SUMMARY OF THE FINAL REPPORT

Reporting Period: January 2008 - December 2009

Submission Date: 31 March 2010

Acknowledgements

The National AIDS Control Commission recognizes the contributions of the national institutions, civil society, development partners, stakeholders and individuals to the development of the Rwanda United Nations General Assembly Special Session on HIV and AIDS Country Progress Report for 2010.

The civil society umbrellas have played a remarkable role to ensure the views expressed in this report are representative of the views of civil society and PLHIV. We also thank the several human rights organizations for their inputs. We assure all civil society groups that the government values their continued support of the HIV response in the country, and that their views are critical components in charting the way forward.

We would also like to acknowledge the work done by various Government ministries and departments – in particular the Ministry of Health, TRAC Plus - Center for Infectious Disease Control (TRAC, PNILP, PNILT), the Ministry of Education, CAMERWA, the National Blood Transfusion Centre, the National Institute of Statistics, the Ministry of Gender and Family Promotion, the CDLS and other key government authorities – to provide us with the information required for this report in a timely fashion.

We appreciate the efforts of our development partners and programs that have participated in the collection and validation of the information in this report, including the United Nations agencies, the United States Agency for International Development/ the President's Emergency Plan for AIDS Relief, the Global Fund to fight AIDS, Tuberculosis and Malaria, and Population Services International.

Finally, we would like to thank the Joint United Nations Programme on HIV and AIDS (UNAIDS) for the technical and financial assistance provided in the development of this Report.

This is the fifth progress report of the UNGASS commitments to fight HIV/AIDS in Rwanda. Since the last report, we have continued our progress in areas identified as successes, while addressing the challenges identified in 2007 and achieving significant results in new dimensions. Our sustained and coordinated efforts and the support of partners in Rwanda should place us firmly on the path of meeting UNGASS targets.

 

 

Rwanda is a small, landlocked country in East Africa, bordered by Burundi, the Democratic Republic of Congo, Tanzania, and Uganda. The country is administratively divided into 5 provinces – Kigali, North, South, East and West – and 30 districts. It has over 9,200,000 estimated number of the population and population density of 351 persons/sq km which makes him the most densely populated country in Africa. The urban population is estimated to be 21.8% and is growing. The under 15 years old population is 43.5% and 55.2% are aged between 15-49 years. The median age is 19 years and life expectancy at birth is 53.1 years.

Rwanda’s gross domestic product (GDP) per capita is US$ 272; 57% of the population lives below the national poverty line and 37% live in extreme poverty. In the most recent UNDP Human Development Report, Rwanda was ranked 161st out of 179 countries on the Human Development Index [http://hdrstats.undp.org/countries/data_sheets/cty_ds_RWA.html].

Although poverty levels remain high, Rwanda has made progress in stabilizing and rehabilitating its economy. The Government is focused on increasing production and reducing poverty while creating an environment of good governance.

Vulnerable households (headed by women, widows and children) represented 43% of all households in 2006 (against 51% in 2001) and were concentrated in rural areas. Recent years have seen progress on gender equality. There are about 1,350,800 orphans and vulnerable children in Rwanda between the ages of 0 and 17. It is estimated that AIDS accounts for nearly a fifth of these [Source: NSP 2009-12].

 

The RDHS 2010 is still ongoing at the time of this report. However available data from the RDHS 2005 indicates that HIV prevalence is 3.0% in the general population aged between 15 – 49 years. The total estimated number of people living with HIV in Rwanda was about 169,200 in 2009, including near 22,200 children [Source: EPP/Spectrum national estimates, 2010].

HIV prevalence in urban areas (7.3%) is much higher than in rural areas (2.2%); and HIV prevalence in women (3.6%) significantly higher than in men (2.3%) [Source: RDHS, 2005]. HIV prevalence in pregnant women was 4.3%. As per ANC 2007, overall HIV prevalence for young pregnant women aged 15-24 is 3.7%. There is low HIV prevalence among young people aged 15-24 compared to the general population. However, young women are far more often infected than men by HIV: respectively 3.9% versus 1.1% in urban areas and 1% versus 0.3% in rural areas. In general, women become infected at younger ages than men [Source: RDHS, 2005]

As per the EDPRS 2009-12 and the NSP 2009-12 targets, the HIV prevalence among young people aged 15-24 should decrease to 0.5% by 2012.

The UNGASS report shows also regional variations were Kigali and the western region has the highest HIV Prevalence. The north has relatively low prevalence. [Triangulation project, 2008, TRACPlus]

 

In Rwanda, the Most-at-risk Populations are:

• HIV sero-discordant couples: 2.2% of heterosexual couples are HIV sero-discordant (around 60,000 couples) [Source: TRAC Plus (2008)].

 

• Commercial sex workers: A minimum of 5,000 commercial sex workers in Rwanda has been identified in a CSWs mapping carried out in 2009 BSS. There are thus no recent representative studies of HIV prevalence in sex workers in Rwanda. The data that are available were obtained from the records of HIV testing facilities and confirm that sex workers are at higher risk of HIV than other subgroups by some order of magnitude (19.2% in mobile VCT by PSI in 2007 and 16.4% in 2008). [Source: Mapping of HIV prevention, care and treatment with sex workers, CNLS (November 2009)]

 

• Prisoners: While HIV prevalence in prisons does not appear to be significantly higher than outside, there is evidence of sexual activity within prisons, where condoms are unavailable. [Source: The Data Synthesis (or Triangulation) project, TRACPlus (2008)] 

 

• Truck drivers: Though truckers are highly mobile, they only constitute a small population. [Source: The Data Synthesis (or Triangulation) project, TRACP lus (2008)] 

 

• Men who have sex with men (MSM):  The first behavioural study of MSM, reported that MSM in Kigali are at elevated risk for HIV infection compared to the general population, and require specific HIV/STI prevention services/support. MSM have wide sexual networks.  Men reported an average of two male sexual partners. Data on HIV prevalence among this population are not available so far.

 

• Injecting drug users: Injecting drug use (IDU) appears to be rare in Rwanda, but a comprehensive study of injecting drug use is yet to be conducted. AESD reported that though youth are using drugs that impair their judgment and put them at greater risk for contracting HIV.

 

• Refugees: Refugee camps have been shown to be protective for women in Rwanda in terms of abstinence, low levels of high-risk sex, and condom use with high-risk sex. The camps have relatively high programmatic coverage of VCT and PMTCT services.  Refugees do not appear to be driving the HIV epidemic in Rwanda.  This group should be studied further as a possible source of lessons learned for other at-risk groups. [Source: The Data Synthesis (or Triangulation) project, TRACPlus (2008)] 

 

National AIDS Spending Assessment (NASA) is a method used to measure the flow of resources in the national response to HIV and AIDS. The main objective is to determine what is disbursed or spent and the process that follows funds from the origin (financing source) down to the beneficiaries who receive goods and services. At the same time, it offers an understanding of the current levels of spending across categories/programme areas.

 

NASA methodology addresses the following questions: Who finances the AIDS response? Who manages the funds? Who provides goods and services? Which intervention was provided? Who benefits from the funds? What was brought to realize the intervention?

 [Source: NASA Classification and Definitions, UNAIDS (2007)] 

Sources of funding were respectively: International partners (Global Fund, the United States Government (USG) through PEPFAR, bilateral agencies, UN agencies, the ADB and other donors) and the government. Total expenditure on HIV and AIDS in Rwanda increased from USD 74.6 million in 2007 to USD 110.8 million in 2008 (an increase of about 33%).

 

Table 3: Sources of Financing for HIV and AIDS in Rwanda for the period 2006 - 2008

National Bank of Rwanda: Average Exchange rate 2006: 1$= 551.74 RwF, 2007: 1$=544   RwF, 2008: 1$=547 RwF

Financing Source	2006		2007		2008
	US$	%	US$	%	US$	%
USG	28,844,816	32	43,210,466	58	59,529,512	54
Global Fund	13,004,277	15	11,235,324	15	26,924,796	24
Others (bilaterals, foundations...)	22,706,639	25	7,988,037	11	12,317,152	11
GOR	4,397,311	5	6,081,417	8	6,133,292	6
UN agencies	2,196,519	2	3,215,993	4	2,718,463	2
ADB	867,751	1	1,847,896	2	2,821,479	3
MAP/World Bank	11,577,224	13	985,805	1	366,902	0
Out-of-pocket	3,541,185	4	NA		NA
All other private	392,037	0	NA		NA
Corporations	45,773	0	NA		NA
	87,573,532	100%	74, 564,938	100%	110,811,596	100%

 

The main financial contributor to HIV response was USG, which contributed 58% and 54% of the overall total in 2007 and 2008 respectively. Global Fund was the second largest contributor and its share increased from 15% in 2007 to 24% in 2008. The government of Rwanda ranks as the third largest single contributor in terms of financing HIV and AIDS interventions (after the group of bilaterals).

This section provides a breakdown with respect to AIDS spending categories in 2006, 2007 and 2008 and the relative weight of each.

 

Table 4: Breakdown by AIDS Spending Categories in Rwanda for the period 2006 - 2008

Spending category	2006 (in US$)	2007(in US$)	2008 (in US$)	% variation from 2007 to 2008
Prevention programmes	20,878,368	17,115,251	29,308,085	+42%
Care and treatment component	27,142,088	27,793,912	44,670,057	+38%
Programme management and administration strengthening	25,828,454	10,790,812	13,272,550	+19%
Incentives for human resources	416,132	5,839,282	4,915,545	-19%
Social protection and social services excluding OVC	5,634,419	579,841	1,283,576	+55%
Orphans and vulnerable children	7,033,937	9,358,637	12,850,247	+27%
Enabling environment and community development	196,058	2,310,109	2,868,683	+19%
HIV and AIDS related research	485,344	777,094	1,642,853	+53%
Total	87,573,532	74,564,938	110,811,596	+33%

National Bank of Rwanda: Average Exchange rate 2006: 1$= 551.74 RwF, 2007: 1$=544   RwF, 2008: 1$=547 RwF

• HIV prevention programs expenditure increased from US$ 17 M in 2007 to US$ 29 M in 2008.  
• Expenditures on care and treatment increased from US$ 27 M in 2007 to 44 US$ M in 2008.
• The management and administrative cost of HIV and AIDS programs increased by 18% in 2008 compared to 2007.

USG contributed approximately US$ 5 M in 2007 and US$ 6 Millions in 2008 for this component; The GoR was the second largest contributor and the funds were spent by public institutions to plan and coordinate for the epidemic, Incentives for human resources were largely introduced in 2007 and there was a slight decrease from US$ 5.8 million in 2007 to US$ 4.9 million in 2008.

There has been an increase in social protection interventions excluding OVC from US$ 0.52 million in 2007 to US$ 1.2 million in 2008. OVC Funding rose from US$ 9.3 million in 2007 to US$ 12.8 million in 2008.

There was an increase of funds for HIV and AIDS-related research (excluding operation research) from about US$ 0.80 million to US$ 1.6 million. More and more HIV research-related activities are conducted under the coordination of TRACPlus and CNLS to provide data and information for planning

Figure 5: Financing by spending categories

• We observe that in 2008 care and treatment consumed the largest share of HIV and AIDS funds (40%),

 

• The prevention component consuming 26% of the total funds, then OVC and Programme management components accounted for 12%.

•  The social protection is still low (1%).

HIV and AIDS spending towards non-targeted intervention accounted for 18% in 2007 and 20% in 2008. Non-targeted intervention includes coordination, planning and management of epidemic, monitoring and evaluation, training, HIV institutional development and research related to HIV and AIDS. 

Small amounts were spent on most-at-risk groups including sex workers, men who have sex with men, injecting drug users (IDU), internally displaced populations, police, and truck drivers.

Table 5: Expenditures by beneficiary population, 2007 and 2008

BENEFICIARIES	2007		2008
	US$	%	US$	%
Children (under 15 years) living with HIV not disaggregated by gender	138,381	0	259,374	0
Children born or to be born of women living with HIV	1 487,616	2	2,936,839	3
Children and youth out of school	1,408,764	2	1,059,064	1
Factory employees (e.g. for workplace interventions)	49,144	0	65,315	0
General population not disaggregated by age or gender.	10 801 116	14	24,397,099	22
Health care workers	3,053,200	4	2,931,548	3
Junior high/high school students	2,548,577	3	2,493,213	2
Orphans and vulnerable children (OVC)	9,358,637	13	12,850,247	12
People living with HIV not disaggregated by age or gender	29,194,740	39	42,585,793	38
Police and other uniformed services (other than the military)	42,380	0	82,703	0
Sex workers, not disaggregated by gender, and their clients	20,540	0	224,142	0
Specific targeted populations not elsewhere classified	70 766	0	18,877	0
Truck drivers/transport workers and commercial drivers	45,186	0	4,655	0
Youth (age 15 to 24 years) not disaggregated by gender	36,176	0	5,287	0
Adult and young women (15 years and over) living with HIV	0	0	626,410	1
Female sex workers and their clients	0	0	2,696	0
Injecting drug users (IDU) and their sexual partners	0	0	17,238	0
Internally displaced populations (because of an emergency)	0	0	16,788	0
Non-targeted intervention	16,309,715	22	20,234,308	18
Total	74,564,938	100%	110,811,596	100%

 

As these groups may account for a higher proportion of new HIV infections, we recommend that funds be reallocated with more focus on these groups as per the strategic plan for 2009-12. The same observation and recommendation applies to children and most-at-risk youth.

 

 

Rwanda fully adheres to the “Three Ones” principles: the existence of one national coordinating body, one strategic national plan of action and one sole monitoring and evaluation framework.

Overall coordination is the function of CNLS (National AIDS Commission) in collaboration with CDLS (District AIDS Control Committees), its decentralised structures at the district level. Each CDLS supports its corresponding district mayor in managing the HIV and AIDS response and is comprised of representatives of decentralized public services (health, education, planning), mass organizations (national women and youth councils) and civil society organizations (PLHIV, NGO, FBO networks as well as people living with disabilities (PWD) in some districts). Every year, the CDLS facilitate a participatory process to develop an Annual Action Plan for their districts.

Within the public sector, the Ministry of Health/TRACPlus is central to the HIV response.  Other ministries involved include Ministry of Finance and Economic Planning (MINECOFIN), Ministry of Education (MINEDUC), Ministry of Youth (MINIYOUTH), Ministry of Gender and Family Promotion (MIGEPROF), Ministry of Local Government, Community Development and Social Affairs (MINALOC), Ministry of Public Sector and Labour (MIFOTRA), Ministry of Agriculture (MINAGRI), Infrastructures (MININFRA) and Justice (MINIJUST).

Civil society organizations, mass organizations, and the private sector are also active in the national response. There are several umbrella organizations in charge of the coordination of civil society in the response to HIV: ABASIRWA (Media Umbrella); Rwanda NGO Forum on HIV/AIDS and Health promotion; Network of FBOs in the Response to HIV/AIDS (RCLS); Rwanda Network of People Living with HIV and AIDS (RRP+); Umbrella of People with disabilities in the fight against HIV and AIDS (UPHLS); and Umbrella of Transporters.

The key reference documents for the HIV and AIDS response in Rwanda are:

• The Government of Rwanda’s Vision 2020,
• The Economic Development and Poverty Reduction Strategy (EDPRS) 2008-2012,
• The National Strategic Plan on HIV and AIDS 2009-12, the NSP aims to make Universal Access to HIV Prevention, treatment, care and support a reality. The overarching results that this plan will achieve by 2012 are: firstly, halving the incidence of HIV in the general population; secondly reduced morbidity and mortality among people living with HIV; and thirdly, that people infected and affected by HIV have the same opportunities as the general population.
• The Health Sector Strategic Plan (HSSP) 2009-2012,
• The TRACPlus HAS unit Strategic Plan 2009-2012.

 

The NSP 2009-12 is closely aligned with Rwanda’s Economic Development and Poverty Reduction Strategy 2008-2012 (EDPRS),The multi-sectoral EDPRS includes the Health Sector Strategic Plan (HSSP II), which is also one of the bases of the NSP.

The National Centre for Blood Transfusion is in charge of the country’s blood security. The number of blood units collected has risen from around 29,000 in 2004 to 35,495 in 2008 and 40,567 in 2009.  100% of the blood units donated since 2005 were screened for HIV in a quality-assurance manner and comes from volunteers donors.

During 2008, 6,387 HIV-positive pregnant women received ARVs to reduce the risk of mother-to-child transmission (MTCT). This number increased 7,030 in 2009. According to EPP/Spectrum estimates, there were about 10,400 (5,300-15,700) and 10,300 (5,200-15,600) HIV-positive pregnant women in need of ARVs for PMTCT in 2008 and 2009 respectively.

Figure 8: Percentage of Pregnant Women attending

                ANC tested for HIV: 2001-2009

The number of PMTCT sites increased from 11 in 2001 to 372 in 2009. Given that the total number of health facilities in Rwanda is 517, this number corresponds to 72% coverage across all districts in the country.

The number of pregnant women tested for HIV reached 294,704 and 294,457 in 2008 and 2009 respectively. Nearly all women tested received their results in 2009 [Source: TRACPlus].

In Rwanda, great efforts are made to encourage the partners of pregnant women to be tested for HIV and to offer couple counselling and testing.  Among pregnant women who tested for HIV, an average of 78% in 2008 and 84% in 2009 of their partners agreed to have a test [Source: TRACPlus]., while the number of partners who tested was only 33% in 2005.

The number of discordant couples is high, about 3.7% of heterosexual couples are HIV sero-discordant [Source: TRACPlus]. In Kigali, 7.1%% of cohabiting couples seeking voluntary counselling and testing services are HIV discordant (TRACPlus, 2009).

The number of infants receiving prophylaxis at birth has also increased since 2001, reaching 5,755 and 6,684 in 2008 and 2009 respectively. These represent about 86% of all notified births from HIV positive mothers. About 50% of PMTCT sites in 2008 and 70% of sites in 2009 offer Early Infant Diagnosis of HIV (EID) to increase chances of early initiation of treatment for children. However, only 28% of children are in fact accessing EID in 2008 [Source: TRACPlus].

Behaviour Change Communication - General Population (Ref. indicators 13, 15, 16) 

Rwanda’s behaviour change strategy is based on promoting EABC: Education, Abstinence, Being Faithful, and using Condoms. A range of methods are used to deliver IEC and BCC, including but not limited to community events, mobile video shows, counselling, peer education, radio and television programs, posters and billboards, theatre, songs, documentation centers, printed material, and a telephone hotline. Still, it is estimated that a large proportion of the population was reached by basic HIV and AIDS information in 2008 and 2009 and the number of people reached seem to have steadily increased [Source: CNLS Joint Review, Final Report (2009)].

As per RDHS 2005, 45.3% of girls aged 15-19 and 57.1% of girls aged 20-24 correctly identified ways of preventing the sexual transmission of HIV and rejected major misconceptions about HIV transmission, as did 49% of boys aged 15-19 and 59% of boys aged 20-24.

One of the HIV prevention strategies with young people is delaying age of sexual debut. RDHS 2005 showed a relatively late sexual debut (at 20 years): 3.9% of girls aged 15-24 and 13.2% of boys in the same age range had had sexual intercourse before the age of 15. [Source: BSS (2009)]. 

 

Condom Use – general population (Ref. Indicator 17)

During 2008 and 2009, there was a substantial increase in the supply of condoms as shown in Table 6, with a 21% increase from 2008 to 2009 alone. In 2006, the number of condoms distributed by the MOH was of 833,863 male and 2,441 female condoms only.

Table 6: Distribution/sales of condoms in 2008 and 2009 [Source: RHC quantification data 2009]  

Sector		2008	2009
Public sector (free condoms)	Male condoms	4,139,917	7,173,234
	Female condoms	3,512	52,290
	AHF MC	0	403,200
Social Marketing	Prudence MC	10,320,440	10,683,984
Total		14,463,869	18,312,708

 

Male and female condoms are available in health facilities free of charge to all. Awareness building about responsible sexual behaviour and the involvement of different stakeholders in advocacy and campaigns to de-stigmatize condoms has also played a role in the increase of condom procurement and utilisation.

Behaviour Change Communication and condom use - Most-at risk Populations

This program were also addressed to specific groups, the most-at-risk population: sex workers, MSM, truck drivers, and Injecting drug users. No data available between 2007 to 2010, only 2000 TO 2006 are available. The Rwanda DHS 2010 Will provide more updated information and data on BCC and Condom use by the Most-at-risk population.

 

As part of the country HIV prevention strategies, Rwanda offers a comprehensive package of services for the prevention and management of STIs other than HIV. These services include counselling, and offer to test for HIV, advice on safer sex and access to STI treatment. The percentage of women and men with STIs appropriately diagnosed, treated and counselled at health facilities were 49% and 52% respectively [Source: RDHS (2005)].

The main achievements in 2008 and 2009 were:

-   The development of the New National STI Guidelines, availability of STIs  essential drugs

-   The availability of new and revised STIs Indicators in the online reporting tool TRACnet;

-   Capacity building/trainings in the management of STIs of doctors and nurses in all districts in order to improve quality of services;

Current prevalence of MC in males of ages 15-59 is estimated at 15% [Source: Interim DHS (2008)].

Rwanda has adopted Male Circumcision (MC) as part of a comprehensive package of HIV prevention strategies since 2007. In addition, MC has been integrated into the national HIV prevention policy.

The number of antiretroviral therapy (ART) centres in Rwanda has increased substantially from four in 2002 to 195 sites in 2008 and 269 sites in 2009 (52% of all health facilities). In addition, consequently Coverage of patients has also increased steadily.

Figure 10: Number of patients (adults and children) receiving ART

There was an increase from 870 people on ART in 2002 to 76,726 patients on ART in 2009(61%). Efforts have been made to ensure access to ART in all districts.

The number of children on ART reached 6,678 by December 2009.  Measures have been put in place to scale up paediatric care and treatment.

The vast majority of people are on first-line treatment, numbering 56731 in 2008 and 75,041 in 2009. The number of people on second-line treatment is 783 in 2008 and 1,685 in 2009 but still below 2%. (TRACPlus].

Treatment success rate for TB has been improving in Rwanda, rising from 86% in 2007 to 87% in 2008.  However, the detection rate for TB is still low.  Efforts are being made to improve detection through case tracking and directly observed therapy short-course (DOTS) [Source: (PNILT) Report (2009)].

Overall, 7,642 tuberculosis patients were registered on TB treatment in 2009. The number of patients under second line treatment for TB increased from 35 patients in 2005 to 86 patients in 2008. Currently (as of March 2010), there are more than 334 patients under second-line treatment for tuberculosis.

The number of HIV positive patients that were diagnosed for TB and received treatment for HIV and TB was 1,148 in 2008 and 1,558 in 2009.

The number of sites (FOSA) providing VCT increased considerably from 44 sites 2003 to 395 sites in 2009, offering VCT.  

Figure 12: Number of people tested at VCT sites by sex during 2003-2009

The number of tests performed in VCT sites (and for which a result was given – 98.5% of all tests-);

During 2008 was 976,859; during 2009, this number increased to 1,370,326,

[Source: TRACPlus].

Data on HIV testing for sex workers and truck drivers are available through BSS conducted in 2000 and 2006. 2009 BSS data are under analysis at the time of writing of the UNGASS report.

In 2006, 65.3% of CSWs were HIV tested and get their results. Among truck drivers the number of HIV tested and who get results rose to 55.6% in 2006. Much emphasis was on prevention programs for truckers in the past few years.

 [Source: Rwanda data synthesis/triangulation project, 2008 TRACPlus].

No specific HIV prevention activities addressing MSM were carried out during 2008 and 2009. However, MSM are now included in the NSP 2009-12.

No systematic research has been done for injecting drug users.

The prisoner population in Rwanda is declining.  The mobile VCT prevalence declined from 10% in 2006 to 4% in 2007 and remains static (4%) as of July 2008. In prisons, condoms are contraband and [Source: Rwanda data synthesis/triangulation project, TRACPlus (2008)].

The Refugees camps have relatively high programmatic coverage of VCT and PMTCT services which cover around 50 000 Refugees living in Rwanda [Source: Rwanda data synthesis/triangulation project, TRACPlus (2008)].

Orphans are more vulnerable in the education system: while 91% of non-orphans aged 10-14 attend school, just 74.6% of orphans do so [Source: RDHS (2005)]. 

The substantial support to OVCs for access to education is a major achievement of the last few years and will help to decrease the vulnerability of these children and youths. Access to health services (Mutuelles de Sante) has also improved significantly in 2008 and 2009.

As per RDHS (2005), Only 0.2% of OVC aged 0-17 had access to all types of support needed (medical, emotional, school related, social/material). The target set in EDPRS 2009-12 and NSP 2009-12 is 10% by 2012. The percentage of households of OVC aged 0-17 that received support was 12.6% [Source: RDHS (2005)]. The relevant national target is 30% by 2012 as set by NSP 2009-2012.

In Rwanda, a minimum package for OVC support has been defined and it covers health (including PMTCT, HIV prevention services and VCT), nutrition, formal and non-formal education, protection, psychosocial and socio-economic support. However, coordination of partners providing services for OVC is still low, funds are insufficient and the identification of OVC at the district level remains challenging.

In Rwandan secondary schools, life skills in the HIV context are taught to students through anti-AIDS clubs. 98% of schools had operational anti-AIDS clubs in 2008, with an average coverage of 95% of schools in each district [Source: MINEDUC].  About 12% of teachers (1,326 out of 10,715) were trained in HIV during 2008. HIV issues are integrated into teaching curriculums for disciplines such as civic education, sciences (in both primary and secondary schools), and teaching/learning tools have been developed to support teachers.

The Stigma Index study of 2009 showed that around 20% of people living with HIV of either sex are unemployed and not working at all. 37.2% of respondents reported that they had been refused employment opportunities as a result of HIV status. The proportion of HIV positive people who have not had any formal education is also higher among women (18.5%) than men (12.2%).

 

Income generation activities (IGA) funded through the micro project mechanisms of various projects (MAP, GF, CHAMP, CNLS/UNDP/ADB) have helped a large number of HIV-positive member associations to initiate or strengthen collective projects that have had profound effects on their livelihoods, this contributed to decrease stigmatization. However, there are gaps in support for management and technical assistance to IGAs, as well as in access to credit [Source: CNLS Joint Review, Final report (2009)].

Important steps have been made in the establishment of a legal and policy framework to protect the rights of people living with HIV and AIDS and for the prevention and prosecution of sexual violence. [Source: CNLS Joint Review, Final report (2009)].

In 2009, CNLS led an exercise to select best practices in the prevention area in country over the period 2006-2009. The full report for the exercise is available at: http://www.cnls.gov.rw.

Some of the selected best’s practices were:

• PHARE project (Prevention HIV and AIDS in Rwanda through Education), implemented by Volunteer Service Oversees (VSO) in Nyagatare and Nyamagabe district.This experience shows that anti-AIDS clubs that are well-supervised constitute an efficient and effective channel to convey messages on HIV and AIDS prevention to young people.

• PMTCT in Health centers supported by ICAP in Karongi District: Integration and strengthening of PMTCT and ART in 14 Health centers sites over the years.
• Gender Based Violence (GBV-One Stop Centre):The One Stop Centre was opened in Kacyiru Hospital in 2009 and is relatively a new  multi-sectoral  initiative  of  the GoR through Rwanda National Police,  and the UN (UNFPA, UNIFEM  and UNICEF).
• Male participation in PMTCT in Rwanda: The uptake of male partners’ HIV testing has dramatically increased from a national average of 7% in 1999 to 84% in 2009. However, the testing rate among male partners still remains low in a few areas in Rwanda (slightly less than 50%).

In the UNGASS report submitted in 2008 (ref. 2007), a number of areas were identified as challenging to the achievement of the UNGASS targets.  Some of them are as follows:

• HIV Prevention: An evidence-based prevention strategy was not developed and fully implemented as of 2007;  
• Condom acceptance, use and availability. Condoms were still associated with promiscuity, making it difficult for young people and married couples to negotiate condom use for HIV protection and as a family planning method;
• Male circumcision as one of the possibility of in children and men to prevent the spread of STIs, including HIV. 
• The WITERGERIZA Social Support Campaign, a large mass media campaign, was conducted to address parental support for young people with respect to sexual reproductive health information, including teaching young people how to use condoms;
• The Key message developed: “Condom as a means of dual protection. Let’s talk about it, let’s access it, let’s use it: a fundamental right for all!”

 

• Need for better integration of HIV and AIDS with reproductive health and vice versa.
• Enhanced integration of PMTCT and reproductive health into overall health services
• Need to finalise the breast-feeding policy for HIV-positive women in accordance with country-specific needs.

 

• Existing Financial gaps at the level of health infrastructure.
• Large gap between the needs and the available resources for interventions for PLHIV, OVC and most at risk populations at the community level. 
• Donor partners who are unwilling to finance infrastructure, human resources and nutritional support for PLHIV.
• Rwanda’s commitment to the HIV response is well supported by donors and partners. Main donors include: The GFATM, PEPFAR, The African Development Bank (ADB); The Great Lakes Initiative on AIDS (GLIA).
• Implementing partners are too many to mention and they are almost all funded by donors listed above. Technical assistance has been provided by a number of partners, notably, UNAIDS, UNDP, WHO, the USG, and the GTZ.
• The interventions of all development partners in the Heath sector, including all HIV related activities, are consolidated in a Joint Annual Work Plan (JAWP).

 

For UNGASS targets to be met, partners should sustain their support to the national response in a harmonized and coordinated way.

At the international level, efforts should be made to accelerate the harmonization process and to reduce reporting requests to countries. On a positive note, in Rwanda there is now a national list of standard HIV indicators used by all development partners in the country and harmonised with EDPRS, MDGs, Universal Access, UNGASS, PEPFAR and Global Fund proposed Indicators.

 

The National M&E system is primarily divided between health facility-based and community-based components of monitoring and evaluating the national response, and is decentralized from the national to district levels.

The health facility-based components of the M&E system are led by MOH and TRACPlus at the national level and District Health Officers at the district level. In general, health facility-based HIV M&E is integrated and mainstreamed within the existing M&E structures of MOH.

However an M&E assessment conducted in 2009 shows that the national level should improve the dissemination of the tools, guidelines and other reports and resources developed to decentralized level. At the same time, community and district-level stakeholders need to reinforce data collection and reporting.