AIDSTAR-One | CASE STUDY SERIES August 2012Rwanda’s Mixed EpidemicResults-based Strategy Refocuses Prevention Priorities I n 2009, Rwanda found itself in an unusual and enviable position: its national HIV program was nearly fully funded for all activities. With primary support from the Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM) and the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR), Rwanda won an Leigh Ann Evanson additional GFATM grant to fill remaining budget gaps in its HIV programming. Possibly for the first time ever, an African nation had the financial resources to undertake a complete, comprehensive HIV program, including prevention, care, treatment, and impactOne in a series of HIV preventionbillboards warning young Rwandans mitigation. How would Rwanda respond?to avoid “sugar mamas” and“sugar daddies”: adults who offer In many ways, the groundwork had been laid. Earlier that year, Rwandaadolescents cash or gifts in exchangefor sex. The Rwandan Government had used newly available data to significantly revise its nationalhas been conducting research into strategic direction in HIV programming. The National Strategic Plan onthe factors that increase risk foryoung women and girls, who have HIV and AIDS 2009–2012 (NSP 2009)1 was designed as a response tohigher HIV prevalence than males a modeling exercise, suggesting that Rwanda has a “mixed epidemic”their age. with transmission occurring within both most-at-risk populations (MARPs) and the general population (Republic of Rwanda 2009). Commissioned by the government, new sources of data—a modes of transmission study, a triangulation exercise, behavioral surveillance research, and more—provided the evidence necessary for planning the new strategy to address the realities of Rwanda’s epidemic (see Box 1). In fact, the GFATM granting application itself—the National Strategy Application (NSA)—was a valuable undertaking that strengthened the NSP 2009, helping Rwanda analyze its national HIV strategy,By Leigh Ann Evanson operationalize its new program, and project its resource needs.and Margaret Dadian 1 Throughout this case study, the National Strategic Plan on HIV and AIDS 2009–2012 is referred to as the NSP 2009, whereas its predecessor, the country’s first National Strategic Plan (2005 to 2009), is referred to as NSP 2005.AIDSTAR-OneJohn Snow, Inc. This publication was made possible through the support of the U.S. President’s1616 North Ft. Myer Drive, 16th Floor Emergency Plan for AIDS Relief (PEPFAR) through the U.S. Agency for InternationalArlington, VA 22209 USA Development under contract number GHH-I-00-07-00059-00, AIDS Support andTel.: +1 703-528-7474 Technical Assistance Resources (AIDSTAR-One) Project, Sector I, Task Order 1.Fax: +1 703-528-7480 Disclaimer: The author’s views expressed in this publication do not necessarily reflect the views of the Unitedwww.aidstar-one.com States Agency for International Development or the United States Government.
AIDSTAR-One | CASE STUDY SERIES What followed was a big step forward for public health in Rwanda. BOX 1. NEW SOURCES Recognizing the need to focus on vulnerable groups, the Rwandan OF DATA FOR government used the development of the new NSP to reorient STRATEGIC DECISION prevention programming to target behaviors shown by research to be MAKING driving new infections and fueling the country’s epidemic. In addition to adopting this data-based approach to planning, the NSP 2009 and To fully understand the drivers other strategy documents provided concrete goals and objectives of its epidemic before the NSP for stakeholders, making all parties responsible for success. The 2009 planning process began, broadly participatory nature of the planning process brought together the Rwandan government hundreds of stakeholders from many sectors, who contributed diverse commissioned several key perspectives and a broad array of experience and expertise. The studies to gather new data on result was a bold move away from planning based on re-implementing MARPs, including: traditional program activities toward an ambitious, evidence-based, • An exploratory study comprehensive strategy responsive to the nature of Rwanda’s looking at behaviors that put epidemic. Rwandan men who have sex with men (MSM) in Kigali at It is still too early to determine the overall effectiveness and impact high risk (Binagwaho et al. of the NSP 2009 because many program components were slow to 2009). launch. But the strategic planning approach underlying Rwanda’s HIV • A modes of transmission prevention programming redesign presents important lessons learned study: a modeling exercise to and suggests promising practices for other countries with a similar identify most-at-risk groups epidemiological profile. and groups with rising rates of HIV infection, including female sex workers and their clients, and MSM. Among other Rwanda’s Mixed Epidemic findings, it estimated that With a population of over 10 million in an area about the size of MSM would account for about the U.S. state of Maryland, Rwanda is the most densely populated 15 percent of new infections country in Africa. The country is landlocked and mountainous, and its (Asiimwe et al. 2010). economy is primarily agricultural, with 83 percent of the population • The Rwandan HIV/AIDS Data living in rural areas. Rwanda has made impressive progress in Synthesis Project: a data recovering from the genocide of 1994, during which more than triangulation exercise that 800,000 of its citizens were killed, the economy was crippled, and combined information from infrastructure—including much of the health care system—was earlier research to detect destroyed. epidemiological trends in different populations (TRAC In 1983, Rwanda was one of the first countries in Africa to identify Plus and the Ministry of cases of AIDS (Van de Perre et al. 1984). Today, Rwanda is among Health 2008). a dozen or more sub-Saharan African countries whose epidemic is characterized as “mixed” (see Box 2). The 2005 Demographic Health Survey estimates Rwanda’s national HIV prevalence at 3 percent among the general adult population aged 15 to 49. Although this is much lower than in most other East African countries, small2 AIDSTAR-One | August 2012
AIDSTAR-One | CASE STUDY SERIESstudies of specific at-risk populations in Rwanda show much higherHIV prevalence, including a population of sex workers in Kigali with BOX 2. THE DYNAMICS57 percent prevalence (Ministry of Health [MOH] 2010). Vulnerable OF MIXED EPIDEMICSsubpopulations within the general population also show higher HIV In recent years, the advent ofprevalence. For example, prevalence among women 20 to 24 years improved and expanded dataold is five times that of men their age (2.5 percent versus 0.5 percent; gathering in developing countriesRepublic of Rwanda 2009), a pattern seen throughout much of East has helped health expertsand Southern Africa. There is also geographic variability, most notably identify the populations athigher HIV prevalence in urban areas (7.3 percent) than in rural areas greatest risk of HIV. One result(2.2 percent; Republic of Rwanda 2009). has been the recognition that some national epidemics are inRwanda’s recognition of the mixed nature of HIV transmission within fact several different epidemics,its borders—in line with the global imperative promoted by PEPFAR or “mixed.”for countries to collect and use data to better understand the driversof their own epidemics—prompted the country to reorient its priorities A mixed epidemic isand redesign its strategies to be more targeted and cost-effective. operationally defined as low HIVThese efforts have put Rwanda among a handful of nations on the prevalence of 2 to 5 percentcontinent whose governments are gathering evidence on MARPs and in the general population,targeting prevention programming to them. combined with high prevalence (15 percent or higher) amongIn much of the world, MARPs—including sex workers, men who have MARPs and vulnerable groupssex with men (MSM), and people who inject drugs—are not effectively within the general population.reached by HIV prevention programming. MARPs are sociallymarginalized and face intolerance, stigmatization, and imprisonment.As a result, they tend to avoid health services, a situation worsenedby public health agencies that are unwilling or ill equipped to addresstheir specific needs, which exacerbates their vulnerability to HIV.Less marginalized than MARPs are subpopulations within the generalpopulation who are significantly more vulnerable to HIV infection dueto a mix of socioeconomic and contextual risk factors. These mayinclude serodiscordant couples, city dwellers, and mobilepopulations.Because these groups carry a disproportionate burden of theepidemic, countries are developing targeted prevention programsin hopes of decreasing HIV incidence. This requires a fundamentalchange in program design. Mixed epidemics are dynamic andcomplex, requiring a better understanding of the factors fuelingnew HIV infections and a clear focus on targeted populations andbehaviors. Mixed epidemic planning requires that data measure actualrather than perceived risk; these data should be regularly collectedfrom reliable sources to inform and adapt programs. Rwanda’s Mixed Epidemic: Results-based Strategy Refocuses Prevention Priorities 3
AIDSTAR-One | CASE STUDY SERIESProgram implementers must develop sensitivities subsumed within the Rwanda Biomedical Center/and skills to effectively work with new populations. IHDPC—which was responsible for clinical careHIV program planners must commit to funding and research, and the MOH, which acts as theprevention programs that respond to data, and principal recipient for all GFATM grants to Rwanda,be prepared to reduce or eliminate programs that which total U.S.$379 million for 2010 through 2013are proven ineffective. Programming for mixed (Dongier 2011a).epidemics forces planners to deal with thornyquestions. Where funding is limited, which activities Decentralization: Since 2001, Rwandaor regions will lose some or all of their support has pursued a policy of decentralization forfor prevention activities, and how will those cuts all development activities, including the HIVbe made? How will longstanding programs, built response. This strategy is designed to improveon conventional wisdom, respond and adapt? the responsiveness, appropriateness, andWhat is the right balance in reaching underserved accountability of programming by increasing localpopulations while maintaining some support participation and consultation in developmentfor existing programs that reach the general initiatives. Although the national governmentpopulation? provides strategic leadership and technical guidance, districts are charged with operationalizing policies and plans with appropriate actions.Rwanda’s Strategic District AIDS Control Commissions coordinate theResponse to HIV HIV response across Rwanda’s 30 districts. Each commission has dedicated staff who work withSince 2005, Rwanda’s Institute of HIV/AIDS representatives from local governments, variousand Disease Prevention and Control (IHDPC, ministries (health, education, planning), and civilknown before 2012 as the National AIDS Control society. Through district-level joint action forums,Commission or CNLS, its French acronym) has the commissions conduct annual planning exercisesdeveloped and coordinated two successive national and convene regular coordination meetings withstrategic plans to guide the country’s HIV response. local implementers and stakeholders.A variety of stakeholders have implemented theseplans in a decentralized manner. Civil society: In the wake of the 1994 genocide, the government monitors the activities of civilOrganizational structure: The IHDPC is a society organizations, including nongovernmentalcomponent of the Rwanda Biomedical Center, a organizations (NGOs), the private sector, media,coordinating body created in 2012 that is governed faith-based organizations, and groups for peopleby a board of directors chosen by the office of the living with HIV. A U.S. Agency for Internationalprime minister. The IHDPC’s general directorate is Development-funded assessment published incharged with monitoring the implementation of the 2002 described a passive civil society that focusednational strategic plan. Although all government on implementation rather than advocacy, andagencies participate in Rwanda’s national response partially attributed that situation to the government’sto HIV, two agencies in particular have been strong negative reaction to criticism (Managementdeeply involved in the planning and coordination Systems International 2002). Since that time,of HIV programs: the former Treatment, Research relations have improved but tend to focus more onand AIDS Center Plus (TRAC Plus)—now consensus building than confrontation.4 AIDSTAR-One | August 2012
AIDSTAR-One | CASE STUDY SERIESNGOs especially continue to be beholden to thegovernment for legitimacy, direction, and funding.This is evidenced by Rwandan legal requirementsthat international and national NGOs registerannually at both the national and district levels.NGOs are also legally required to align theirstrategic plans with key national policy documentsoutlining economic development goals and todocument their commitment to these plans. TheRwandan government also created umbrella Leigh Ann Evansonorganizations to coordinate the different facets ofcivil society participation.Civil society organizations, which often have deep A 2011 conference in Kigali on improving Africa’s nationalroots in the communities they serve, typically health care systems. Rwanda is among the African nationshave better access to MARPs than public sector that has worked hardest to build the evidence base for its national HIV strategy.agencies or service providers. Yet a 2009 situationanalysis noted that Rwandan civil society lacksa full understanding of MARPs and their needs; understanding of: 1) the nature of HIV in a countryits response was deemed largely ad hoc, lacking (“Know Your Epidemic”) and 2) the achievementsrigorous evaluation and quality assurance (Rwanda and gaps in current HIV programming (“Know YourNGO Forum 2009). Response”; UNAIDS 2007).2 The first encourages countries to use available data, supplemented withFunding sources: External financial support for modeling, to understand what drives their epidemicRwanda’s HIV programs currently comes from two and what impedes access to HIV services. Themain sources: GFATM and the U.S. Government second identifies which organizations and agenciesthrough PEPFAR. As part of the national strategic are working in HIV prevention and identifiesplan/NSA development process, the CNLS costed programmatic gaps in coverage and serviceout the NSP 2009. The total cost for fiscal year delivery for high-priority areas or populations.2009 through fiscal year 2013 was estimatedat U.S.$934 million, with GFATM and PEPFAR “Know Your Epidemic”: A systematic andcommitments combined providing U.S.$649 million. comprehensive review of important data helpedThe costing exercise estimated the government’s identify the populations in Rwanda at the greatestcontribution to be 13 percent, with the remainder risk of infection, which in turn helped definecoming from the United Nations and other donors. priorities for the NSP 2009. Led by the MOH and TRAC Plus, the Rwandan HIV/AIDS Data Synthesis Project reviewed more than 100 independentCollecting the Evidence Base sources of information to discern HIV trends among different population groups, as well as potentialIn 2008, as Rwanda embarked on the design of causes for these differences (TRAC Plus andits new HIV strategic plan, planners embraced 2 Later encapsulated in PEPFAR’s Guidance for the Preventionthe Joint UN Programme on HIV/AIDS (UNAIDS) of Sexually Transmitted HIV Infections as the “Four Knows”—guidelines, which were designed to foster a better know your epidemic, context, response, and costs. Rwanda’s Mixed Epidemic: Results-based Strategy Refocuses Prevention Priorities 5
AIDSTAR-One | CASE STUDY SERIESMOH 2008). Among its findings were that rapid Rwanda’s NSP 2005 (CNLS 2008). The reviewurbanization may be responsible for increases in found that although access to HIV treatment andHIV prevalence; prevalence among youth overall is prevention services increased during the periodlow, although young women have higher prevalence of the NSP 2005, HIV prevalence remained high.than young men; and refugees and truckers self- To respond to this persistent challenge, Rwandareport decreasing levels of risk behaviors. reoriented the NSP 2009 and gave it the primary goal of halving HIV incidence.A modes of transmission modeling exerciseconducted by CNLS and MEASURE Evaluation The NSP 2009 fits into the national government’sadded to the knowledge base (Asiimwe et al. strategic planning framework, which demonstrates2010). It used behavioral, demographic, and the government’s larger commitment to planningepidemiological data to examine an individual’s and program design, as well as its prioritization ofrisk, creating groupings of low-, medium-, and HIV. This commitment is embodied in a series ofhigh-prevalence populations to reveal what may documents that lay out long-term goals and developbe driving new infections in Rwanda. The exercise operational plans to achieve them. These includeidentified high-risk groups and subpopulations Rwanda Vision 2020, which “seeks to fundamentallywithin the general population with rates of HIV that transform Rwanda into a middle income countryare elevated or trending upward. The modeling by the year 2020” (Republic of Rwanda Ministryprocess included different scenarios and varying of Finance and Economic Planning 2000, 9) andHIV prevalence and size of different risk groups; includes goals to reduce HIV prevalence. Theit used the best available data to predict how HIV medium-term strategy to improve Rwandans’ qualityinfections would change between scenarios and of life—the government’s Economic Developmentto look for commonalities. Notably, estimations and Poverty Reduction Strategy 2008–2012—isshowed that MSM accounted for about 15 percent woven into Rwanda’s overall development planningof new infections across a range of scenarios (Republic of Rwanda 2007). The Health Sectormodeled. This finding prompted researchers to Strategic Plan 2009–2012 outlines the MOH’s HIVconduct an exploratory study of a population of response, which reflects the goals and objectivesMSM in Kigali (see Box 3) and emphasized the laid out in the higher level documents (MOH 2008a).need to focus on MSM in the NSP 2009. The The MOH also worked with districts to develop thedata also indicate that female sex workers, both District Health System Strengthening Framework, acommercial and transactional, will make a major costing and strategic planning tool for use in publiccontribution to new infections in Rwanda. health facilities (MOH 2008b).These studies confirmed that Rwanda is experiencinga mixed epidemic and pointed to the need toaddress new HIV infections among high-prevalence Constructing a New Policygroups. These findings, as well as an assessmentof Rwanda’s existing programmatic response and In early 2009, armed with a clearer understandingcapacity, were essential in developing the new, of the epidemic and potential responses as a resultevidence-based strategic direction for the NSP 2009. of these exercises, Rwanda sped up the extensive planning process that created the NSP 2009.“Know Your Response”: To prepare for the Combined with the results-oriented approach, thedevelopment of the NSP 2009, in 2008 CNLS data collected during the planning process weregathered all stakeholders for a joint review of critical in reorienting Rwanda’s HIV strategy.6 AIDSTAR-One | August 2012
AIDSTAR-One | CASE STUDY SERIES BOX 3. MSM RESEARCH SHOWS HIGH VULNERABILITY AND SIGNIFICANT NEEDS Throughout Africa, very little is known about populations of MSM. Because of profound stigmatization and discrimination, African MSM have been nearly invisible to the public health establishment and the larger public. Some political and health leaders question the existence of MSM within their societies, whereas others seek to pass laws criminalizing homosexual acts. In recent years, Rwanda has become one of a handful of African nations to recognize their MSM populations and conduct research to learn more about them. When the modes of transmission study suggested that 15 percent of new HIV infections stem from homosexual sex (Asiimwe et al. 2010), many rejected those findings. To test this assertion, CNLS and MEASURE Evaluation conducted a study from 2008 to 2009, gathering exploratory behavioral research on MSM in Kigali (Binagwaho et al. 2009). The researchers recruited a cohort of 98 MSM aged 18 to 52 years. To understand risk factors for this MARP, the researchers asked about their sexual partnerships (including commercial and transactional), their HIV testing and sexually transmitted infections history, as well as attitudes about possible HIV prevention strategies for MSM. Findings from this research show significant HIV risk for this population, with widespread sexual networks, a high frequency of casual sex, low levels of condom use, and high levels of alcohol consumption. One in 10 respondents reported exchanging sex for money. One-quarter of MSM said that they had also had sex with women within the past year. Based on these preliminary data, the researchers recommended several directions for Rwanda’s programming for MSM. First, all prevention programming should be conducted within a human rights framework, with great care to ensure privacy and safety for this stigmatized population. Second, health services should be MSM-friendly and should focus on the specific health needs of MSM, with increased access to counseling sensitive to their sexuality. Finally, wider distribution of condoms and lubricants is needed to promote safe sex. The minimum package of health services for MSM recently developed by CNLS/IHDPC reflects these priorities, but further research is needed to design responsive programs that will engender behavior change.The NSP 2009 took shape between January workshop, participants convened and reconvenedand March 2009, three months packed with in small working groups to discuss multiple issuesworkshops and meetings organized by the from a wide range of perspectives, with workshopexecutive secretariat of CNLS to discuss the full organizers often rushing from group to grouprange of strategy options. The first gathering— to communicate different positions and to helpthe “Know Your Epidemic, Know Your Response” participants seek a common ground. The Economicworkshop in Kigali—was a hectic but productive Development and Poverty Reduction Strategytwo-day collaboration. Attended by more than was used extensively to correlate planning with100 stakeholders, including government officials, Rwanda’s existing economic and developmentdistrict-level HIV coordinators, civil society goals.organizations, donors, and international partners,its purpose was to review available evidence from This intensive immersion in the planning processRwanda and around the world to identify program was followed by weeks of meetings of smallstrategies for the Rwandan context. During the technical working groups to formulate key strategies Rwanda’s Mixed Epidemic: Results-based Strategy Refocuses Prevention Priorities 7
AIDSTAR-One | CASE STUDY SERIESand to design the basic components of the NSP in the NSP 2005. The NSP 2005 prioritized2009. This work was facilitated by a team of prevention activities, but the joint review notedinternational consultants with skills and experience that the prevention-related objective—“to reinforcein strategic and operational planning, modeling, measures of preventing HIV/AIDS transmission”—and HIV programming. Operational plans, an lacked direction and made it difficult to objectivelyanalysis of resource needs, and a budget came conduct evaluations (CNLS 2008). In contrast,next. The monitoring and evaluation plan was also the NSP 2009 used a results-based approachdeveloped during this stage, a key program activity and established a clear goal for prevention withrarely integrated into strategic planning. Final steps measurable indicators: halving HIV incidence in theincluded a situation analysis that examined the role general population by 2012 (Republic of Rwandaplayed by Rwandan civil society organizations in the 2009).nation’s HIV activities, the current capacity of civilsociety organizations to implement HIV programsat scale, and proposed strategies to strengthen thatsector. The National Strategy Application: A Catalyst forDefining high-priority populations: The NSP the NSP 20092009 identifies five high-priority populations for HIVprevention: female sex workers, clients of female The development of the NSP 2009 was furthersex workers, serodiscordant couples, women accelerated when GFATM invited Rwanda to submitaged 20 to 24 years, and MSM. Epidemiological an application for its new experimental grantingdata demonstrate higher levels of HIV infection in module, the NSA, which would allow CNLS tothese groups than in the general population. Other fully fund all the activities in the NSP 2009. Thepopulations also referenced as vulnerable are NSA was designed to strengthen national HIVprisoners, truck drivers, people with disabilities, frameworks by using the grant application processmembers of the military and uniformed services, to bolster areas of policy development that haveand refugees. However, evidence demonstrates typically been weak.that HIV prevalence is lower in some of thesesubpopulations (such as refugees) and that some The NSA had three basic components: a rigorousalso report fewer risky behaviors (such as truck costing exercise, a “gap analysis” to identify thedrivers). Despite these data, the organizations program elements not covered by other funding,working with these subpopulations successfully and a national operational plan to show howadvocated for their inclusion in the NSP, citing the application could be integrated into existinginherent vulnerability (in the case of refugees) or programs. The NSA process unfolded as the NSPregional impact on HIV (members of uniformed 2009 was being developed, and the two activitiesservices and truck drivers), which underscores the became intertwined, prompting the planning team tobalancing act required to plan a program for mixed speed their work to quickly operationalize and costepidemics. out the NSP 2009. The amount of work required was significant because each of the dozen or moreEmphasizing results-based planning: of the proposed implementing partners had toThe NSP 2009 also marks a shift toward results- submit program plans and budgets. Time pressuresbased planning and management, a significant were also a challenge because the planning teamchange from the activity-based planning used had only two weeks to complete the gap analysis.8 AIDSTAR-One | August 2012
AIDSTAR-One | CASE STUDY SERIESDespite these challenges, completion of the NSA was invaluable inhelping Rwanda reorient to results-based planning. One particularly CHRONOLOGY OF NSPuseful element of the NSA’s gap analysis was the consolidation 2009 DEVELOPMENTprocess, which unified all GFATM grants under one agreement, AND NSA AWARDhelping Rwanda detect programming weaknesses and duplication ofactivities. • August to December 2008: joint review of NSP 2005The final result was a successful NSA for Rwanda, which was the • January to March 2009:first country to receive this form of GFATM support for its national workshops and consultationsHIV strategy. Although operationalizing strategic plans often takes for NSP 2009many months to accomplish, the NSA rapidly turned the newly mintedNSP 2009 from a planning document into a working blueprint for • April 2009: submission of NSPimplementation. The NSA learning process has also helped Rwandan 2009 to GFATM for initial NSAhealth leaders build budgeting and planning skills that will strengthen reviewthe country’s planning efforts in the future. • May to July 2009: NSP 2009 costing gap analysis completed; monitoringWhat Worked Well and evaluation framework designedThe most successful elements of Rwanda’s intensive HIV strategy-building efforts are valuable for other countries to review and adapt to • August 2009: NSA proposaltheir own context. submission • November 2009: GFATMGovernment leadership: All statements from high-level approval of Rwanda HIV NSAgovernment officials (including President Paul Kagame’s June 2011speech at the UN General Assembly) indicate that HIV remains a • November 2010: completionpriority in the government’s agenda. Moreover, the political leadership of post-award negotiations;that built and maintained momentum for the NSP 2009 process signing of grant award.remains in place. The current minister of health is the former headof the CNLS, which indicates that HIV will likely retain its importancefor the government. Government officials have demonstrated theirwillingness to fight to ensure the success of the new plan. Forinstance, when members of the Rwandan Parliament presentedlegislation in 2009 to criminalize MSM behavior, CNLS and civilsociety advocates successfully lobbied for the withdrawal of theproposed clause, using research findings to explain the negativeimpact the law would have on prevention programming.Donor support: Donors supported the NSP 2009 process; theyworked together to align their activities with government prioritiesand to ensure minimal overlap and adequate coverage. Thedevelopment of the NSP 2009 paralleled the development of thePEPFAR Partnership Framework with Rwanda, and NSP 2009 goals, Rwanda’s Mixed Epidemic: Results-based Strategy Refocuses Prevention Priorities 9
AIDSTAR-One | CASE STUDY SERIESstrategies, and timeframes are directly reflected in guide the development of the NSP 2009, includingthe partnership framework. epidemiological and programming data that revealed the priority populations, if and how theyCommitment to planning and priorities: were reached, and impact. Planners used modelingThe logical framework consistent throughout all and proxy data when information was not available,government policies and documents (Rwanda and current research activities are filling informationVision 2020, the Economic Development and gaps. The midterm review, scheduled for releasePoverty Reduction Strategy, and The Health in late 2012, will provide important information onSector Strategic Plan) gave coherence and clear the effectiveness of the NSP 2009 and point to anydirection to the NSP 2009. The commitment necessary adjustments.to comprehensively address HIV is especiallyevident in the Economic Development and Poverty Asking the right people the rightReduction Strategy, in which all development questions: The exploratory study of MSMsectors explicitly identify HIV as a cross-cutting in Kigali is an example of using rigorous dataissue. All three documents demonstrate the collection methods to gather information aboutgovernment’s commitment to planning and goal marginalized MARPs. During a validation exercise,setting and identify HIV as a national development researchers presented initial results to MSMissue. The government’s investment of time, effort, respondents, who provided invaluable insightsand money in developing the NSP inspired civil that refined the analysis and pointed the way tosociety, donors, and district governments to be appropriate approaches for prevention amongactively involved in the process. MSM. This study and its methodology also underscore the importance of engaging membersA forward-moving participatory of these populations to describe their own lives andprocess: The NSP 2009 was developed with discuss their own risk behaviors and preventionthe active participation of stakeholders from needs. It is critical to engage MARPs in this way toall sectors involved in health, although some gain knowledge and understanding, particularly in agroups (notably MARP advocates) did not feel mixed-epidemic setting.adequately represented. A balance was struck byusing dedicated technical staff to complete the Results-based planning: The NSP 2009’sdocuments while at the same time implementing results-based approach provided clear directionparticipatory mechanisms that gave opportunities for Rwanda’s response to HIV. The broader resultsfor CNLS to check in and for stakeholders to allow for successful programs to continue andvalidate the outcomes. The consultative/validation expand, and for new programs to rationally fill in theprocess happened multiple times during the gaps. The simultaneous design of the monitoringdevelopment of the NSP 2009. These meetings and evaluation system links all performancewere not perfunctory but resulted in changes to the indicators and data sources to an NSP 2009 result.documents based on the validation exercises. For This approach allows stakeholders to understandexample, the results of the MSM study provided and demonstrate how their work contributes tonew data that influenced the strategies and larger objectives. Finally, the monitoring andactivities included in the NSP 2009. evaluation plan design requires that each result include indicators and data sources, which meansUse of data for decision making: The that all results have to be measurable and realistic.planning process used all available evidence to This in turn facilitated the costing exercise.10 AIDSTAR-One | August 2012
AIDSTAR-One | CASE STUDY SERIESChallenges high-priority populations as sex workers, MSM, and serodiscordant couples are relatively new and may not yet be fully disseminated. These documentsLittle impetus to streamline are critical for implementers seeking to provideprogramming: Because Rwanda’s HIV activities appropriate services.are fully funded, there is no imperative to streamlineor reduce the activities within the prevention Lack of program data: The Data Synthesisportfolio. The current approach, which simply adds Project noted the lack of high-quality programactivities to the current prevention portfolio, may data. Most programs collect output data (e.g.,only maintain the current levels of service delivery number of people trained) but do not rigorouslywithout achieving the desired impact on incidence. evaluate programs to determine their impact. Even with the NSP 2009 in place, key data elementsWeak civil society: Through CNLS and TRAC remain uncollected. For instance, size estimationsPlus (now the IHDPC) and MOH, the government for MARPs—which provide a baseline and allowof Rwanda has played a remarkable leadership role implementers to establish targets for programin driving the NSP 2009 process by ensuring donor coverage—are still in process. In addition, betteralignment with national strategies and priorities and analysis of program data can reduce programmaticby managing GFATM grants. However, this leaves overlap, fill programming gaps, and promote morelimited space for other actors, particularly those within efficient scale-up. This is increasingly important incivil society. For example, the government is the sole light of pending funding reductions.principal recipient for all GFATM monies. Althoughthe justification for this is that civil society is currently A rushed planning process: Although thetoo weak to take on this role, this arrangement NSA process sparked intense activity and anconflicts with GFATM’s stated preference for a co- investment of time and effort, the fast pace of theprincipal recipient structure—with both civil society process forced the NSP 2009 to move forwardand government managing funds—as a check on without adequate background documents orthe power of a single entity and a diversification of information. With more time, the missing technicallocal capacity. Allowing the government to control guidance could have been developed along withsignificant funding for civil society organizations the NSP 2009, reducing the gap between the NSPundermines the role those organizations could 2009 launch and the start-up of activities.play as government watchdogs or advocates formarginalized populations. Also, few organizationshave experience working with MARPs in Rwanda,and the organizations led by these populations require Recommendationssignificant capacity building. It is unclear who isresponsible for building local organizational capacity Rwanda’s experience in planning for mixedto work with these newly targeted populations. epidemics provides valuable lessons learned and recommendations both for Rwanda as it nearsInsufficient technical guidance and the end of the NSP 2009 and for other countriescapacity: The lack of technical guidance from working in similar contexts.the Rwandan government has delayed roll-out ofprevention programs targeting MARPs. Rwanda’s Commit to a comprehensive planningminimum packages of prevention services for such process: Although the investment in time and Rwanda’s Mixed Epidemic: Results-based Strategy Refocuses Prevention Priorities 11
AIDSTAR-One | CASE STUDY SERIESmoney to complete a comprehensive planning Continue to build the evidence base:process is significant, it is worthwhile. The final Although the NSP 2009 and associated datareport on the operationalization of the NSA (Dongier analysis exercises clearly identified MARPs,2011b) concludes that, although Rwanda was able more research is needed to better understand theto speed up many of the steps of the NSP 2009, drivers of risk for those populations. For instance,a similar planning process would normally take up all women aged 15 to 24 are not uniformly at riskto two years. In addition, planning is well worth the for HIV infection, and further research is neededcost. Although the report estimates Rwanda’s NSP/ to understand the specific characteristics and riskNSA external costs for planning (workshops and behaviors to effectively target these women withinternational consultants) at over U.S.$500,000, prevention interventions. Similarly, serodiscordantthis represents only 0.07 percent of the entire NSP couples may need different approaches, depending2009 budget. on which partner is infected. In addition, more data are needed on such marginalized groups as MSMDo not wait for perfect data: Rwanda’s to develop appropriate programs and activities andcommitment to building an evidence base provided ensure adequate coverage of these populations.sufficient information for analysis. Although thedata available were neither perfect nor complete,Rwanda’s investment in compiling and analyzing Current Status ofavailable information yielded important andsurprising findings that, among other things, Implementation and Nexthighlighted the contribution of MSM to newinfections, prompting Rwanda to recognize and Stepsaddress this prevention gap. Rwanda was also able Although the NSA represented full funding forto use data and information gathered from other Rwanda’s comprehensive HIV prevention strategy,parts of East Africa that served as an adequate there have been significant delays in startingsubstitute for actual data from Rwanda. Although up new activities. The NSP 2009 was officiallythis proved sufficient for initial planning purposes, launched in June 2010, but the time needed forprogram planners understand that these informationgaps must be filled over time. post-award negotiations and the consolidation of all GFATM grants into one agreement meant theRemain flexible: The speed required to final grant was not signed until November 2010. Thecomplete the NSA application required Rwanda competitive selection process used to choose theto budget for activities that were not yet well subrecipients also caused delays to the subgrantingdefined. As these new activities became clearer, program. As a result, many disbursements werethe estimated costs changed, prolonging budget held up; some recipients did not receive their firstnegotiations. Fortunately, the consolidation process tranche of funding until June 2011.identified a number of cost savings that providedflexibility to adjust the budgets, and the granting In fiscal year 2012, PEPFAR funding was reducedmechanism allowed Rwanda to shift funds. Funding by 10 percent, compelling the U.S. Government toagencies should recognize the need for this funding examine its funding priorities. Through intensiveflexibility, which is key to responding to the dynamic consultation with the government and implementers,shifts that characterize mixed epidemics. some programs in Rwanda had to be scaled back.12 AIDSTAR-One | August 2012
AIDSTAR-One | CASE STUDY SERIESNew and continuing prevention activities: and building monitoring and evaluation systems,Because most new activities were to be funded with particular focus on the evaluation component.through the NSA, the bulk of activities up andrunning in 2011 represent continuations or scale- District activities: Given the push towardup of activities from the NSP 2005. Programs that decentralized programming, it was critical thatfocus on newly identified populations have been the NSP 2009 provide an initial roadmap forslower to launch. This is due in part to delayed implementers and local government entities thatfunding, and also because the development coordinate HIV programming at the district level.of technical guidelines, especially for MARPs, Districts used the NSP 2009 as the basis for thewas delayed as well. For example, the minimum annual district-level HIV action plan, a processpackage of HIV prevention services for female sex coordinated by the 30 District AIDS Controlworkers was not finalized until October 2010; the Commissions. These plans were completed by Aprilminimum packages for other groups were finalized 2010. HIV prevention activities are now integratedin early 2011. into the district economic and social development plans. The commissions have put in place planning,Research: Rwanda’s research agenda continues coordination, and monitoring tools to track localto move apace, driven by the gaps in research and programs and partners, including quarterlyevidence identified through the national strategic coordination meetings and annual supervisoryplanning process. The gaps in data previously noted visits. Some civil society partners, however,have informed the government’s current research question whether the commissions have adequateagenda. Studies to estimate the population size guidance and skills to coordinate implementation ofand HIV infection rates for sex workers and truck the entire NSP 2009, particularly activities targetingdrivers—critical for setting goals for outreach and MARPs.coverage, and for assessing reductions of incidencewithin these groups—were scheduled for 2009; in Evaluation: A midterm review of the NSP 2009 is2010, the same studies were planned for prisoners scheduled for release in late 2012. As with the firstand MSM. The U.S. Centers for Disease Control joint review, stakeholders will see how much of theand Prevention supports the MOH to conduct NSP 2009 is operational and identify major gapsanother behavioral surveillance survey for MSM in implementation. This will provide an opportunityusing a different methodology to recruit a broader for refocusing and prioritizing resources. The finalarray of respondents. Other operational research report on the operationalization of the NSA alsopriorities include size estimation studies for MSM, calls for another round of budgeting, which will likelytruck drivers, prisoners, and sex workers. In coincide with the review.addition, further research is planned to understandthe broader sociocultural and environmental drivers The promise of the NSP 2009 remains strong,of vulnerability to HIV infection, particularly to but it is still too early to assess its impact on HIVunderstand why young women are at such high risk in Rwanda. For it to be successful, all actors willfor infection. Rwanda will evaluate progress made need to stay the course. The IHDPC and thetoward the Millennium Development Goals on HIV government of Rwanda will need to persevere inprevention in the coming years. The final evaluation their commitment to prevention strategies builtis scheduled to be completed by 2015; the IHDPC on an ever growing evidence base. Implementersis currently adapting UNAIDS evaluation guidelines will need to be nimble to respond to the changing Rwanda’s Mixed Epidemic: Results-based Strategy Refocuses Prevention Priorities 13
AIDSTAR-One | CASE STUDY SERIESdynamics of the epidemic, and funding agencies will Geneva, Switzerland: Joint UN Programme onneed to remain flexible to allow funding shifts based HIV/AIDS. Available at http://data.unaids.org/pub/on new information on the actual costs of effective Manual/2007/20070306_prevention_guidelines_strategies implemented in Rwanda. All actors must towards_universal_access_en.pdf (accessedmaintain an open and collaborative dialogue to September 2011).share lessons learned, to raise and solve issuestogether, and to continue to work together to reduce Management Systems International. 2002.HIV incidence in Rwanda. g Rwanda Democracy and Governance Assessment. Produced for the USAID Office of Democracy and Governance. Washington, DC: ManagementREFERENCES Systems International, Inc. Available at http://pdf. usaid.gov/pdf_docs/PNACR569.pdf (accessed AprilAsiimwe, Anita, Andrew Koleros, Jenifer Chapman, 2012).and Pierre Dongier. 2010. Evaluating the Dynamicsof the HIV Epidemic in Rwanda. Kigali, Rwanda: Ministry of Health. 2008a. Health Sector StrategicCNLS and MEASURE Evaluation. Plan January 2009–December 2012. Kigali, Rwanda: Government of Rwanda.Binagwaho, Agnes, Jenifer Chapman, AndrewKoleros, Yves Utazirubanda, Elisabetta Pegurri, Ministry of Health. 2008b. The Rwanda Districtand Rose Gahire. 2009. Exploring Risk Among Health System Strengthening Framework (Best Practices for District Planning). Kigali, Rwanda:MSM in Kigali, Rwanda. Kigali, Rwanda: CNLS and Government of Rwanda.MEASURE Evaluation. Ministry of Health. 2010. Behavioral and BiologicalDemographic and Health Survey. 2005. Rwanda Surveillance Survey Among Female CommercialDemographic and Health Survey 2005. Kigali, Sex Workers, Rwanda-2010. Kigali, Rwanda:Rwanda, and Calverton, MD: Ministry of Finance Center for Treatment and Research on AIDS,and Economic Planning and ORC Macro. Available Malaria, Tuberculosis and Other Epidemicat www.measuredhs.com/publications/publication- Diseases.FR183-DHS-Final-Reports.cfm (accessedSeptember 2011). National AIDS Control Commission (CNLS). 2008. Joint Review of the National Multisectoral HIV/AIDSDongier, Pierre. 2011a. Personal communication, Strategic Plan 2005-2009. Kigali, Rwanda: RepublicAugust 2011. of Rwanda.Dongier, Pierre. 2011b. Final Report: Republic of Rwanda. 2007. Economic DevelopmentOperationalization of Rwanda HIV NSA/SSF. Kigali, and Poverty Reduction Strategy, 2008–2012.Rwanda: CNLS. Kigali, Rwanda: Republic of Rwanda. Available at http://siteresources.worldbank.org/INTRWANDA/Joint UN Programme on HIV/AIDS. 2007. Practical Resources/EDPRS-English.pdf (accessedGuidelines for Intensifying HIV Prevention. September 2011).14 AIDSTAR-One | August 2012
AIDSTAR-One | CASE STUDY SERIESRepublic of Rwanda. 2009. National Strategic and Disease Prevention and Control, as well asPlan for HIV and AIDS 2009-2012. Available at other government officials who graciously gavehttp://apps.who.int/medicinedocs/en/d/Js18409en/ their time to meet with the authors. Thanks to(accessed September 2011). the numerous civil society and implementing partner representatives who provided insight and analysis, particularly FHI 360’s ROADS staff forRepublic of Rwanda Ministry of Finance and arranging a site visit. Staff at the U.S. AgencyEconomic Planning. 2000. Rwanda Vision 2020. for International Development (USAID)/RwandaKigali, Rwanda: Republic of Rwanda. and the U.S. Centers for Disease Control and Prevention/Rwanda provided invaluable supportRwanda NGO Forum. 2009. Situation Analysis of in helping the authors successfully organize thethe Role of Civil Society in the Response to HIV/ field work, particularly Stephanie Joseph de Goes.AIDS in Rwanda. Kigali, Rwanda: NGO Forum. Timothy Mah of USAID/Washington collaborated on design of the case study. The authors areTRAC Plus and the Ministry of Health. 2008. especially grateful to Andrew Koleros of MEASURE Evaluation and Pierre Dongier for their generosityRwandan HIV/AIDS Data Synthesis Project: Final and patience in answering questions and providingReport. Kigali, Rwanda: Republic of Rwanda. critical context, clarification, and review. Deepest appreciation goes to John Snow, Inc./RwandaVan de Perre, Philippe, Philippe Lepage, Philippe colleague, Daniel Hanyurwimfura, who tirelesslyKestelyn, Anton C. Hekker, Dominique Rouvroy, Jos arranged interviews, organized logistics, and madeBogaerts, Joseph Kayihigi, Jean-Paul Butzler, and the time in Rwanda highly productive and veryNathan Clumeck. 1984. Acquired Immunodeficiency enjoyable.Syndrome in Rwanda. The Lancet 2 (8394):62–65. RECOMMENDED CITATIONRESOURCES Evanson, Leigh Ann, and Margaret Dadian. 2012. Rwanda’s Mixed Epidemic: Results-based StrategyAIDSTAR-One. 2012. PEPFAR Technical Refocuses Prevention Priorities. Case Study Series.Consultation on HIV Prevention in Mixed Epidemics, Arlington, VA: USAID’s AIDS Support and TechnicalAccra, Ghana, February 8–10, 2011. Available at Assistance Resources, AIDSTAR-One, Task Order 1.www.aidstar-one.com/sites/default/files/AIDSTAR-One_MeetingReport_MixedEpidemics_Ghana_ Please visit www.AIDSTAR-One.com forFeb2011.pdf (accessed July 2012) additional AIDSTAR-One case studies and other HIV- and AIDS-related resources.ACKNOWLEDGMENTSThe authors are indebted to dozens of Rwandansand others who agreed to be interviewedfor this case study. These include Dr. AnitaAsiimwe, Dr. Placidie Mugwaneza, and theircolleagues at Rwanda’s Institute of HIV/AIDS Rwanda’s Mixed Epidemic: Results-based Strategy Refocuses Prevention Priorities 15
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