Exploring what works

in Rwanda

Dr Sabin NSANZIMANA
Head of HIV&AIDS, STIs & OBBI Division
Institute of HIV Disease Prevention and Control
RWANDA BIOMEDICAL CENTER
 Presentation Outline

1.HIV program in Rwanda

2.Introduction to Sugar daddies project in Rwanda

3.Evidence from Kenya

4.Plan for piloting, evaluating and scaling in Rwanda

5.Preliminary program design details for Rwanda

6.Way forward
AIDS is Caused by HIV

H = Human

I = Immunodeficiency

V = Virus

The Virus causing AIDS

M5 • 3
 AIDS Defined

A = Acquired = Get HIV from someone

who is infected

I = Immune = The body’s defense system which

protects the body from disease

D
= Deficiency = Not having enough
of something
= Syndrome = A group of symptoms associated

S with a particular disease

M1 • 4
Transmission

M1 • 5
M1 • 6
M1 • 6
B Outline of NSP document – Strategic framework

HIV related deaths are People infected

New HIV infections and/or affected by
reduced by ½ from 5K
are reduced by
to 2.5K by June 2018, HIV have the same
2/3 - from 6K to 2K -
and HIV morbidity is opportunities as the
by June 2018
decreased general population

Prevention Care and Treatment Impact Mitigation

Health Support Systems, Coordination, and Strategic Information

7
 HIV prevalence in Rwanda is 3%

National
Average: 3%

Male: 2.3%
Female: 3.6%

Even in Kigali, disparity of

prevalence, high pockets of
City of HIV prevalence: FSWs: 56%
Kigali 7.3% (BSS2010).

Source: RDHS 2010

8
 Epidemiological situation
HIV Prevalence by Sex HIV Prevalence by Age
4 3.6 3.7
3.5
3 3
3
2.5 2.3 2.2
2 2005
1.5
2010
1
0.5
0
Total Women Men
Source: RDHS 2005 & RDHS 2010 Source: RDHS 2010

HIV Prevalence in Other Populations:

• FSW: 51% (BSS SW 2010)

• Pregnant Women in Sentinel Sites: 3.3% (Sero-surveillance 2011)
• Youth aged 15-24 Years: 1.6% ( DHS-2010)
• Men in uniform : 2,8% ( Rda Seroprev study , 2010)
• Prisoners 4,7% ( Mobile VCT , 2010)
 HIV among youth in Rwanda

Prevalence among population aged 15–24 years

1.6 1.48 1.5

1.4
1.2
1
0.8
0.6 0.45 0.4 Female
0.4
Male
0.2
0
2005 2010
Sugar Daddies Risk
Information Program
 1. Why is this program important in Rwanda?

2. Evidence from Kenya

3. Plan for piloting, evaluating and scaling in Rwanda

4. Preliminary program design details for Rwanda

 Sugar Daddies Risk Information Program

• Goal: Promote adolescents’ understanding of the role

of cross-generational sex in the spread of HIV.
• Evidence: A randomized evaluation in Kenya found
significant reductions in teenage childbearing as a result
of the program.
• Why: Eliminating cross-generational sex could break
transmission of HIV to youth populations – and thus end
the disease.
Preventing Adolescent HIV: a national priority
The Government of Rwanda has identified reducing cross-
generational sex as critical to controlling the spread of HIV
and keeping young people safe.
• Older men are more likely to have HIV than adolescent boys: 3.5% of
30-34 year-old men have HIV in Rwanda vs. 0.3% of 15-19 year-olds
(Demographic and Health Survey 2010)

• One out of 10 girls has first sexual experience with a man ≥10 years
older (Rwanda BSS 2009)

• Girls aged 20-24 are five times more likely to have HIV than same age
boys (RDHS 2010)
• Young girls appear to be getting infected by older men, rather than by
boys of their own age (RDHS 2010)
Eliminating cross-generational relationships could end HIV.
 Preventing Adolescent HIV: a national priority (Cont’d)

Rwanda: HIV prevalence (%) by age & sex

9
7.9
8 7.5
7
6.1
5.8 5.6
6
5
4.2
3.9 3.8
4 3.5
3 2.4
2 1.7
0.8
1 0.3 0.5
0
15-19 20-24 25-29 30-34 35-39 40-44 45-49
Women (%) Men (%)

Data source: RDHS 2010

 Teenage childbearing
Teenage childbearing in Rwanda
(% of women ages 15-19 who have had children or are pregnant)
12
10.5
10
8.65
8
Percent

6.8
6 5.7 6.1

4 4.1

0
1992 1995 2000 2005 2008 2010

Data source: World Bank, World Development Indicators

 Unwanted pregnancies most common in s1-S3

140
P4 – P6
Unwanted Pregnancies

120
S1 – S3
100 S4 – S6
80
60
40
20
0
Western Northern Southern Eastern Kigali City
Source: Rwanda Ministry of Education, In School Rapid
Assessment on Unwanted Pregnancies, 2011
Teenage childbearing, a Barrier to Education

• Rwanda has made enormous strides in increasing access

to education
• Primary school net enrollment is nearly universal, at 96%
• In lower secondary school, female enrollment exceeds
that of males (MINEDUC Statistical Yearbook 2012)

• However, unintended pregnancies still cause girls to drop

out of school

• Reducing teenage pregnancies can help young girls stay

in school and improve their life outcomes.
 2.Evidence from Kenya
3. Plan for piloting, evaluating and scaling in Rwanda

4. Preliminary program design details for Rwanda

Evaluation: Sugar daddies campaign in Kenya
•J-PAL affiliated professor Pascaline Dupas (Stanford
University) evaluated a “relative risk information campaign”
in Kenyan primary schools
• Trained project officer visited schools and spoke to grade
8 students
• Students were shown a 10-minute educational video on
“sugar daddies”
• An open discussion on the role of cross generational sex
in the spread of HIV followed the video screening
• Students were given detailed information about local
HIV prevalence rates, by gender and age group
Girls responded to information on relative risk

• Girls reduced engagement in unprotected sex with older

men
» Teenage childbearing with older men fell by 61%
» No offsetting increase in childbearing with same-
age partners -> After the campaign, girls were more
likely to use condoms with younger boys
• Most girls knew how HIV was spread but not that older
men were much more risky
• Risk reduction campaigns have greater success than total
risk avoidance campaigns in schools (i.e. abstinence only
education)
 3. Plan for piloting, evaluating and scaling in Rwanda

4.Preliminary program design details for Rwanda

Plan for Piloting, Evaluating & Scaling

National
priority to
prevent
adolescent HIV

Rwanda
Biomedical Centre
plans to evaluate
& scale the “sugar
daddies” program
Compelling
evidence from
a program in
East Africa
shown to be
effective
 Plans
• Phase 1: Visit a sample of schools to find out what girls
already know about the relative risk of contracting HIV from
older partners.
• Phase 2: Design the program for the Rwandan context
• Phase 3: A mini pilot to test the practical implementation of
the program and the reaction of the community, teachers and
students in order to best tailor the program to meet their
needs
• Phase 4: Full scale randomized evaluation in several hundred
schools to test impact in Rwanda
• Phase 5: If found to be effective, scale up to the rest of the
country
 Partnerships

• The Rwanda Biomedical Centre in the Ministry of Health is

driving this process
• Imbuto Foundation have been selected as an implementing
partner
• J-PAL will offer technical assistance in designing and
implementing the pilot and evaluation.
4. Preliminary program design details for Rwanda
Implement in Lower Secondary School Students

• Implementing in schools will reach the

widest distribution of students while
targeting students on the brink of making
sexual decisions
• Holding the sessions during the school day would
match the successful model from Kenya.
• An in-school program could target both boys and
girls.
• The short 45 minute session including the
educational video and discussion will not greatly
impact class time.
 Program Curriculum

• The risk information program will be conducted during

school hours by a trained facilitator.
• 40 minute program led by young, charismatic female
facilitator
• To ensure an open discussion, the teacher will be asked to
leave the room.
• Content:
• 10 minute video on sugar daddies
• Present info on the HIV rates by age and gender in that
area
• Classroom discussion and Q&A on cross-generational sex
Thank you