a3/html5/thumbnails/19.jpg)
Challenges remaining Funding reduction to support programs:
~40% of external HIV funding declined in 4 years
mainly from the GF and PEPFAR is a major barrier
to end AIDS
It is possible to see the end of AIDS from Rwanda
-With strategic use of resources
-Simplifications of models of care
- Ending AIDS is no longer dream
“La bataille n ‘est pas encore finie”
Conclusion
![Page 20: HIV control in Rwanda: Lessons and challenges · DHS 2010 0.5 1.5 2.9 3.9 6.3 6.7 5.7 RAIHIS 2013 0.4 1.0 2.1 4.4 5.0 7.2 6.5 PERCENT HIV PREVALENCE DHS 2005 DHS 2010 Reduction of](https://reader033.vdocuments.us/reader033/viewer/2022050213/5f5f9deb9b83d522372fa6a3/html5/thumbnails/20.jpg)
Acknowledgements • Eric Remera,
• Jpaul Uwizihiwe,
• J Claude Ntirenganya
• Kirk Catherine
• Mary Dain
• Heiner Bucher
• Edward Mills,
• Sophie Hadder
• Agnes Binagwaho
![Page 21: HIV control in Rwanda: Lessons and challenges · DHS 2010 0.5 1.5 2.9 3.9 6.3 6.7 5.7 RAIHIS 2013 0.4 1.0 2.1 4.4 5.0 7.2 6.5 PERCENT HIV PREVALENCE DHS 2005 DHS 2010 Reduction of](https://reader033.vdocuments.us/reader033/viewer/2022050213/5f5f9deb9b83d522372fa6a3/html5/thumbnails/21.jpg)
10/1/2015 Rwanda HIV Continuum Care 21
The courage of our convictions