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Eliminating Cross-Generational HIV Spread in Rwanda

Learn about Rwanda's innovative Sugar Daddies Risk Information Program and its impact on preventing adolescent HIV transmission. Get insights from the successful pilot in Kenya and the plan for evaluation and scaling in Rwanda.

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Eliminating Cross-Generational HIV Spread in Rwanda

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  1. 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

  2. Presentation Outline • HIV program in Rwanda • Introduction to Sugar daddies project in Rwanda • Evidence from Kenya • Plan for piloting, evaluating and scaling in Rwanda • Preliminary program design details for Rwanda • Way forward

  3. AIDS is Caused by HIV H = Human I = Immunodeficiency V = Virus The Virus causing AIDS

  4. AIDS Defined A = Acquired = Get HIV from someone who is infected = Immune = The body’s defense system which protects the body from disease = Deficiency = Not having enough of something = Syndrome = A group of symptoms associated with a particular disease I D S

  5. Transmission

  6. M1 • 6

  7. Outline of NSP document – Strategic framework B New HIV infections are reduced by 2/3 - from 6K to 2K - by June 2018 HIV related deaths are reduced by ½ from 5K to 2.5K by June 2018, and HIV morbidity is decreased People infected and/or affected by HIV have the same opportunities as the general population Impact Mitigation Prevention Care and Treatment Health Support Systems, Coordination, and Strategic Information

  8. HIV prevalence in Rwanda is 3% National Average: 3% Male: 2.3% Female: 3.6% Even in Kigali, disparity of prevalence, high pockets of HIV prevalence: FSWs: 56% (BSS2010). City of Kigali 7.3% Source: RDHS 2010

  9. Epidemiological situation HIV Prevalence by Sex HIV Prevalence by Age 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% ( RdaSeroprev study , 2010) • Prisoners 4,7% ( Mobile VCT , 2010)

  10. HIV among youth in Rwanda Prevalence among population aged 15–24 years

  11. Sugar Daddies Risk Information Program

  12. Why is this program important in Rwanda? • Evidence from Kenya • Plan for piloting, evaluating and scaling in Rwanda • Preliminary program design details for Rwanda

  13. Sugar Daddies Risk Information Program • Goal: Promoteadolescents’ 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.

  14. 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.

  15. Preventing Adolescent HIV: a national priority (Cont’d) Rwanda: HIV prevalence (%) by age & sex Data source: RDHS 2010

  16. Teenage childbearing in Rwanda(% of women ages 15-19 who have had children or are pregnant) Teenage childbearing Data source: World Bank, World Development Indicators

  17. Unwanted pregnancies most common in s1-S3 • Source: Rwanda Ministry of Education, In School Rapid Assessment on Unwanted Pregnancies, 2011

  18. 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.

  19. Why is this program important in Rwanda • Evidence from Kenya • Plan for piloting, evaluating and scaling in Rwanda • Preliminary program design details for Rwanda

  20. Evaluation: Sugar daddies campaign in Kenya • J-PAL affiliated professor PascalineDupas(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

  21. 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)

  22. Why is this program important in Rwanda • Evidence from Kenya • Plan for piloting, evaluating and scaling in Rwanda • Preliminary program design details for Rwanda

  23. Plan for Piloting, Evaluating & Scaling

  24. 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

  25. 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.

  26. Why is this program important in Rwanda • Evidence from Kenya • Plan for piloting, evaluating and scaling in Rwanda • Preliminary program design details for Rwanda

  27. 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.

  28. 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

  29. Thank you

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