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Background Currently, there is limited evidence on the effectiveness of second-line antiretroviral therapy (ART) in sub-Saharan Africa. To address this challenge, outcomes of second-line protease inhibitor (PI) based ART in Rwanda were assessed. Methods A two-stage cluster sampling design was undertaken. 49 of 340 health facilities linked to the open-source electronic medical record (EMR) system of Rwanda were randomly sampled. Data sampling criteria included adult HIV positive patients with documented change from first to second-line ART regimen. Retention in care and treatment failure (viral load above 1000 copies/mL) were evaluated using multivariable Cox proportional hazards and logistic regression models. Results A total of 1688 patients (60% females) initiated second-line ART PI-based regimen by 31st December 2016 with a median follow-up time of 26 months (IQR 24–36). Overall, 92.5% of patients were retained in care; 83% achieved VL ≤ 1000 copies/ml, 2.8% were lost to care and 2.2% died. Defaulting from care was associated with more recent initiation of ART- PI based regimen, CD4 cell count ≤500 cells/mm 3 at initiation of second line ART and viral load > 1000 copies/ml at last measurement. Viral failure was associated with younger age, WHO stage III&IV at ART initiation, CD4 cell count ≤500 cells/mm 3 at switch, atazanavir based second-line ART and receiving care at a health center compared to hospital settings. Conclusions A high proportion of patients on second-line ART are doing relatively well in Rwanda and retained in care with low viral failure rates. However, enhanced understandings of adherence and adherence interventions for less healthy individuals are required. Routine viral load measurement and tracing of loss to follow-up is fundamental in resource limited settings, especially among less healthy patients.

Background & objective: The year 2014, marks an important public health anniversary. It is exactly 40 years ago that the World Health Organization (WHO) established the Expand Program Immunization (EPI). Since its launch, countries in the region of sub-Saharan Africa (SSA) have been found to be behind regarding new vaccine introduction (NVI) such as HepB, HibCV, PCV, RotaV and HPV. These vaccines have been developed in the era post EPI establishment and are currently recommended by WHO for routinely immunization for all. The objective of this review is to give an update of the status of these new vaccines introduced for routine childhood immunization in SSA since the establishment of EPI in 1974 and to identify their challenges and opportunities. Methods and findings: A systematic review including a grey literature search was conducted to identify papers reporting about the introduction of new vaccines in the routine immunization programs of SSA countries. Different databases (PubMed, ISI Knowledge Center, and AIM) and records from WHO, UNICEF, MoH, NGO and other agencies working on immunization were searched by using keywords and were limited to the articles or reports published in the last five years. Inclusion and exclusion criteria were applied to find the most relevant articles or reports for this review. The search yielded 459 papers dating from May 31st May 2009 to May 31st 2014 of which 23 (5%) were found to be relevant and included in the review analysis. We found that in the recent decade, and with the support of the several donors, the majority of SSA countries have made remarkable progress in introducing new vaccines into their NIP. HepB and HibCV vaccines have been added to all the immunization programs of 48 countries. The introduction of PCV and rotavirus vaccines has reached 66% and 41% of countries respectively. PCV-13 and monovalent rotavirus vaccines are the ones most widely used in immunization programs across SSA countries. For HPV vaccination Rwanda and South Africa completed the roll-out at national level through a schoolgirl based approach, and several other countries in SSA have started HPV demonstration projects. The implementation of school based vaccination programs in SSA countries given still lower school enrolment and attendance constitutes however a challenge. The WHO recommended immunization schedule of 6, 10, 14 weeks for infant vaccinations has been adopted by majority of SSA countries. The routine administration of birth dose monovalent HepB vaccine is currently only given in seven countries in SSA and poses a challenge as many home deliveries still occur in SSA limited access for skilled health-care providers at the time of childbirth. The GAVI Alliance has provided an opportunity for many SSA countries to procure new vaccines. Good governance is the most important factor for donors to determine the ability of SSA countries to introduce new vaccines. Countries in SSA with proactive planning benefit regarding scaling up the systems of cold chain and vaccine logistics, improveme...

BackgroundRwanda has identified several targeted HIV prevention strategies, such as promotion of condom use and provision of antiretroviral therapy (ART) and pre-exposure prophylaxis (PrEP) for female sex workers (FSWs). Given this country’s limited resources, understanding how the HIV epidemic will be affected by these strategies is crucial.MethodsWe developed a Markov model to estimate the effects of targeted strategies to FSWs on the HIV prevalence/incidence in Rwanda from 2017 to 2027. Our model consists of the six states: HIV-; HIV+ undiagnosed/diagnosed pre-ART; HIV+ diagnosed with/without ART; and death. We considered three populations: FSWs, sex clients and the general population. For the period 2017–2027, the HIV epidemic among each of these population was estimated using Rwanda’s demographic, sexual risk behaviour and HIV-associated morbidity and mortality data.ResultsBetween 2017 and 2027, with no changes in the current condom and ART use, the overall number of people living with HIV is expected to increase from 344,971 to 402,451. HIV incidence will also decrease from 1.36 to 1.20 100 person-years. By 2027, a 30% improvement in consistent condom use among FSWs will result in absolute reduction of HIV prevalence among FSWs, sex clients and the general population by 7.86%, 5.97% and 0.17%, respectively. While recurring HIV testing and improving the ART coverage mildly reduced the prevalence/incidence among FSWs and sex clients, worsening the two (shown by our worst-case scenario) will result in an increase in the HIV prevalence/incidence among FSWs and sex clients. Introduction of PrEP to FSWs in 2019 will reduce the HIV incidence among FSWs by 1.28%.ConclusionsContinued efforts toward improving condom and ART use will be critical for Rwanda to continue their HIV epidemic control. Implementing a targeted intervention strategy in PrEP for FSWs will reduce the HIV epidemic in this high-risk population.