TRAC Plus Center for Treatment and Research on AIDS, Malaria, Tuberculosis and Other Epidemics RWANDAN HIV/AIDS DATA SYNTHESIS PROJECT Final Report 1 PREFACE Public health practitioners frequently must make programmatic decisions with data that are less than perfect. The main reason to use such data is because few well-conducted, high-quality studies exist that can answer an everyday public health question directly, and often we rely instead on imperfect surveillance data to guide our actions. This lack of data has been of concern for the human immunodeficiency virus (HIV) epidemic in Rwanda, where the scale-up of international resources has required rapid responses in planning and targeting prevention and treatment programs. In recent years in Rwanda, there has been a proliferation of HIV surveillance data, including sentinel surveillance in pregnant women, demographic and health surveys, and behavioral surveillance in youth, truck drivers, and sex workers. There also has been an increase in the number of quantitative and qualitative research studies, as well as an accumulation of local and national expertise. Despite this increase in available information, no method for synthesizing the data and no consistent way to analyze or interpret diverse data has been available. In the absence of time and resources to conduct the perfect study to guide programmatic and policy decision making, the important question of how can we use existing data to achieve similar purposes remains. The Center for Treatment and Research on HIV/AIDS, Malaria, Tuberculosis and other epidemics (Trac Plus), in conjunction with the Centers for Disease Control and Prevention––Global AIDS Program (CDC-GAP) Rwanda and with technical assistance from the University of California, San Francisco (UCSF), conducted an HIV data triangulation exercise to answer high priority questions using existing data sources in Rwanda. This exercise, funded by the Presidential Emergency Fund for AIDS Relief (PEPFAR), aimed to better define at-risk populations by geography and risk behavior and to determine the reach and intensity of corresponding programmatic responses. This report describes the steps involved in the triangulation exercise, presents the main findings of the triangulation process, and provides a launching point for next steps, including additional data collection and future research questions to be answered through triangulation. The true success of this exercise has been the integral participation of Rwandans, and we hope that the recommendations in this report will be used to strengthen HIV prevention efforts and improve the quality of life for Rwandan people living with HIV/AIDS. 2 ACKNOWLEDGEMENTS The Coordinating Committee for Data Triangulation and Modes of Transmission would like to thank the following: Trac Plus and CDC-GAP Rwanda for support in planning and conducting the HIV data triangulation exercise in Rwanda. This work would not have been possible without the scientific expertise and logistical support of the people in these organizations. The Institute for Global Health, University of California, San Francisco, for technical and logistical support. For their leadership and support of the triangulation process, the Committee would like to thank the Triangulation Sub-Working Group members: Hinda Ruton, Adeline Kabeja, Eugenie Kayirangwa, Gakunzi Sebaziga, and François Ndamage (in memoriam). For their technical assistance, the Committee would like to thank Stephanie Taché, Jonathan Aberle-Grasse, Willi McFarland, Heidi Frank, Hilary Spindler, Karen White, Roger Myrick, Lily Asrat, and Irene Iuppa. For participation in the Triangulation Stakeholders Meeting, the Committee would like to thank the Triangulation Task Force: the Center for Infectious Disease Control (CIDC), Center for Treatment and Research on HIV/AIDS, Malaria, Tuberculosis and other epidemics (Trac Plus); Commission Nationale de Lutte Contre le SIDA (CNLS); Institut National de Statistique (INS), the Joint United Nations Programme on HIV/AIDS (UNAIDS), Family Health International (FHI), Population Services International (PSI), the United States Agency for International Development (USAID), and the Ecole de Santé Publique de l‘Université Nationale du Rwanda (School of Public Health of the Rwanda National University). For their involvement in the Triangulation Technical Working Group, especially in refining the top questions from 10 to two, the Committee would like to thank Michael Kramer, Anita Asiimwe, Noni Gachuhi, Justus Kamwesigye, Eugenie Kayirangwa, Félix Ndagije, Elevanie Nyankesha, François Ndamage, Adeline Kabeja, Catherine Kayitesi, Hinda Ruton, Emilien Nkusi, Elisabetta Pegurri, Jessica Price, Janine Condo, Gatarayiha Philip, Gakunzi Sebaziga, Claire Nyiransabimana, Laurence Nyiramasarabwe, and François Sobela. 3 Acronyms ADB African Development Bank AIDS Acquired immunodeficiency syndrome ANC Antenatal care ART Antiretroviral therapy ARV Antiretroviral BSS Behavioral surveillance survey CDC-GAP US Centers for Disease Control and Prevention Global AIDS Program CHK Centre Hospitalier Kigali CNLS Commission Nationale de Lutte Contre le SIDA (National AIDS Control Commission) CSW Commercial sex worker CVCT Couples voluntary counseling and testing DHS Demographic and Health Survey (conducted every five years in Rwanda by ORC-Macro) DRC Democratic Republic of Congo EPP Estimation and projection package FHI Family Health International FY Fiscal year GAMET Global AIDS Monitoring and Evaluation Team GLIA Great Lakes Initiative in AIDS HIV Human immunodeficiency virus INS Institut National de Statistique (National Institute of Statistics) MARPS Most-at-risk populations 4 MOH Ministry of Health MSF Médecins Sans Frontières (doctors without borders) MSM Men who have sex with men NASA National AIDS spending assessment NEC National Ethics Committee NGO Nongovernmental organization NHA National Health Accounts OGAC Office of the US Global AIDS Coordinator PEPFAR Presidents Emergency Plan For AIDS Relief PLACE Priorities for local AIDS control efforts PLWHA People living with HIV/AIDS PMTCT Prevention of mother-to-child-transmission PNLS National Program for the Fight Against AIDS PSF Project San Francisco PSI Population Services International STI Sexually transmitted infection THIS Tanzania HIV/AIDS Indicator Survey Trac Plus The Center for Treatment and Research on HIV/AIDS, Malaria, Tuberculosis and other epidemics UCSF-PPHG University of California, San Francisco–Prevention and Public Health Group UNAIDS The Joint United Nations Programme on HIV/AIDS UNGASS United Nations General Assembly Special Session UNICEF United Nations Children‘s Fund 5 USAID The United States Agency for International Development VCT Voluntary counseling and testing WHO World Health Organization 6 EXECUTIVE SUMMARY This report summarizes the processes, findings, and recommendations of the Rwanda Triangulation Project, 2008. ―Triangulation‖ aims to synthesize data from multiple sources to strengthen the understanding of complex health issues and help make evidence-based public health decisions. The methodology of triangulation involves overlapping data on prevalence, risk behaviors, cofactors, and programmatic response for a specific subpopulation or geographic area of concern. Triangulation was applied to data from Rwanda to answer two over-arching questions: What are the differences in HIV prevalence among different population groups over time? What are the potential causes for these differences? Are there gaps in HIV/AIDS programmatic coverage according to prevalence and/or need? The Rwanda Triangulation Project was carried out from December 2007 to September 2008. The project was launched with a stakeholder meeting to identify relevant questions. These questions were prioritized, data sources were identified, and a task force was created. Four months were devoted to compiling and analyzing data. Over 100 independent sources of information on the HIV epidemic in Rwanda were found, including demographic and health surveys, HIV behavioral surveillance data, quantitative and qualitative research studies, and programmatic reports. A final workshop was held in Kigali in September 2008 to conduct training on the methods of triangulation, interpret the data, and make recommendations. Participants at the final triangulation workshop in September 2008 examined a multitude of HIV/AIDS-related indicators at the national, new province, and former province levels to understand epidemic patterns by geography. Data from sentinel surveillance at antenatal clinics (ANCs) were used as the basic gauge of HIV prevalence trends, while the 2005 Demographic and Health Survey (DHS) was used to look at magnitude of HIV prevalence. Using the ANC data, the DHS data, and potentially corroborative data from other sources, participants were charged with identifying regional (new province) epidemic patterns. Participants categorized the epidemic by ―concerning‖ and ―reassuring‖ using the national DHS indicators as a basis for comparison. Data gathered from the Great Lakes Initiative in AIDS (GLIA) show that indicators of risk in Rwanda appear to be substantially lower than those in other GLIA countries, such as Kenya, Tanzania, and Uganda. National data indicate low and apparent decline in HIV prevalence between 2003 and 2005, with a plateau after 2005, based on ANC and DHS HIV prevalence data. Although the HIV epidemic in Rwanda appears stable and declining, there are significant urban-rural differences in ANC prevalence. Urban sites