Fighting HIV/ AIDS requires a holistic approach and should encompass behavioural change towards routine testing and medical adherence for those found to be positive, Dr Sabin Nsanzimana, the director of National HIV programme at Rwanda Biomedical Centre said. 

Speaking during an exclusive interview with The New Times’ Solomon Asaba, in Kigali, last week, Nsanzimana said this will ensure Rwanda achieves the zero infection target.

Below are the excerpts:

There are new findings on the HIV prevalence in the country, tell us about the study?

Recently, we presented new data from a survey that we conducted from 2013 to 2014. This is one of the biggest surveys ever conducted in the history of HIV in Rwanda, that is why it took us time. To go directly to the findings, 3 people out of 100 are HIV infected and 3 out of 1,000 individuals get new infections every year. It is the first time we are able to know how many people are infected each year. Previously, we relied on estimates but this time round we conducted a household survey.

What was the methodology used to cover households across the country?

We went to all the 416 sectors in Rwanda and randomly selected households. All the provinces were covered as well as Kigali. We selected 14,000 people using a computer based selection tool and tested all of them for HIV. This is how we arrived at the 3 per cent rate.

Among this population, those found negative were 13,000 more but we followed them up for 12 months. After the 12 months, we went back to these people to do another test. We confirmed that 3 out of 1,000 were HIV positive yet before they were not. This is how we arrived at the incidence rate.

How do these findings reflect on the behavioural patterns of Rwandans as far as HIV and AIDS is concerned?

Behaviour is something very complex and changing it takes a very long time. It can take 10 years, 100 years or an entire generation without one changing their behaviour. We have done that survey before and we did not see big improvement. It was a little bit discouraging to see that the comprehensive knowledge of HIV in regards to behaviour didn’t really improve as we wished.

That somehow raised a number of questions; is it because the behaviour should change or the way we measure behavior should change, that is a debate that is not yet concluded.

So what kind of behaviour do you think exposes people to HIV/ Aids that they should look out for?

The major cause of HIV transmission is known, it is sexual intercourse, which accounts for more than 90 per cent.

We still see that sexual activities are increasing, this increases risks of new infections. Behaviour, among other risks, like alcohol consumption, push people towards indulging in unsafe sex.

That for me is the first thing I would flag in regard to behaviour and still maintain that protection, condom use and avoiding multiple partners should be practiced.

Another important number that I need to mention is that 65 per cent of new infections are coming from stable couples.

Among these couples, it is an issue of multiple partners who are hidden outside marriage when the man or woman could be having a secret girlfriend or woman and vice versa. Sexually, data shows that this kind of behaviour is a high risk.

One of the measures that had been adopted to help check HIV prevalence was to place condom dispensers in bars and other public places but if you randomly visited any of those place today, you will find that just a few of the dispensers are functional. Haven’t we become a little complacent?

Condom distribution by dispensers is not the only strategy to fight HIV, it is just one of the many ways but as you can easily see, today it is not our main focus and we have been asked frequently why we don’t put those machines back in the bars and hotels.

In our technical groups we have discussed this for a long time and among the issues is that these machines are very expensive, at one point when we got machines they were paid for by one of our partners and that was just a test to see if they could serve the purpose here.

Today, with the limited resources, we think that investing in the machines would be more expensive and less protective than buying more condoms so we prefer to invest money in buying more condoms than buying the machines to dispense condoms.

Number two, these machines have helped in some areas but in other areas they were easily broken and repairs became expensive. People could not use the machines in a proper way, Some regularly broke down when people tried to recover coins that had dropped inside.

You should also remember that the machines were hidden in toilets making it hard to monitor. We found out that 94 per cent of the machines broke that way. Some people did not want to use the machines because they were in public places.

So we have combined these elements and decided we are not going to buy more machines, we are going to buy more condoms instead, each year more than 20 million condoms are distributed.

Are there any new strategies in the pipeline to distribute condoms?

We are using the community health workers to distribute condoms; we are also using people who are at a great risk, for instance the sex workers. We are also building condom kiosks in partnership with the City of Kigali. We shall launch the condom access points from these kiosks.

The machines will be delivered this August to selected hotspots like Remera, Biryogo, Mirongo-Ine, Gikondo and other places where there is a lot of human activity. They will be functional 24 hours.

Someone in the kiosk will be able to give out free condoms and that is one thing we thought would be useful.

We are also starting another project dubbed ‘Dial a condom’, where one can call while at home that they need condoms, and they are delivered to them. At this level I will not specify, but it is a great idea and I find it innovative.

Do you think the self-testing strategy will further address the HIV prevalence?

Self testing is a new strategy that is coming up in many countries. The few countries that have already adopted it have gone far in this fight. Self testing means you get a device, the most preferred being the oral quick, and requires no blood sample.

A swab is put in the mouth or the teeth without inflicting any pain, then put on the device and read the results within a few minutes. That is one easy way of getting people tested from their homes without going to the health centre. We think this will be useful, especially in Kigali.

Studies that looked at this showed higher acceptability which is more than 90 per cent and our scientific committee recently endorsed it, so we are waiting for approval by the Ministry of Health. It will help many people I believe, but it is not going to replace the current testing mechanism, it is just going to complement it.

Once it is approved, we shall go on to procure those devices and train people. Studies have shown that it is less expensive compared to traditional testing methods because you don’t need a doctor, nurse and lab technician to help you.

And, contrary to the traditional method where you need a needle, a tube for blood, a machine in the lab to separate the constituents of plasma which takes a long time. This new method is easier.

On test and treat, the way we operated before meant you are tested for HIV now, then you wait until your immunity level of CD4 is less than 500. Two big studies presented this year, one called ‘stat study’ and another ‘temprano’ have provided results that changed the way people think about treating HIV.

People who are tested and treated earlier are less likely to die because of opportunistic infections. 53 per cent would die if you don’t delay treatment, while another study found that 96 per cent of people who are HIV positive, once treated early, will not transmit the virus to other people. This week we shall present the results to the ministry.

Why is the HIV prevalence rate high among women than men?

Anatomically, the genitalia of women are exposed to infectious diseases such as HIV than their male counterparts.

Secondly, women are more vulnerable, they are easily exposed to violence, and forced sex. Lastly, in our culture, the woman has no say when it comes to issues of sex. Some times girls indulge in sexual activity against their wish but because society says so.

Currently, how is the situation of medical adherence among infected individuals?

The situation is not bad, a recent survey shows that 83 per cent of people take medication correctly but adherence is an issue among adolescents.

Sometimes their bodies push them to take wrong decisions regardless of the advice and exposure. We have seen poor adherence amongst adolescents and youths compared to other people.

Discordance is rising, how is this affecting the whole fight against HIV?

It is a big problem, 3 per cent of couples in Rwanda are discordant. 65 per cent of infection rate is among stable couples as I mentioned earlier, and the main contributor to that number is cell discordant couples. Every member of a discordant couple who is HIV positive is initiated on treatment immediately, this policy started in 2012.

If you treat the positive partner, the chances of reducing transmission goes up to 96 per cent. We have more than 5,000 couples who are discordant.

editorial@newtimes.co.rw