Rwanda AIDS Indicator and HIV Incidence Survey 2013

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1 Ministry of Health Rwanda AIDS Indicator and HIV Incidence Survey 2013 Key Findings 1 1

2 Table of Contents INTRODUCTION... 3 SURVEY OBJECTIVES...3 METHODS USED...3 MAP OF RWANDA: SELECTED VILLAGES... 5 Survey Respondents... 6 Table 1: Distribution of respondents demographic and socio-economic characteristics by sex... 6 HIV Prevalence... 8 Table 2. HIV prevalence by demographic and socio-economic characteristics... 8 Table 3. HIV prevalence by age and sex... 9 Figure 1: HIV prevalence by age overtime [2005, 2010, 2013] Sexual Risk Behaviours Table 4: Sexual risk behaviours Table 5: HIV prevalence and consistent condom use with casual HIV Testing Table 6. Self-reported history of HIV testing and counselling Table 7. HIV testing and counselling in the last 12 months prior to the survey Table 8. Reasons for not being tested for HIV HIV and AIDS Knowledge Table 9. HIV and AIDS Comprehensive knowledge among women age 15-49* Table 10. HIV and AIDS Comprehensive knowledge among men age 15-59* Table 11. Knowledge about mother to child transmission of HIV among women age Table 12. Knowledge about mother to child transmission of HIV among men age Male Circumcision Table 13. Percentage of men aged who reported having been circumcised by socio-demographic characteristics Other Sexually Transmitted Infections (STIs) Table 14. Self-reported STI symptoms by sex and socio-demographic characteristics Table 15. Syphilis prevalence by demographic characteristics HIV Incidence Table 16. HIV incidence by socio-demographic characteristics Table 17. HIV incidence by selected risk factors

3 INTRODUCTION Three decades past since the first case of Human Immunodeficiency Virus (HIV) was reported in Rwanda. Since that time, the epidemic has been a real burden for many sectors of the country. As a response, the country, in collaboration with partners, established national programs for interventions focussing on prevention, care and treatment services. With the scale up of both HIV prevention and ART programs, HIV prevalence declines up to 3% among adults aged 15 to 49, and this remained stable for the last decade. For the first time, the Rwanda AIDS Indicator and HIV Incidence Survey (RAIHIS 2013) was conducted to better understand the dynamics of the epidemic in Rwanda. The RAIHIS 2013 was a nationally representative, population-based, HIV behavioural and serological survey. It was implemented by the Ministry of Health through Rwanda Biomedical Centre and coordinated by HIV/AIDS, STIs and Other Blood Born Infection Division. SURVEY OBJECTIVES The RAIHIS 2013 was conducted to primarily provide up-to-date estimates on the prevalence of HIV and syphilis infection and the incidence of HIV. The RAIHIS 2013 specifically collected data on knowledge, attitudes and behaviours regarding HIV/AIDS, sexual risk behaviours, sexually transmitted infections, HIV services and HIV testing results. The RAIHIS 2013 data will be used to guide strategic interventions and planning, monitoring and evaluation of HIV and AIDS programs, and to complement and calibrate the findings from the existing HIV surveillance systems, surveys and studies. METHODS USED The RAIHIS 2013 was a cross-sectional, nationally representative and population-based survey. A sample of 492 villages was selected across the country (i.e.: in all five provinces of Rwanda and in each of the 30 districts of Rwanda), 58 in urban and 434 in rural areas. The RAIHIS used a two-stage sample design where at the first stage the same sample frame of RDHS 2010 villages was used. At the second stage, households were randomly selected, after the households listing activity. A sample of 14,222 survey respondents from 6,796 households participated, including 7,419 women and 6,803 men aged and 15-59, respectively. The survey involved both individual interviews and blood sample analysis. The survey individual questionnaire used to collect data includes the following key topics: o Socio-demographic characteristics (sex, age, residence, marital status, education and religion) 3

4 o o o o o o o o o o Sexual behaviour Knowledge and attitudes towards HIV/AIDS Knowledge, attitude and use of condom Voluntary Counselling and Testing Prevention of Mother-to-Child Transmission Care and Treatment Sexually transmitted infections Male Circumcision Exposure to HIV programs Contraceptive Methods The serological components includes: o HIV testing o Syphilis testing 4

5 MAP OF RWANDA: SELECTED VILLAGES 5

6 Survey Respondents This chapter aims at providing a demographic and socioeconomic profile of the individual women and men interviewed in the 2013 Rwanda AIDS Indicator Survey (RAIS). The chapter describes basic background characteristics such as age, sex, marital status, religion, residence, and wealth status at the time of survey. Table 1: Distribution of respondents demographic and socio-economic characteristics by sex Background characteristics Weighted % Women Men Both sexes 6 Weighted N Weight ed % Weight ed N Weight ed % Weighted N Overall Age group Marital status Single Married/Cohabiting Divorced/Separated or Widowed Urban Rural Province East North South West Kigali city Education level No education Primary Vocational

7 Secondary Highest education Religion Other Catholic Protestant/Adventists Muslim Wealth index Lowest Second Middle Fourth Highest The Table 1 shows that the overall 52.2% and 47.8% women and men participated in the Rwanda AIDS Indicator Survey, respectively. It also shows no major disparities in the distribution of women and men age grouped by five-year age increments. Proportions in each age group decline with increasing age. For women, the percentages ranged from 23.8% for the age group to 7.9% for the age group For men, the percentages ranged from 22.4% for age group to 4.3% for age group The mean age of the survey participants was 29 (28 and 30 women and men, respectively). 7

8 HIV Prevalence Table 2. HIV prevalence by demographic and socio-economic characteristics Socio-demographic characteristics Women Men Both sexes %[95%CI] N %[95%CI] N %[95%CI] N Overall Urban Rural Province North South East West City of Kigali Marital Status Never married Married/Cohabiting Divorced/Separated or Widowed Education level No education Primary Vocational Secondary Higher education The overall prevalence of HIV in both sexes in Rwanda was 3.0% [95%CI: ]. It was higher among women 3.5% [95%CI: ] while it was 2.4% [95%CI: ] among men. HIV prevalence in urban areas was higher (5.6%) compared to 2.6% in rural areas. The difference in HIV prevalence by sex was also present in both urban and rural, where it was 7.2% among women in urban areas compared to 3.0% among women in rural areas. The same is for males, where 4.0% of males in urban areas tested HIV positive compared to 2.2%. HIV prevalence showed variation by provinces. It was highest in Kigali City (6.1%) and lowest in Northern Province (1.9%). The prevalence of HIV among women in Kigali (7.4% [ ]) was significantly higher compared to the observed HIV prevalence in women in other provinces. Once again, the prevalence of HIV among men in Kigali (4.8% [95%CI: ]) was significantly higher compared to the observed HIV prevalence in men in other provinces. 8

9 Table 3. HIV prevalence by age and sex Sociodemographic characteristics Age Women Men Total %[95%CI] Number %[95%CI] Number %[95%CI] Number Overall 3.5[3.1,4.1] [2.1,2.8] [2.6,3.4] [0.2,0.8] [0.2,1.0] [0.2,0.8] [1.1,2.5] [0.1,0.9] [0.7,1.5] [1.9,3.7] [0.8,2.5] [1.5,2.8] [4.7,7.5] [1.8,3.9] [3.6,5.4] [4.4,7.8] [2.4,5.8] [3.9,6.3] [6.3,11.0] [3.9,8.2] [5.7,9.1] [4.4,8.3] [4.7,10.4] [5.0,8.3] [4.0,8.8] [4.0,8.8] [2.9,8.0] [2.9,8.0] 300 The HIV prevalence observed in men was significantly different among age groups and was consistently increasing with age. This prevalence was 0.4% [95%CI: ], 2.0% [95%CI: ] and 5.3% [95%CI: ] respectively in 15-24, and 35 and more aged men. The similar significance was observed among women. The HIV prevalence was 0.7% [95%CI: ], 3.1% [95%CI: ] and 6.0% [95%CI: ] respectively in 15-24, and 35 and more aged women (Table 3). 9

10 Percent HIV Positive Figure 1: HIV prevalence by age overtime [2005, 2010, 2013] DHS DHS RAIHIS DHS 2005 DHS 2010 RAIHIS 2013 The figure above shows the HIV prevalence by age groups, as per Rwanda Demographic and Health Surveys 2005 and 2010, and Rwanda AIDS Indicator Survey The findings from both surveys overtime show that in both sexes, the prevalence of HIV was high among people aged

11 Sexual Risk Behaviours Table 4: Sexual risk behaviours Sexual activity in the last 12 months Had Commercial Had Casual sex Had Forced sex sex Overall (12.2) (1.6) 1953 (4.9) Age group (24.9) 1961 (2.4) 4157 (4.4) (11.5) 4186 (1.6) 4213 (4.0) (7.1) 4243 (1.3) (4.3) Sex Male 4954 (15.1) 4954 (1.9) 4922 (3.0) Female 5436 (9.6) 5436 (1.3) 5401 (5.6) Marital Status Never Married 1939 (41.2) 1939 (4.2) 1933 (5.6) Married/Cohabitating 7598 (4.2) 7598 (0.9) 7541 (3.9) Divorced/Separated/Widow 853 (17.6) 853 (2.6) 849 (4.9) Rural 9033 (10.9) 9033 (1.4) 8972 (4.5) Urban 1357 (20.7) 1357 (3.1) 1350 (3.0) Education level No education 1917 (7.5) 1917 (1.6) 1883 (3.3) Primary 6773 (11.3) 6773 (1.7) 6745 (4.9) Vocational 223 (12.4) 223 (0.9) 220 (3.8) Secondary 1178 (22.2) 1178 (1.6) 1175 (3.2) Higher 299 (23.7) 299 (0.8) 299 (1.9) HIV Status Negative 9911 (12.1) 9911 (1.6) 9849 (4.4) Positive 422 (14.7) 422 (3.2) 419 (3.9) The table 4 shows the sexual risk behaviours in the last 12 months. As per the table, 12.2% of the respondents had casual sex; 1.6% paid or were paid for sex, while 4.9% were forced to have sex. By age group, the results that the youth (15-24) had casual sex (24.9%) compared to other people in other age groups. By marital status, for all variables presented in the above table, the peak is observed among never married people (41.2%, 4.2% and 5.6% having casual, commercial and forced sex, respectively). 11

12 Table 5: HIV prevalence and consistent condom use with casual Socio-demographic characteristics Overall 366 (25.0) Age group (31.3) (23.8) >= (23.1) Sex Male 156 (22.9) Female 210 (26.5) Marital status Not in union 135 (29.6) In union 231 (22.3) Rural 334 (24) Urban 32 (35.2) Province East 105 (27.1) North 206 (24.7) South 12 (7.8) West 28 (31.2) Kigali City 15 (16.4) Education level No education 52 (32.1) Primary 264 (22.7) Vocational 10 (20.5) Secondary 33 (35.3) Higher education 7 (16.3) Religion Others 8 (12.3) Catholic 327 (23.3) Protestant/Adventist 16 (40.0) Muslim 15 (53.8) HIV status Negative 348 (24.7) Positive 17 (33.1) Casual sex in the last 12 months N (%) The RAIHIS 2013 collected data on condom consistent use during casual sex. The findings show that only 25% of those who had casual sex consistently used condom. Among those who tested HIV positive, the percentage was 33.1%. 12

13 HIV Testing The study collected data on the knowledge of HIV testing and counselling. Questions covered knowledge of where to get an HIV test, HIV testing status and reception of the results of the last HIV test. Table 6. Self-reported history of HIV testing and counselling Socio-demographic characteristics Know where to get an HIV test N (%) Ever had an HIV test N (%) Received Test results N (%) Overall (98.2) (82.6) (95.7) Age group (96.4) 4983 (67.2) 3350 (90.8) (99.4) 4187 (94.5) 3958 (98) (99.4) 3866 (89.6) 3462 (97.7) Sex Male 6243 (98.3) 6242 (80.2) 5007 (95.4) Female 6795 (98.1) 6794 (84.8) 5764 (95.9) Marital Status Single 5362 (96.6) 5361 (66.3) 3554 (90.5) Married & Cohabitating 6897 (99.4) 6896 (94.6) 6523 (98.3) Divorced/separated/Widow/er 779 (99.0) 779 (88.9) 693 (97.7) Urban (98.3) (82.6) 9334 (95.7) Rural 1742 (97.8) 1742 (82.5) 1436 (95.5) Province East 2031 (98.6) 2031 (82.4) 1673 (96.2) North 2990 (97.7) 2990 (80.1) 2396 (95.5) South 3179 (98.8) 3179 (83.9) 2669 (96.2) West 2926 (98.3) 2924 (84) 2455 (94.2) Kigali City 1912 (97.7) 1912 (82.5) 1578 (96.8) HIV status Negative (98.2) (82.2) (95.6) Positive 398 (100) 398 (96.7) 384 (97.8) Knowledge of where to get an HIV test is almost universal among women (95.7%) and men (98.3%). The knowledge of where to get a HIV test does not vary by province and residence. Four out five (80.2%) of men and 84.8% of women self-reported to have ever had an HIV test. This percentage is lower among youth aged (67.2%) and singles (66.3%). By marital status, the percentage is high among people in union (94.6%). For those that ever had an HIV test, an almost equal proportion of males (95.4%) and females (95.9%) received their HIV test results. The percentage is lower among young people (15-24), where 9.8% did not receive their HIV test results. The percentage is also lower among singles (90.5%). 13

14 Table 7. HIV testing and counselling in the last 12 months prior to the survey The data on HIV testing and counselling in the 12 months preceding the survey was collected. Of all males participated in the survey, 46% had an HIV test in the last 12 months; the percentage was similar among women (45.8%). However, this percentage is lower among respondents aged 35 and more (i.e.: 39.6% and 35.7% among males and females, respectively). Of those who had an HIV test in the last 12 months, more than 95% got their HIV test results. Of those who got their HIV test results, 2.7% of males and 3.1% of females self-reported being tested HIV positive. The findings showed that the self-reported HIV prevalence varies with marital status where it was 0.6% among never married, 3.1% (men) and 3.7% (women) being in union and 5.4% of men and 11.8% of women who ever been married. Socio-demographic characteristics Had an HIV test in the last 12 months Men Got the result of the last HIV test Tested HIV positive* Had an HIV test in the last 12 months Women Got the result of the last HIV test Tested HIV positive* N (%) N (%) N (%) N (%) N (%) N (%) Overall 5091 (46.0) 2340 (95.3) 2199 (2.7) 5894 (45.8) 2697 (96.3) 2559 (3.1) (50.6) 743 (89.8) 652 (0.3) 1977 (51.2) 1013 (93.9) 931 (0.6) (48.3) 895 (97.8) 871 (1.4) 2165 (48.9) 1058 (98.1) 1025 (2.6) (39.6) 701 (97.7) 676 (6.6) 1751 (35.7) 625 (97.1) 603 (7.8) Marital Status Never Married 1807 (47.0) 850 (89.8) 749 (0.6) 1837 (46.3) 851 (92.4) 772 (0.6) Married/Cohabitating 3183 (45.4) 1445 (98.4) 1406 (3.7) 3454 (47.0) 1625 (98.2) 1577 (3.1) Divorced/Separated/Widow 101 (44.2) 45 (98.2) 44 (5.4) 603 (36.7) 221 (96.7) 210 (11.8) Rural 4355 (46.3) 2015 (95.3) 1895 (2.6) 5169 (45.8) 2365 (96.5) 2247 (2.5) Urban 736 (44.2) 325 (95.0) 304 (3.5) 725 (45.7) 331 (94.9) 312 (7.4) Province East 1269 (45.0) 571 (95.3) 540 (1.6) 1429 (44.2) 632 (97.5) 609 (1.8) North 756 (47.8) 361 (96.7) 345 (1.7) 949 (48.7) 463 (94.8) 437 (1.8) South 1126 (42.1) 474 (93.8) 443 (2.1) 1317 (42.9) 565 (97.3) 544 (3.1) West 1125 (51.8) 583 (94.8) 534 (3.6) 1422 (49.7) 707 (95.1) 651 (3.6) City of Kigali 815 (43.0) 351 (96.5) 337 (4.6) 777 (42.6) 331 (96.9) 318 (6.2) Education level No education 693 (42.5) 294 (96.8) 280 (5.4) 917 (41.9) 385 (96.7) 365 (3.4) Primary 3118 (46.7) 1456 (95.7) 1378 (2.2) 3765 (46.4) 1745 (96.7) 1665 (3.5) Vocational 130 (38.6) 50 (93.7) 47 (11.5) 93 (43.4) 40 (95.7) 39 (8.8) Secondary 952 (46.8) 446 (92.1) 403 (1.7) 978 (48.4) 474 (94.0) 438 (1.3) Higher 197 (47.2) 93 (98.8) 91 (1.3) 140 (37.5) 52 (100.0) 52 (0.0) * This percentage does not only include new HIV cases in the last 12 months, rather both old and new cases 14

15 Table 8. Reasons for not being tested for HIV Reasons for not being HIV tested Socio-demographic characteristics VCT site too far away Afraid of others knowing that he/she has the AIDS virus Not necessary, confident of being HIV negative Don t want to know if I have the AIDS virus N (%) N (%) N (%) N (%) Overall 1294(5.3) 1285(3.8) 1599(79.8) 1221(3.5) Age group (5.6) 901(3.4) 1125(79.2) 869(2.2) (3) 150(3.5) 181(78.2) 131(7.2) (5.6) 234(5.7) 292(83.1) 221(6.3) Sex Male 689(4.8) 689(3.4) 846(77.4) 635(3.1) Female 605(5.9) 597(4.3) 753(82.6) 585(3.8) Marital Status Single 1006(5.3) 1002(3.3) 1253(80.1) 971(2.7) Married & Cohabitating 234(4.7) 230(4.4) 283(78.6) 197(5.7) Divorced/separated/Widow/er 54(8.1) 54(10.1) 62(81.1) 52(8.8) Urban 191(2.2) 195(6.7) 253(82.4) 192(3.8) Rural 1102(5.8) 1091(3.3) 1345(79.3) 1029(3.4) Province East 253(5.4) 250(1.9) 310(82.3) 244(1) North 294(3.4) 290(1.9) 362(81.1) 270(3.7) South 110(2) 109(4.6) 139(60.4) 80(6.5) West 391(10) 392(4.8) 474(83) 384(3.9) Kigali City 246(1.4) 245(6.1) 314(79.8) 243(4.1) HIV status Positive 9(0.0) 11(40.5) 11(56.6) 10(17.7) Negative 1273(5.3) 1262(3.5) 1574(79.9) 1199(3.3) The Rwanda AIDS Indicator survey collected reasons for not testing, among the respondents that reported never having an HIV test. Being confident of their HIV negative status was the most sighted reason for not having had an HIV test. Four out of five (79.8%) respondents that had not had an HIV test say that it was not necessary as they were confident of their negative HIV status. This was mostly cited by adults aged above 35 years (83.1%), females (82.6%), not in union (81.1% of those singles, 81.1% among the widows/separated/divorced) and those in urban areas. Only 3.8% of the respondents say that they are afraid of others knowing their HIV status. This was mainly reported by those that tested HIV positive (40.5%) and those out of Union 15

16 (Divorced/separated/Widowed) (10.1%). Also 3.5% say they do not want to know that they have the HIV virus. This was mainly reported by those aged 25 years and above, those out of union and those that tested HIV positive. 17.7% of the respondents that tested HIV positive who had not had an HIV test reported that they did not want to know that they have HIV. Only 5.3% say that the testing sites are far. This was less than 1% among those that tested HIV positive during the survey. More than half (56.6%) of respondents that tested HIV positive during the survey, who also reported never to have had an HIV test reported that they were confident of their HIV negative status. Also 17.3% said they did not want to know their HIV status. Two out of five (40.5%) of the respondents that tested HIV positive during the study cite the fear of others knowing their status as the main reason for not being tested for HIV. 16

17 HIV and AIDS Knowledge Table 9. HIV and AIDS Comprehensive knowledge among women age 15-49* Age Group Ever heard about HIV/AIDS A Healthy looking person can have the AIDS virus HIV/AIDS cannot be transmitted by mosquito bites HIV cannot be prevented through supernatural means 17 HIV can be prevented through abstinence HIV can be prevented through faithfulness HIV can be prevented through consistent condom use HIV Comprehensive knowledge HIV comprehensive knowledge without abstinence and faithfulness N (%) N (%) N (%) N (%) N (%) N (%) N (%) N (%) N (%) Overall 7690(99.2) 7594(86.3) 7608(74.6) 7605(90.3) 7597(84) 7607(67.2) 7608(87.9) 7630(31.0) 7630(53.6) (98.9) 3087(79.3) 3092(77.0) 3091(88.7) 3087(86.8) 3091(62.6) 3092(87.0) 3106(28.7) 3106(50.1) (99.6) 2418(91.7) 2423(72.4) 2423(90.7) 2418(82.5) 2423(71.9) 2423(89.9) 2428(34.1) 2428(56.5) (99.3) 2089(90.5) 2093(73.5) 2091(92.2) 2092(81.7) 2093(68.5) 2093(86.8) 2096(30.8) 2096(55.5) Marital status Single 3094(98.9) 3042(79.2) 3046(77.6) 3045(89.5) 3039(87.7) 3045(59.9) 3046(86.0) 3060(27.9) 3060(50.4) Married & Cohabitating 3874(99.4) 3838(91.1) 3844(72.5) 3843(90.7) 3840(80.5) 3844(73.4) 3844(89.2) 3851(33.1) 3851(55.7) Divorced/separated/Widow 722(99.6) 714(91.2) 718(72.7) 718(91.5) 718(87.3) 718(65.2) 718(88.6) 720(32.9) 720(55.8) Urban 946(99.6) 941(89.4) 942(82.0) 942(94.4) 940(84.5) 942(63.5) 942(87.6) 942(35.7) 942(61.6) Rural 6745(99.2) 6654(85.9) 6666(73.5) 6664(89.7) 6657(83.9) 6665(67.8) 6666(87.9) 6688(30.4) 6688(52.5) Province East 1723(99.3) 1707(87.5) 1709(75.2) 1709(92.7) 1708(88.6) 1709(68.9) 1709(90.6) 1710(35.0) 1710(57.0) North 1269(98.9) 1248(84.1) 1249(71.5) 1249(86.9) 1247(82.0) 1249(70.3) 1249(87.6) 1256(28.7) 1256(48.5) South 1933(99.2) 1908(88.4) 1908(80.1) 1907(92.9) 1905(76.3) 1907(61.0) 1908(87.9) 1918(30.9) 1918(60.2) West 1793(99.1) 1766(81.4) 1773(65.5) 1772(85.0) 1770(87.6) 1773(71.7) 1773(85.4) 1777(25.6) 1777(41.4) Kigali City 972(99.6) 965(92.2) 969(82.9) 969(95.2) 967(87.2) 969(64.3) 969(88.1) 969(37.1) 969(63.5) Education No education 1185(97.7) 1141(86.0) 1148(65.1) 1148(88.0) 1148(82.6) 1148(71.5) 1148(83.6) 1157(25.0) 1157(43.7) Primary 4932(99.4) 4886(86.2) 4891(72.6) 4889(89.4) 4886(83.9) 4890(68.0) 4891(88.9) 4904(30.5) 4904(52.5) Vocational 112(100.0) 112(95.0) 112(78.8) 112(95.9) 110(78.7) 112(58.7) 112(88.6) 112(33.2) 112(64.0) Secondary 1301(99.6) 1295(85.1) 1295(87.6) 1295(94.4) 1293(86.1) 1295(62.1) 1295(88.2) 1296(36.6) 1296(63.0) Higher education 161(100.0) 161(97.5) 161(94.8) 161(98.6) 159(85.7) 161(60.7) 161(85.1) 161(43.2) 161(76.0)

18 Religion Others 169(97.0) 160(84.8) 160(72.0) 160(90.8) 160(80.3) 160(64.0) 160(85.0) 164(29.9) 164(50.3) Catholic 3196(99.0) 3147(85.9) 3149(75.5) 3149(91.1) 3143(81.8) 3149(66.6) 3149(88.3) 3165(30.9) 3165(54.5) Protestant/Adventist 4186 (99.4) 4148(86.5) 4160 (73.6) 4157(89.5) 4155(86.0) 4158(68.0) 4160(87.6) 4163(31.1) 4163(52.6) Muslim 139(100.0) 139(92.2) 139(85.8) 139(94.8) 139(82.0) 139(63.8) 139(88.5) 139(34.3) 139(65.2) HIV status Positive 269 (100.0) 266(93.3) 267(22.5) 267 (90.5) 267 (85.3) 267 (64.4) 267 (92.5) 269 (34.5) 269 (62.5) Negative 7385 (99.2) 7292 (86.1) 7305 (25.5) 7305 (90.4) 7294 (84.0) 7304 (67.3) 7305 (87.8) 7326 (30.9) 7326 (53.4) Table 10. HIV and AIDS Comprehensive knowledge among men age 15-59* Ever heard about HIV/AIDS A Healthy looking person can have the AIDS virus HIV/AIDS cannot be transmitted by mosquito bites HIV cannot be prevented through supernatural means 18 HIV can be Prevented through abstinence HIV can be prevented through faithfulness HIV can be prevented through consistent condom use HIV Comprehensive knowledge HIV comprehensive knowledge without abstinence and faithfulness N (%) N (%) N (%) N (%) N (%) N (%) N (%) N (%) N (%) Overall 7030(99.1) 6933(89.2) 6540(73.1) 6925(92) 6924(83.5) 6825(67.9) 6836(91.2) 6968(30.8) 6968(52.6) Age group (98.6) 2650(81.4) 2495(73.0) 2645(89.7) 2645(87.3) 2575(63.7) 2604(90.9) 2669(26.7) 2669(47.6) (99.5) 2119(95.1) 2013(73.9) 2118(93.8) 2117(82.5) 2104(69.0) 2102(90.9) 2127(34.2) 2127(57.1) (99.4) 2163(93.0) 2032(72.4) 2162(93.0) 2161(79.9) 2145(72.0) 2130(91.7) 2171(32.6) 2171(54.4) Marital status Single 3204(98.7) 3141(83.8) 2958(75.4) 3136(91.4) 3135(87.2) 3062(61.6) 3090(90.5) 3161(28.5) 3161(51.2) Married/Cohabiting 3696(99.5) 3664(93.7) 3462(71) 3661(92.4) 3660(80.3) 3638(73.3) 3619(91.6) 3677(32.7) 3677(53.5) Divorced/separated/widow 130(100) 128(93.6) 120(78.4) 129(95) 129(86.1) 125(65.3) 126(94.5) 130(35.4) 130(60.2) Rural 6053(99.2) 5972(88.6) 5631(71.5) 5966(91.5) 5965(83.1) 5877(68.3) 5887(91.4) 6005(29.6) 6005(51.0) Urban 977(98.5) 960(93.0) 909(82.9) 959(95.3) 959(86.1) 949(65.7) 949(89.5) 962(38.2) 962(62.8) Province North 1085(98.9) 1061(88.7) 1002(72.1) 1060(88.6) 1061(80.1) 1048(68.6) 1045(91.7) 1073(27.2) 1073(50.0) South 1793(99.5) 1769(91.4) 1666(75.3) 1760(92.8) 1760(75.3) 1740(61.2) 1754(89.5) 1784(27.8) 1784(54.8) East 1650(99.2) 1635(89.2) 1561(73.7) 1636(94.3) 1636(88.9) 1609(70.4) 1611(92.9) 1636(35.8) 1636(55.2) West 1453(99.1) 1432(84.8) 1344(64) 1435(87.9) 1433(86.2) 1405(72.6) 1403(91.7) 1440(26.3) 1440(42.6) Kigali City 1048(98.7) 1035(92.3) 967(82.1) 1035(96.1) 1034(88.7) 1023(68.3) 1023(90.1) 1035(38.2) 1035(61.4)

19 Education level No education 934(97.6) 899(88.7) 798(59.8) 900(88.8) 899(81.8) 879(71.8) 870(91) 911(23.3) 911(39.9) Primary 4477(99.3) 4424(88.8) 4162(70.5) 4419(91) 4418(82.8) 4349(68.0) 4363(91.7) 4446(29.0) 4446(50.2) Vocational 156(100.0) 156(94.7) 153(80.9) 155(97.5) 156(76.5) 155(69.2) 156(88.7) 156(36.5) 156(63.8) Secondary 1238(99.4) 1229(89.0) 1204(86.3) 1227(95.9) 1226(88.2) 1219(65.8) 1224(89.7) 1230(38.8) 1230(64.1) Higher education 224(100) 224(98.4) 223(93.7) 224(99) 224(84.3) 224(61.9) 223(90.1) 224(49.1) 224(82.4) Religion Other 244(97.9) 235(87.0) 208(72.4) 236(92.9) 236(81.6) 229(64.3) 227(94.1) 239(28.2) 239(50.4) Catholic 3309(99.3) 3265(88.8) 3091(72.9) 3258(92.3) 3258(81.6) 3212(67.1) 3218(90.8) 3286(29.2) 3286(52.3) Protestant/Adventist 3284(99.1) 3244(89.8) 3067(72.7) 3244(91.5) 3243(85.5) 3197(69.1) 3204(91.2) 3255(32.3) 3255(52.4) Muslim 193(97.8) 188(90.1) 173(84.9) 187(94.0) 187(86.3) 187(64.6) 187(93.3) 188(36.0) 188(64.4) HIV status Positive 169(98.6) 167(94.8) 155(76.9) 167(91.3) 167(83.1) 166(68.2) 166(95) 167(34.7) 167(60.9) Negative 6809(99.1) 6714(89.1) 6336(73.1) 6707(92) 6706(83.5) 6608(67.9) 6619(91) 6750(30.7) 6750(52.4) *In the table above, the analysis of HIV comprehensive knowledge was reported with and without abstinence and faithfulness considered. The study collected information on the knowledge about HIV/AIDS. The results showed that almost all respondents (99.2% of females and 99.1% of men) have ever heard of HIV/AIDS. This knowledge was almost universal in all socio-demographic characteristics. The analysis of HIV comprehensive knowledge was presented using two definitions. The first definition refers to the knowledge that (1) a healthy looking person can have HIV, (2) that HIV/AIDS cannot be transmitted by mosquito bites, (3) that HIV cannot be prevented through supernatural means and (4) that HIV can be prevented through consistent condom use. The second definition refers to the first definition plus the knowledge that HIV can be prevented through abstinence and that HIV can be prevented through faithfulness. By using the first definition, the HIV comprehensive knowledge was 53.6% among females and 52.6% among males. Comprehensive knowledge is high in Kigali City (61.4% and 63.5%) as well as other urban areas for both males and females. Comprehensive knowledge is low in western Province (41.4% and 42.6%), among both females and males. Knowledge also varies by the education level. It increases by the increase in education level. It is lower among people with never attended the school (43.7% and 39.9%) and higher among those with higher level of education (76.0% and 82.4%) for both females and males. The increase of comprehensive knowledge of HIV in Kigali city and other cities could be due to exposure to radio and television, as per results from this survey showing that the exposure to radio and television was higher in the city of Kigali compared to other provinces. The level of misconception about HIV/AIDS is still at a noticeable level. For example, nearly one third (33%) of males and females interviewed do not agree that HIV can be prevented through faithfulness, and 23.4% of females and 22.9% of males still believe that HIV/AIDS can be transmitted by mosquito bites. 19

20 Table 11. Knowledge about mother to child transmission of HIV among women age RAIHIS 2013 collected data to assess the knowledge of the respondents (both adult males and females) about the transmission of HIV from mother to child. Comprehensive knowledge was measured by considering respondents that know all aspects of Prevention of Mother to Child Transmission (PMTCT), namely: HIV transmission from mother to child during pregnancy; Mother to child transmission during delivery; HIV can be transmitted by breastfeeding; and the knowledge that the risk of MTCT can be reduced by mother taking special drugs during pregnancy. Socio-demographic characteristics HIV can be transmitted from mother to child during pregnancy Percentage of women who know that: HIV can be transmitted from mother to child during delivery 20 HIV can be transmitted from mother to child during breastfeeding Risk of MTCT can be reduced by mother taking special drugs during pregnancy PMTCT comprehensive knowledge* N (%) N (%) N (%) N (%) N (%) Overall 7367(46.2) 7559(85.8) 7608(88.9) 7608(83.6) 7630(34.8) Age (48.5) 3071 (82.9) 3092 (88.4) 3092 (80.0) 3092 (35.2) (45.2) 2411 (87.7) 2423 (89.7) 2423 (86.8) 2423 (34.9) (44.0) 2078 (88.0) 2093 (88.6) 2093 (85.0) 2093 (34.4) Marital status Single 2957 (47.8) 3021 (82.1) 3046 (87.4) 3046 (79.3) 3046 (34.2) Married & Cohabitating 3710 (45.5) 3825 (88.3) 3844 (90.3) 3844 (86.4) 3844 (35.4) Divorced/ separated/ Widow 701 (43.1) 713 (88.1) 718 (88.1) 718 (86.4) 718 (34.7) Urban 6457 (46.5) 6625 (85.3) 6666 (88.8) 6666 (83.2) 6666 (34.9) Rural 910 (44.5) 934 (89.4) 942 (89.8) 942 (86.4) 942 (34.9) Province East 1652 (41.3) 1704 (90.9) 1709 (86.9) 1709 (89.2) 1709 (33.0) North 1208 (52.3) 1239 (83.6) 1249 (89.9) 1249 (81.9) 1249 (39.5) South 1853 (45.8) 1900 (77.6) 1908 (89.1) 1908 (75.4) 1908 (30.2) West 1727 (49.5) 1754 (87.6) 1773 (89.4) 1773 (84.4) 1773 (39.0) Kigali City 927 (41.7) 963 (92.8) 969 (89.8) 969 (90.3) 969 (34.0) Education No education 1116 (45.7) 1140 (83.0) 1148 (84.4) 1148 (81.7) 1148 (35.0) Primary 4730 (46.8) 4860 (84.8) 4891 (88.8) 4891 (83.2) 4891 (34.6) Vocational 108 (36.8) 111 (84.8) 112 (85.9) 112 (78.0) 112 (28.5) Secondary 1256 (45.7) 1288 (91.4) 1295 (93.1) 1295 (85.9) 1295 (35.9) Higher education 157 (43.1) 161 (92.8) 161 (92.1) 161 (93.2) 161 (38.2) HIV status Negative 7073 (45.8) 7259 (85.6) 7305 (88.8) 7305 (83.2) 7305 (34.5) Positive 259 (54.5) 264 (91.1) 267 (93.5) 267 (91.7) 267 (44.3) Pregnancy Not currently pregnant 3743 (44.8) 3851 (90.4) 3869 (89.5) 3869 (88.4) 3869 (36.3) Currently pregnant 429 (46.4) 449 (90.3) 451 (92.4) 451 (88.4) 451 (35.1)

21 The findings presented in the above table show that, among females aged 15-49, comprehensive knowledge about prevention of mother to child transmission was low. Only 34.8% of them have comprehensive knowledge about HIV transmission from mother to child. Only 46.2% of the women know that HIV transmission can happen during pregnancy, while the knowledge about other aspects of MTCT was high. The same trend is observed across all social demographics. The survey also assessed the PMTCT knowledge according to the HIV status. The results show that 44.3% of women that tested HIV positive during the survey had comprehensive knowledge about PMTCT, compared to 34.5% for those that tested HIV negative. Also among women who were currently pregnant during the time of the survey, only 35.1% of them had comprehensive knowledge about PMTCT. About the special drugs that mothers can take during pregnancy to reduce risk of MTCT, 83.6% of women interviewed knew their existence. This was low among those single during the survey (79.3%) compared to those that were in union (86.4%). 91.7% of women who tested HIV positive during the survey knew existence of the special drugs. Table 12. Knowledge about mother to child transmission of HIV among men age Knowledge about PMTCT among men was collected during Rwanda AIDS Indicator Survey The results show that comprehensive knowledge about PMTCT among men is also low. Only 28.2% of males interviewed had comprehensive knowledge. The knowledge does not show much variation by age, marital status and place of residence. It is slight lower among males who were HIV positive compared to those who were negative. Socio-demographic characteristics HIV transmission from mother to child during pregnancy 21 Percentage of men who know that: Mother to child transmission during delivery HIV can be transmitted by breastfeeding Risk of MTCT can be reduced by mother taking special drugs during pregnancy PMTCT comprehensive knowledge* N (%) N (%) N (%) N (%) N (%) Overall 6741 (39.3) 6889 (83.3) 6939 (84.4) 6939 (80.2) 6939 (28.2) Age (41.8) 2633 (79.1) 2654 (83.1) 2654 (76.8) 2654 (28.1) (37.8) 2107 (87.9) 2120 (87.8) 2120 (83.8) 2120 (29.3) (37.6) 2148 (83.9) 2164 (82.8) 2164 (80.8) 2164 (27.4) Marital status Single 3051 (40.5) 3122 (80.5) 3145 (83.0) 3145 (76.4) 3145 (27.2)

22 Married & Cohabitating 3564 (38.3) 3639 (85.8) 3665 (86.0) 3665 (83.4) 3665 (29.2) Divorced/ separated/ Widow/er 127 (38.3) 128 (79.5) 129 (75.9) 129 (80.7) 129 (27.6) Urban 5810 (39.8) 5938 (82.5) 5978 (84.3) 5978 (79.6) 5978 (28.6) Rural 931 (35.7) 951 (88.4) 960 (85.2) 960 (83.8) 960 (26.2) Province East 1590 (36.1) 1626 (87.6) 1636 (82.3) 1636 (84.6) 1636 (26.8) North 1036 (43.4) 1057 (82.6) 1062 (87.0) 1062 (78.8) 1062 (32.6) South 1744 (38.3) 1762 (74.8) 1771 (85.0) 1771 (70.5) 1771 (24.6) West 1380 (44.0) 1414 (84.2) 1435 (85.8) 1435 (83.0) 1435 (32.1) Kigali City 992 (35.2) 1030 (90.4) 1035 (82.4) 1035 (87.2) 1035 (27.0) Education No education 880 (41.7) 896 (77.4) 900 (79.0) 900 (75.6) 900 (29.7) Primary 4317 (38.3) 4390 (81.2) 4429 (84.6) 4429 (79.0) 4429 (27.1) Vocational 148 (37.7) 156 (88.7) 156 (85.3) 156 (85.6) 156 (24.0) Secondary 1179 (42.0) 1224 (91.9) 1229 (86.9) 1229 (86.3) 1229 (31.6) Higher education 217 (35.6) 223 (95.9) 224 (88.2) 224 (83.3) 224 (29.0) HIV status Negative 6529 (39.2) 6672 (83.2) 6721 (84.5) 6721 (80.1) 6721 (28.3) Positive 161 (38.3) 166 (84.8) 167 (82.5) 167 (84.3) 167 (25.4) The knowledge on prevention of mother to child transmission was likely being higher in respondents from our survey compared to respondents in Ugandan and Tanzania surveys. For example, women knowing that taking special drugs during pregnancy can reduce HIV transmission from the mother to the child was 72.8% among women in Uganda and was 62.9% among men respondents from Ugandan survey [2]. In respondents from Tanzanian survey, this percentage was 68.1% and 63.0% respectively for women and for men [3]. 22

23 Male Circumcision Table 13. Percentage of men aged who reported having been circumcised by sociodemographic characteristics. socio-demographics characteristics Practice of circumcision Circumcised Circumcision performed by health professional N (%) N (%) Overall 6766(20.2) 1369(80.5) Age group (21.3) 559 (80.5) (24.2) 497 (83.9) (14.9) 313 (75.3) Marital Status Single 3090 (25.4) 786 (81.9) Married & Cohabitating 3549 (15.8) 562 (79.5) Divorced/separated/Widow/er 127 (16.7) 21 (55.4) Urban 953 (49.0) 467 (79.6) Rural 5813 (15.5) 903 (81.0) Province East 1643 (17.5) 287 (77.7) North 1023 (8.6) 88 (90.7) South 1651 (7.9) 131 (90.3) West 1409 (27.3) 388 (77.9) Kigali City 1041 (45.7) 476 (79.7) Religion Others 238 (21.7) 51 (72.2) Catholic 3153 (16.4) 522 (83.0) Protestant / Adventist 3188 (20.6) 653 (84.2) Muslim 187 (76.8) 144 (57.7) HIV status Positive 165 (22.0) 36 (52.9) Negative 6554 (19.8) 1301 (81.4) Male circumcision is a common practice in Africa for traditional and religious reasons. Male circumcision is recommended by WHO as one of HIV prevention methods. The Rwanda AIDS Indicator Survey 2013 collected data on prevalence of circumcision among male respondents, age at circumcision, type of practitioner who performed the procedure and their knowledge of male circumcision in risk reduction of HIV infection. The table xx shows that one fifth of Rwandan men age (20%) are circumcised, an increase of 7%, according to RDHS 2010 (13%). 23

24 The prevalence of male circumcision varies according to the respondents background characteristics. The highest percentage (27%) was observed in aged. The percentage of circumcised was 25% among singles. The percentage of circumcised was 31% among respondents from urban residence and it was 14% among respondents from rural residence. The city of Kigali had the highest prevalence of male circumcision (45%), followed by the West Province (27%). As expected, Muslim believers had the highest prevalence of male circumcision (76%) compared to other religions, Catholic Church members had the lowest prevalence (16%). 24

25 Other Sexually Transmitted Infections (STIs) Table 14. Self-reported STI symptoms by sex and socio-demographic characteristics Any STI N (%) Women Ever had genital ulcer/sore during the past 12 months Ever had abnormal genital discharge during the past 12 months Any STI Men Ever had genital ulcer/sore during the past 12 months Ever had abnormal genital discharge during the past 12 months N (%) N (%) N (%) N (%) N (%) Overall 7566(10.9) 7567(8.5) 7612(5.3) 6907(9.1) 6907(8.1) 6959(3) Age group (7.6) 3077(5.8) 3103(3.7) 2634(6.3) 2634(5.3) 2668(2.9) (12.1) 2415(9.7) 2423(5.4) 2113(10.2) 2114(9.2) 2122(3.3) >= (14.4) 2075(11.0) 2085(7.6) 2160(11.4) 2159(10.6) 2170(2.9) Marital Status Single 3023(7.3) 3024(5.3) 3053(3.9) 3114(6.2) 3113(5.0) 3155(3.2) Married/Cohabitating 3833(13.3) 3833(10.6) 3842(5.9) 3665(11.5) 3665(10.8) 3676(3.0) Divorced/Separated/Widower 710(13.3) 710(10.7) 717(8.1) 129(9.9) 129(9.9) 129(2.0) Urban 931(10.2) 931(8.3) 925(4.5) 951(6.0) 951(5.8) 954(1.4) Rural 6636(11) 6636(8.5) 6687(5.4) 5956(9.6) 5956(8.5) 6006(3.3) Province North 1708(8.2) 1708(6.0) 1708(4.5) 1636(6.0) 1636(4.7) 1636(2.1) South 1249(9.4) 1249(7.6) 1269(5.1) 1067(10.9) 1067(9.8) 1092(4.4) East 1873(16.5) 1873(14.1) 1897(5.9) 1740(14.5) 1739(13.8) 1769(3.4) West 1768(9.6) 1768(6.1) 1768(6.2) 1431(6.5) 1431(5.6) 1429(3.4) City of Kigali 969(9.1) 969(7.6) 969(4.4) 1033(6.4) 1033(6.0) 1035(2.0) HIV status Positive 263(20.8) 263(16.9) 265(11.8) 166(18.2) 166(16.9) 167(6.6) Negative 7268(10.5) 7269(8.2) 7311(5.0) 6690(8.8) 6691(7.9) 6741(2.9) The study-collected information on self-reported STIs, defined, as ever had a genital ulcer/sore or abnormal genital discharge in the last 12 months. The overall prevalence of STIs among women was 10.9% [95% CI: 9.8% %] and 9.9% [95% CI: 7.7% -12.7%] among men. Self-reported STIs prevalence increased with age. The highest prevalence was reported was 15.1% and 12.2% among women and men aged respectively. 25

26 The population of southern province reported a prevalence of 16.5% in women and 14.6% in men. The occurrence of any self-reported STI was higher among the respondents in Union (Married/Cohabiting) and those out of the union than those that were single. They are also higher in rural than in urban areas. The occurrence of genital ulcer or sore was high compared to abnormal genital discharge 8.5% [95% CI: 7.5% - 9.6%] versus 5.3% [95% CI: 4.5% - 6.2%] among women and 9.3% [95% CI: 7.2% %] versus 2.8% [95% CI: 1.8% -4.5%] among men. The occurrence of any STI was however higher among the respondents that tested HIV positive (20.8% among females and 18.2% among males) compared to those that tested negative (10.5% for females and 8.8% among males). 26

27 Table 15. Syphilis prevalence by demographic characteristics Background characteristics Women Men Both sexes Overall 7678 (1.0 ) 7013 (0.8) (0.9) Age group (0.8) 2710 (0.5) 5843 (0.6) (1.2) 2124 (1.0) 4562 (1.1) (1.1) 2179 (0.9) 4286 (1.0) Marital status Single 3089 (0.5) 3191 (0.6) 6281 (0.5) Married/Cohabiting 3868 (1.0) 3693 (1.0) 7561 (1.0) Divorced/separated/widow 721 (2.9) 129 (0.0) 849 (2.5) Province North 1269 (0.1) 1091 (0.4) 2360 (0.2) South 1938 (0.8) 1800 (0.9) 3738 (0.8) East 1720 (1.2) 1646 (0.8) 3367 (1.0) West 1794 (1.5) 1465 (0.6) 3260 (1.1) City of Kigali 956 (1.3) 1011 (1.2) 1967 (1.3) Urban 934 (1.3) 953 (0.9) 1887 (1.1) Rural 6744 (0.9) 6060 (0.7) (0.9) HIV Status Positive 271 (5.9) 169 (3.2) 440 (4.8) Negative 7407 (0.8) 6844 (0.7) (0.8) The overall prevalence of syphilis among both sexes was 0.9% (1.0% among females and 0.8% among males). The percentage was found to be high among people who were out of union (2.5%) and those who were tested HIV positive (4.8%) at the time of the survey. The lowest percentage was found in Northern Province (0.2%). 27

28 HIV Incidence Table 16. HIV incidence by socio-demographic characteristics HIV incidence by socio-demographic characteristics Characteristics N % Overall Age group Sex Male Female Marital status Single Married Cohabiting Divorced Widow/er Rural Urban

29 Table 17. HIV incidence by selected risk factors Risk Factors N % Overall Had paying sex in the last 12 months No Yes Experienced rape/forced sex in the last 12 months* No Yes Circumcision status* Not circumcised Circumcised Had STIs during last 12 months No Yes Currently pregnant* No Yes * Do not add up to N due to filters 29

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