Joseph Ntaganira

Introduction

 Rwanda has since 1990 experienced difficult times of civil war which resulted into destruction of socio-economic infrastructures at a large scale. More specifically, the 1994 most tragic event of genocide Rwanda has known in the history of modern time, brought to the start most of socio-economic development initiatives. Public health is among the most affected areas which hitherto, needs the most outstanding plan of action with a total support from government, private sector and the international agencies.

 Our participation in this Symposium is of a paramount importance as the discussion centres on preventing and coping with HIV/AIDS in post-conflict societies where Rwanda is not exclusive. We note that HIV/AIDS is among the complex disasters our country has witnessed in the last two decades and the rates of HIV prevalence among the population has drastically gone up especially in the post genocide Rwanda.

 The National University of Rwanda through Faculty of Medicine is establishing a new school of public health and one element in the Mission Statement of this new school is to become a centre of excellence in the Great Lakes Region for complex emergency/disaster management studies. HIV/AIDS being one of the focal points to deal with as it is highly prevalent in the region, we expect a lot from this symposium which may be applicable to our programme of public health promotion in our school. 

The Rwandan HIV/AIDS situation

 During the last decade, Rwanda has undertaken generic approaches to the prevention of HIV infection. However, the period 1990 – social strife, population displacement and mixing, war, genocide and disruption of established social structures and programs dominated 94. In addition the population structures changed tremendously. The management and implementation of STD/HIV/AIDS programs and operations were adversely affected.

 The impact of HIV/AIDS in the community has generally increased as the epidemic progressed to maturity. The long-term macro and micro economic impact could be expected to be gruesome, costly and very likely disruptive.

 In 1996 a social-demographic survey was conducted to document the actual population structure. The data showed that the number of men was considerably less than that of the women for ages between 20-60 years. The events in the period 1990-1994 would in part explain the short fall in males, particularly in the age group 20-60. The events of 1994 and the following two years entailed massive population movements directly up to a third population, with regard to levels of HIV infection in terms of migration.

 In 96/97, an epidemiological survey was conducted in order to document the actual situation in Rwanda. Other objectives of the study were to estimate the prevalence of HIV infection in the country, determine demographic variations in the HIV infection rates, assess the effect of migration on the epidemiological profile or HIV infection in RWANDA and provide post-war baseline data on the sero prevalence for planning, designing strategies for HIV/AIDS control and prevention and formulating appropriate policies.

 The study found the adult population in Rwanda with a high overall HIV prevalence of 11.1 per cent with a small difference between the males (10.8%) and females (11.3%). The youngest age group of 12-14 years had a prevalence rate of 4.1%, which indicates a high  proportion of new HIV infections in the country. There is a uniformity of prevalence rates in the urban centres (11.6%) and the rural areas (10.8%), an observation that implies wide geographic spread of HIV infection in Rwanda. Comparison of the 1986 Nation-Wide serosurvey results with those of the 1997 survey showed that the prevalence rates in the urban areas have remained relatively high and in the rural areas there has been a rapid increase in the prevalence rates from 1.3% in 1986 to 10.8% in 1997.

 Generally urban respondents were more likely to be infected than respondents in the rural areas. Whereas in the youngest age group of 12-14 years the HIV infection rates in the rural and urban areas were close, in the age group 15-19 years the rate of 8.5% of the respondents in the rural areas was twice that of the respondents in the urban areas (3.4%). The rates in the middle age groups were much higher in the urban areas ranging from 16.2% to 24.2% than in the rural areas where levels were from 9.6% to 15.5%. The study also found women in the urban areas more infected than the women in the rural areas in all the age groups.

 High HIV prevalence rates were found in all categories of marital status including legal marriages. However the widowed, the separated/divorced and those in common law union (cohabitating) had the highest prevalence rates in the range of 15.7% to 17.5%. A more remarkable finding was that the rates among the separated/divorced, widowed and those in common law union were even higher in the urban areas (from 21.6% to 26.3%).

 The highest HIV prevalence levels were found among respondents in the trading and business sector (19.0), managers, administrators and professionals (17.0%) and the unemployed (20.7%). The female business persons and traders had higher rate of 21.8% than of males (15.9%) and similar pattern was found among the administrators and professionals (13.8% for females and 9.7% for males).

 The separated/divorced and widowed and the respondents in trading and business sector as well as the unemployed were more likely to report history of an STD in the 12 months prior to the study than the respondents in other categories. The STDs may be contributing to the high levels of HIV infection observed in these groups of people.

 The survey also found that 2.2% of the respondents were raped of whom 37.8% were in the age group 12-19 years. The respondents who were raped had higher HIV prevalence rates (15.2%) than those who had never been raped (11.0%). A strong association between being raped and reporting history of a STD was observed. The raped respondents were at least three times more likely to report a history of a STD than those with no history of rape.

The majority of the rape cases occurred during the 1990-1994 war and the non migrants suffered more than the other groups. Although, the refugees in camps showed lower HIV infection rates than those who got asylum in towns and villages, it appears that the period in camps was partly responsible for the huge increase in HIV infection among the rural residents between 1986 (1,3%) and 1997 (8,5%). Female refugees were almost exclusively (95.6%) the victims of rape during the war period.

 Figures shows that whereas in the young age group 12-19 years the males and the females had about the same HIV infection rates, in the middle ages 20-34 years the females were about 1.5-2 times more infected than the males. The rates ranges from 13.9% in females with age 20-24 years to as high as 21.5% in the age group 25-29 years compared to 8.6% and 13.9% among males respectively.

 The 1994 civil strife left many children orphans; many women widows and others extremely depressed. A study on prostitution was carried out in April 1997 on 3000 CSW, bar owners and some people on the general population. The results indicated that commercial sex work was very extensive and happened in many ways. The clients for commercial sex workers were equally many and varied and practising unprotected sex. 76% of CSW were between 20-40 years and all had had an STD at one time or another with 70% HIV positive. Married women were apparently exchanging sex for money in order to meet their financial obligations. There were children being marketed for sex by older women who act as matriarchs. Clients determined the use or none use of a condom with no alternative for women. It was clearly understood that sex for money and commercial sex work was an important determinant in the HIV Epidemic and intrinsically linked to the low social economic status.

The civil strife also produced many orphans and child headed households. With the over all low social income status, these children tend to start sex for money at a very low age to fend for themselves and siblings. The low economic status tends to send children out of school early with the potential to sell sex for money. Children who fail to continue in school because of lack of funds come up flocking to towns and commercial centres. These youth especially females are vulnerable because they are not skilled and end up selling sex for money. Homosexuality has been reported and may be more prevalent than previously. Government has responded by creating villages where the unaccompanied children are being looked after. This offers an excellent opportunity to target some of them before they become sexually active.

 There is also a tendency in the country to advocate for marriage in order to procreate given the genocide of 1994. With very high HIV prevalence, marriage without voluntary HIV testing and counselling is inappropriate. However there is a few Voluntary Testing and Counselling centre in the country. Given the status of affairs, transmission of HIV in marriage and or intending parents continue to increase transmission in couples and consequently in infants.

 Another important factor that contribute to the propagation of the epidemic is the long term partner separation in Military service conditions. In fact, the military is currently engaged in a long conflict in East Congo. These conditions tend to make the military vulnerable and hence an important cog in the wheel of the HIV Epidemic.

 The event of 1990-1994 in Rwanda did not destroy the physical infrastructure. They equally destroyed the people’s perception to the risks of HIV infection with consequent tendencies of fatalism. The perception is that nothing can be worse than genocide, even HIV infection.

 After the war, there were many returning refugees from neighbouring countries where they have been in camps with no much by way of recreation. Some of them needed to be resettled and housed. The government decided on communal housing schemes where about 600 households would live in a designated area. There are over 400 such centres scattered all over the country and in rural areas. Overnight rural areas have been semi-urbanised with all the potential effects of urban areas. It is felt that such communal housing were potentially a fertile environment for fuelling the HIV epidemic.

Similarly there are internal refugees camps with limited facilities for activity and recreation. Consequently sex becomes recreational. In presence of high HIV prevalence, these populations are quickly forming foci of high HIV transmission and once resettled in the general population they will act as “Trojan horses for HIV Virus”.

The National Response

 The Government of Rwanda has recognized that the problem of HIV/AIDS should not be just the concern of the ministry of health. In many speeches within Rwanda and abroad, senior level officials have stressed the multi-sectoral nature of the AIDS crisis and its potential impact on the economy. Confronting the epidemic will thus require the formulation of much more encompassing national AIDS programme which will entail close collaboration among many ministries unprecedented levels of co-ordination with donor partners and Rwandan civil society.

 Rwanda has adopted the decentralisation of government social functions. The prefectures should develop action plans based on the National Plan. The prefecture planning will be given support in the implementation of its plan. The private sector has been identified as an uninformed partner, which when informed will play a great role in prevention of STD/HIV/AIDS in the workplace.

 Rwanda has a multitude of NGOs and community based organisations, which already have STD/HIV/AIDS programmes at the grassroots level. They are involved and supported to develop action plans in utilising the National Strategic Plan.