Exploring what works in Rwanda

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