2017 Rwanda

Initiation of ART treatment in Rwanda and understanding barriers to the Treat All approach

Summer 2017

Led by David Riedel, MD, MPH, School of Medicine, Institute of Human Virology

Students (school affiliation): Ilaria Caturegli (medicine) and Chelsea  McFadden (pharmacy)

Project Summary

This project was developed to examine the barriers to the new Treat All approach to HIV treatment in Rwanda. In monthly pre-departure sessions, from January through June, the students reviewed relevant literature about HIV treatment as well as the current situation of HIV care in Rwanda, which included WHO HIV Guidelines and the Rwanda National HIV Treatment Guidelines. In preparing a survey of the barriers to HIV care and stigma, the students learned about how medical, financial, and psychosocial barriers can prevent optimal implementation of HIV programs within a country.

During our trip to Rwanda, the students worked together in various inpatient and outpatient settings to assess how the implementation of the new Treat All approach to HIV care was being realized in Rwanda. We visited three health centers in Kigali (Kaguga, Avega, and Remera) and one district hospital (Kibagabaga) where we met with providers and patients and queried them about the implementation of the new treatment guidelines. We saw firsthand how barriers like transportation and lack of food impacted patients’ ability to adhere to their HIV medications. We learned about how stigma in the community drove some patients to attend clinics across the city instead of the health center located most conveniently near their home. We saw how HIV-infected students who attended boarding school might not be able to get their medications refilled on time, leaving them to skip long periods of their antiretroviral treatment. We spent time in the pharmacies at each clinic to learn how the providers (doctors and nurses) interfaced with the pharmacists. We learned how the role of pharmacists in Rwanda differed significantly from what we were accustomed to in the US. We also found that occasional stock outs in the pharmacies could also impact patient adherence to their HIV medications.

We attended a national workshop that was organized to examine how the 2015 National HIV Guidelines would be revised for 2017 and beyond. Here, we viewed firsthand the public health decision-making process as the Ministry of Health staff grappled with how to roll out newer but more expensive HIV medications to its population. This planning process brought together medical doctors, nurses, pharmacists, public health professionals, and statisticians with other national leaders and demonstrated how professionals from various backgrounds collaborate to make decisions for the good of the population and in a resource limited setting. In conclusion, this project was valuable for students to view Rwanda’s HIV treatment program at the micro/individual patient and provider level as well as the macro/public health/population level from the government’s perspective. In doing so, the students gained a better appreciation for how the professions work together at both levels.

Reflections

"It is wonderful to be able to take students from various backgrounds and different professional schools with diverse travel histories to a country where they see firsthand the barriers and successes of HIV care and treatment in a resource-limited setting. To know that this brief experience can have such a profound and lasting impact on the students’ careers and perspectives on life is extremely rewarding." - Dr. David Riedel, faculty project leader

“This trip has been a transformative journey, allowing me to explore a culture completely different from my own both in its day to day life as well as in the clinical realm.” - Ilaria Caturegli

"While visiting the hospital was one of the most difficult experiences I have had to date, I am thankful for it because I have a stronger appreciation for the healthcare system and resources I have at home. It is something that I truly cannot take for granted. I am confident that this experience at Kibagabaga Hospital while unnerving was an essential component to discovering the type of health care provider I want to be. Despite my feelings of helplessness, I am confident that experiences like these will transform me into a compassionate and innovative practitioner as both will be necessary for effectively caring for my future patients." - Chelsea McFadden

Read the 2017 Rwanda team presentation from the UMB Global Forum in October.

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