Improving health outcomes through concurrent HIV program scale-up and health system development in Rwanda: 20 years of experience.
The 1994 genocide against the Tutsi destroyed the health system in Rwanda. It is impressive that a small country like Rwanda has advanced its health system to the point of now offering near universal health insurance coverage. Through a series of strategic structural changes to its health system, catalyzed through international assistance, Rwanda has demonstrated a commitment towards improving patient and population health indicators. In particular, the rapid scale up of antiretroviral therapy (ART) has become a great success story for Rwanda. The country achieved universal coverage of ART at a CD4 cell count of 200 cells/mm(3) in 2007 and increased the threshold for initiation of ART to ≤350 cells/mm(3) in 2008. Further, 2013 guidelines raised the threshold for initiation to ≤500 cells/mm(3) and suggest immediate therapy for key affected populations. In 2015, guidelines recommend offering immediate treatment to all patients. By reviewing the history of HIV and the scale-up of treatment delivery in Rwanda since the genocide, this paper highlights some of the key innovations of the Government of Rwanda and demonstrates the ways in which the national response to the HIV epidemic has catalyzed the implementation of interventions that have helped strengthen the overall health system.
Institute of HIV Disease Prevention and Control, Rwanda Biomedical Centre, Kigali, Rwanda. nsabinco@gmail.com.|Basel Institute for Clinical Epidemiology & Biostatistics and Swiss Tropical and Public Health institute, University of Basel, Basel, Switzerland. nsabinco@gmail.com.
Sabin
S
Nsanzimana
Harvard University Medical School, Boston, USA.
Krishna
K
Prabhu
Partners in Health, Boston, USA.
Haley
H
McDermott
Project San Francisco, Kigali, Rwanda.
Etienne
E
Karita
School of Population and Public Health, University of British Columbia, Vancouver, Canada.|Global Evaluative Sciences, Vancouver, Canada.
Jamie I
JI
Forrest
Partners in Health, Boston, USA.
Peter
P
Drobac
Harvard University Medical School, Boston, USA.|Partners in Health, Boston, USA.
Paul
P
Farmer
Global Evaluative Sciences, Vancouver, Canada.
Edward J
EJ
Mills
Harvard University Medical School, Boston, USA.|Ministry of Health of Rwanda, Kigali, Rwanda.|Geisel School of Medicine, Dartmouth College, Hanover, USA.
Agnes
A
Binagwaho
D044966:Anti-Retroviral Agents / Q000627:therapeutic use; D003906:Developing Countries; D015658:HIV Infections / Q000188:drug therapy* / Q000453:epidemiology; D006801:Humans; D008297:Male; D012432:Rwanda / Q000453:epidemiology
D044966:Anti-Retroviral Agents