HIV in Rwanda

The global prevalence of HIV has increased from 29.8 million people in 2001 to 36.9 people in 2014, which is believed not only to be due to the spread of infections but also longer lifespan of infected individuals and normal population growth.¹  Although this accounts for a 0.8% prevalence globally, the prevalence rate in Sub-Saharan Africa was 4.8% in 2014.   While Sub-Saharan Africa contains 13% of the world’s population, 70% of all HIV infections are located there with 1.4 million new infections in 2013.¹  Of all HIV-positive children worldwide, 88% of them are living in Sub-Saharan Africa.¹ The extensive spread of HIV in Sub-Saharan Africa is believed to be due to lack of social services, subordinate position of women, rapid modernization, and violent conflicts.²

http://www.avert.org/professionals/hiv-around-world/global-statistics

 In 2011, it was estimated that 2.9% of Rwandan adults and 1.6% of Rwandan children had HIV.³  While this number is lower than the average for Sub-Saharan Africa, this compounds with the recent history of the Rwandan genocide to leave affected individuals particularly vulnerable, especially women and children.  Previous studies have identified the key themes specific to HIV prevalence in Rwanda and found that challenges to child health are correlated to the deterioration of social and community cohesion in post-genocide Rwanda, the cascading effects of poverty, and the impact of caregiver illness and death on caregiving environment.⁴  Within any developing country, the effect of HIV on families is always compounded by societal and economic factors: poverty, lack of infrastructure, limited access to basic services, sexual violence, lack of empowerment and ethnicity.^4,5,5  However, Rwanda’s devastating recent history of the 1994 genocide displaced an estimated 4 million. In addition, an estimated 250,000 women were raped leaving immeasurable physical, emotional, and psychological scars.⁵  Due to the civil war and subsequent genocide, sufficient health infrastructure is highly lacking, especially when it comes to coping with the emotional needs of Rwandans.  Nearly all women who lived through the genocide have experienced some form of sexual violence including rape, mutilation and extermination.^5,6  Even in developing countries, the mental health of HIV-positive individuals is particularly important when addressing treatment since they are twice as likely to develop depression.⁷  Co-morbid HIV and depression has been shown to greatly reduce motivation to seek healthcare, impair adherence to treatment and increased mortality.⁷   Within Rwanda, social ostracism and community stigma of having HIV also prevents individuals and families from seeking treatment and support.³  However, survivors of the genocide are particularly vulnerable to both depression and social stigma considering the high degree of sexual exploitation and the ways in which sexual violence was used to torture and kill women.^5,6  HIV in particular was wielded as a weapon with which perpetrators carrying the virus would describe their intentions of infecting their victims, claiming that raping them was a form of punishment and murder.^5,8 

Furthermore, solutions for this gender based violence and resulting HIV infection are impossible to separate from the socioeconomic conditions of Rwandans, with the average Rwandan woman living on $0.70/day.⁵  Extreme poverty brings about hunger, insecure housing, inability to afford education, susceptibility to sickness and a lack of employment, all of which contribute to the perpetuation of HIV and its impact on quality of life.^5,9  Structural inequalities including low literacy, patriarchal family structures, geography, ethnicity and political violence prevent alleviation of the social constraints preventing successful HIV treatment and suppression.⁵  One particularly vulnerable group is children and orphans, many which are born to HIV-positive mothers.  HIV-positive children are more likely to become orphans due to the increased chance of sickness and mortality of their parents, most especially their mothers.^9,10  When an HIV-positive mother becomes sick, children often have to drop out of school to provide for the family or are placed under the care of another relative, assuming that one is available.^8,9,10  If no such figure is available and willing, orphans are at risk of becoming street children and prostitution, further perpetuating the spread of HIV.^8,9  This effect is even more exaggerated in urban environments where strength community support and family structure is less pervasive and encompassing.¹⁰   More often than not, the care of children affected by HIV/AID’s falls upon the poorest in the community, typically women.^5,9,10

Since 1997 there has been an increase in voluntary counseling and testing (VCT), prevention of mother-to-child transmission (PMTCT) and antiretroviral therapy (ART) which have all been evolving to slowly meet the current needs of Rwandans.⁶  However, by 2004 this still left much to be needed in terms of comprehensive HIV treatment and psychosocial support.  Community-based care is widely considered a sustainable and effective approach to combating the challenges facing orphans in Sub-Saharan Africa, especially in countries like Rwanda where the community involvement is key to mitigating the consequences of becoming an orphans due to HIV.¹²  

http://ghscientific.com/my-responsibility-your-responsibility/

References

1.    UNAIDS. How AIDS Changed Everything; 2015.

2.    Buvé, A., Bishikwabo Nsarhaza, K., Mutangadura, G. (2002). The spread and effect of HIV-1 infection in sub-Saharan Africa. The Lancet, 359(9322), 2011-7.

3.    Betancourt, T., Meyers-Ohki, S., Stulac, S., Barrera, A., Mushashi, C., Beardslee, W. (2011).  Nothing Can Defeat Combined Hands (Abashize hamwe ntakibananira): Protective processes and resilience in Rwandan Children and Families Affected by HIV/AIDS. Social Science and Medicine, 73, 693-701.

4.    Betancourt, T., Williams, T., Kellner, S., Gebre-Medhin, J., Hann, K., Kayiteshonga. (2012).  Interrelatedness of Child Health, Protection and Well-being: An application of the SAFE Model in Rwanda.  Social Science and Medicine, 74, 1504-1511.

5.    Cohen, M., d’Adesky, A. and Anatos, K. (2005). Women in Rwanda: Another World is Possible.  Journal of the American Medical Association, 294(5), 613-615.

6.    Kayirangwa, E., Hanson, J., Munyakazi, L. and Kabeja, A. (2006).  Current Trends in Rwanda’s HIV/AIDS Epidemic.  Sexually Transmitted Infections, 82(suppl. I), i27-i31.

7.    Collins, P., Holman, A., Freeman, M. and Patel, V. (2006). What is the Relevance of Mental Health to HIV/AIDS Care and Treatment Programs in Developing Countries? A Systematic Review.  AIDS 2006, 20: 1571-1582.

8.    Donovan, P. (2002). Rape and HIV/AIDS in Rwanda.  The Lancet, 360(suppl.), s17.

9.    Keogh, P., Allen, S., Almedal, C., Temahagili, B. (1994). The Social Impact of HIV Infection on Women in Kigali, Rwanda.  Social Science and Medicine, 38(8), 1047-1053.

10.  Foster, G. and Williamson, J. (2000).  A Review of the Current Literature of the Impact of HIV/AIDS on Children in Sub-Saharan Africa.  AIDS 2000, 14 (suppl. 3):S275-S284.

11.  Mills, E. J., Lester, R., Thorlund, K., Lorenzi, M., Muldoon, K., Kanters, S., ... Nachega, J. B. (2014). Interventions to promote adherence to antiretroviral therapy in Africa: a network meta-analysis. The Lancet: HIV, 1(3), e104-11.

12.  Thurman, T., Snider, L., Boris, N., Kalisa, E., Nyirazinyoye, L., Brown, L. (2008). Barriers to the Community Support of Orphans and Vulnerable Youth in Rwanda.  Social Science and Medicine, 66, 1557-1567.