Republic of Rwanda. Republic of Rwanda. National Accelerated Plan for Women, Girls, Gender Equality & HIV

Transcription

1 Republic of Rwanda Republic of Rwanda National Accelerated Plan for Women, Girls, Gender Equality & HIV

2 02

3 Republic of Rwanda National Accelerated Plan for Women, Girls, Gender Equality & HIV SPECIAL THANKS TO OUR PARTNER INSTITUTIONS WHO CONTRIBUTED TO THE PRODUCTION OF THIS BOOK 03

4 TABLE OF CONTENTS Introduction 08 Gender Equality and HIV in Rwanda 12 National Commitment to Gender Equality 13 The HIV Response in Rwanda 13 HIV among Women and Girls in Rwanda 15 HIV Prevention 16 HIV Care and Treatment 22 Impact Mitigation of HIV 24 Factors Contributing to Women and Girls Vulnerability to HIV in Rwanda 26 Sociocultural Factors 27 Economic Factors 30 Legal Factors 31 Recommendations to Accelerate Action for Women and Girls in Rwanda 34 National Accelerated Plan 36 Background to the National Accelerated Plan 37 Strategies for Achieving Impact 38 Implementation of the National Accelerated Plan 48 Logical Framework of the National Accelerated Plan 49 Costing of the National Accelerated Plan 52 References 54 04

5 PREFACE The Government of Rwanda is committed to achieving the Millennium Development Goals and Universal Access to HIV prevention, care, treatment, and support services for all of its citizens, especially women and girls. In support of MDGs three and six to promote gender equality and combat HIV/ AIDS the government has prioritized HIV and gender throughout its guiding policies, including Rwanda Vision 2020, the Economic Development and Poverty Reduction Strategy , and the National Strategic Plan for HIV and AIDS Substantial progress towards achieving Universal Access can already be seen, particularly in our current coverage rates for PMTCT and antiretroviral therapy. In addition, the recent adoption of a National Gender Policy has cemented our commitment to protecting and promoting the rights of women and girls in the context of HIV. Nevertheless, women and girls continue to face increased risk of and vulnerability to HIV due to a range of factors, including poverty, violence, and culturally rooted discrimination. It is imperative that our policies, programs, and budgets expressly address the needs and rights of women and girls in the context of HIV. We must break the chains of gender-based violence, poverty, and gender inequalities that help the disease to spread. Effectively addressing the full range of issues related to the needs and rights of women and girls in the context of HIV requires a comprehensive response that is grounded in the experiences of women and girls and includes the active engagement of men and boys in the promotion of gender equality. The National Accelerated Plan for Women, Girls, Gender Equality and HIV is an urgent call for Rwanda s national and international partners in the HIV response to address women, girls, and gender equality in the context of HIV. Universal Access to HIV prevention, care, treatment and support services can only be achieved if greater investment is made to address the specific needs of women and girls. It is now our collective responsibility to rise to this challenge and commit the necessary resources to accelerate action for women, girls, and gender equality in the context of HIV. This plan must be adopted and implemented at once, with the full participation of all partners, women, girls, men and boys. Dr. Richard Sezibera Rwanda Minister of Health 05

6 ACKNOWLEDGEMENTS CNLS is extremely grateful to all who participated in the development of the National Accelerated Plan for Women, Girls, Gender Equality and HIV in Rwanda. This includes representatives of government institutions, civil society organizations, the One UN family, bilateral and multilateral agencies, international NGOs, and other partners who tirelessly committed their time to contribute to a participatory consultation process. Special thanks go to the CNLS Gender Team, UNAIDS, UNIFEM, the UN HIV Theme Group, and the UN Gender Task Force for their leadership and commitment shown during this process. We all share a common commitment to reduce the impact of HIV on women and girls and to improve access to comprehensive HIV prevention, care, treatment, and support services. To date, the collaboration between CNLS, the One UN Family, and implementing partners has led to substantial gains in achieving Universal Access to HIV prevention, care, treatment, and support services. The National Accelerated Plan for Women, Girls, Gender Equality and HIV is the next logical step to ensure that the particular needs and rights of women and girls are addressed in our national HIV response. We encourage all stakeholders involved in the HIV response in Rwanda to pledge their commitment to accelerating action for women and girls, by ensuring that this plan is implemented in a timely and effective manner. In addition, we call on all those involved to align their policies, programs, resources, and budgets to the activities outlined within. Dr. Anita Asiimwe Executive Secretary of CNLS 06

7 EXECUTIVE SUMMARY The National Accelerated Plan for Women, Girls, Gender Equality and HIV identifies actions to overcome the unique challenges, gaps, and barriers which increase women and girls vulnerability to and risk of HIV in Rwanda. The Government of Rwanda has made substantial progress in scaling-up access to HIV prevention, care, treatment, and support services and promoting gender equality. However, women and girls remain disproportionately impacted by the HIV epidemic, comprising 59% of adults infected with HIV. Despite an estimated HIV prevalence rate of 3% in the general population aged 14-59, women and girls experience higher prevalence rates than men at nearly every age level. This trend is particularly pronounced among young women aged 20-24, whose prevalence is five times higher than their male peers. The National Accelerated Plan (NAP) sets ambitious targets aimed at addressing the specific needs and rights of women and girls in the context of HIV. These include steps to improve Universal Access to HIV prevention, care, treatment and support services and to ensure national laws and policies protect and promote the rights of women and girls in the context of HIV. The National Accelerated Plan is closely aligned to the country s National Gender Policy and its National Strategic Plan on HIV and AIDS , which mainstreams gender equality throughout. In addition, the plan supports the achievement of the country s guiding development policies, Vision 2020 and the Economic Development and Poverty Reduction Strategy (EDPRS). The plan was created in response to the UNAIDS Action Framework: Addressing Women, Girls, Gender Equality and HIV, and developed through a national consultation process led by CNlS. The Government of Rwanda, partners involved in the HIV and/or gender response, and intended beneficiaries contributed to the identification of gaps, and barriers to addressing the specific needs and rights of women and girls in the national HIV response. Analysis was done on existing epidemiological and qualitative data, and national laws and policies specific to women, girls, and HIV. These processes led to the development and validation of the NAP in late 2010, with the involvement of stakeholders from across Rwanda. A number of guiding principles frame the development and implementation of the National Accelerated Plan. These include: promotion of human rights and gender equality; equal participation of women and girls, including women living with HIV; utilization of evidence to inform strategies; partnership among all relevant stakeholders in the HIV response; active engagement of men and boys; and strong leadership from both women and men. The plan aims to achieve three overarching impacts by 2014: 1. A tailored, evidence-based national HIV response analyzes and prioritizes the specific needs of women and girls, protects their rights in the context of HIV, and guarantees their equal access to HIV services. 2. Concrete actions, policies, and programs ensure women and girls have equal access to HIV prevention, care, treatment, and support services that address their needs and rights in the context of HIV. 3. National laws and policies protect and promote the rights of women and girls in the context of HIV, and women and girls are empowered to exercise their rights with the support of strong leadership and advocacy The achievement of these impacts requires the active participation, leadership, and support of all stakeholders involved in the HIV and/or gender response in Rwanda. All are encouraged to align their policies, programs, and budgets to the activities and strategies outlined within the National Accelerated Plan over the next four years. The implementation of the plan is estimated to cost approximately US$ 5.7 million. An estimated US$ 5.1 million will be available from the budgets of the NSA, One UN partners, and US government over the four years, leaving a gap of only US$ 588,590 to be mobilized to ensure implementation of the plan in its entirety. 07

8 01 INTRODUCTION Country Demographic and Status of the Epidemic The Republic of Rwanda is the most densely populated country in Africa. The country has an estimated population of over 9,300,000, a total fertility rate of 5.5 children, and a population density of 368 persons per square kilometer. The majority of the population resides in rural areas (86%) and is relatively young, with 65% of the total population under age 25 [Source: IDHS ]. Women and girls comprise an estimated 53% of the total population, and have a life expectancy of 53.8 years at birth, compared with 48.4 years for men. 08

9 The country remains one of the poorest in the world, with a gross domestic product (GDP) per capita of US$272. An estimated 57% of the population lives below the national poverty line and 37% live in extreme poverty. Over one-quarter of the population lives in a female-headed household (three-quarters are widows), and 60.2% of such households are poor. In 2006, vulnerable households (headed by women, widows, or children) represented 43% of all households and were concentrated in rural areas. There are approximately 1,350,800 orphans and vulnerable children aged 0-17, of which AIDS accounts for an estimated one-fifth. In 2009, there were an estimated 169,200 (146, ,400) people living with HIV in Rwanda, including about 22,000 (11,100-34,200) children [Source: EPP/Spectrum estimates, 2010]. The Rwanda Demographic and Health Survey 2005 (RDHS 2005) provides the most recent figure for HIV prevalence, estimated at 3.0% (95% confidence interval: ) in the general population aged HIV prevalence among the general population is significantly higher among women (3.6%) than among men (2.3%), and much higher in urban areas (7.3%) than in rural areas (2.2%) [Source: RDHS 2005]. Women of nearly all ages have significantly higher HIV prevalence than men, particularly in urban areas. Young women aged have a 3.9% prevalence rate in urban areas, compared to 1.1% for young men In rural areas this figure is lower, at 1% for women and 0.3% for men aged The difference is particularly striking for women and men aged 20-24, where women have a five times higher prevalence (2.5% versus 0.5%) [Source: RDHS 2005]. It is likely that a significant proportion of new infections in women occur in the context of relationships with older men. Sentinel surveillance data from pregnant women attending antenatal consultation (ANC) found an HIV prevalence of 4.3% in pregnant women (95% confidence interval: ) in The percentage of young pregnant women who are HIV infected remains high, with 3.7% prevalence among women aged 15-24, and 5.1% prevalence for women aged An overall decrease in prevalence among pregnant women has been noted since 2003, dropping from 5.2% to 4.3% HIV prevalence in However, the estimate for ANC 2007 is slightly higher than ANC 2005 (4.3% compared to 4.1%), showing no improvement in the situation in recent years. Most-at-risk populations to be infected with HIV include: commercial sex workers (59% prevalence in Kigali, BSS 2010 preliminary data); HIV serodiscordant couples (2.2% of heterosexual coupl IV sero-discordant, RDHS 2005); prisoners; truck drivers; and men who have sex with men (MSM). The highest rate of HIV prevalence is seen in Kigali city. There is low overall prevalence in the North and South provinces, but ANC data indicates increases in both. Prevalence in the East province is stable or declining for reasons unknown. The West province has the highest prevalence outside Kigali, where even rural ANC locations show HIV prevalence higher than the national average [Source: The Data Synthesis project, TRACPlus 2008]. Accelerating Action for Women, Girls, Gender Equality and HIV Women and girls are disproportionately affected by the HIV epidemic worldwide. In sub-saharan Africa, women and girls comprise 60% of all those infected with HIV, and women in Rwanda comprise 59% of infected adults., Gender inequality and human rights violations continue to put women and girls at greater risk of and vulnerability to HIV, hampering progress made in preventing HIV transmission and improving access to antiretroviral therapy. In addition to increased biological susceptibility, a number of cultural, social, economic, and legal factors contribute to women and girls vulnerability to HIV infection. In August 2009, UNAIDS launched its Action Framework: Addressing Women, Girls, Gender Equality and HIV to support achievement of Universal Access and the Millennium Development Goals. The Action Framework was developed in response to the pressing need to address persistent gender inequalities and human rights violations that put women and girls 09

10 at greater risk of and vulnerability to HIV. The Action Framework calls on governments and partners to scaleup policies and programming for women, girls, and gender equality, to support the goal of Universal Access to HIV prevention, treatment, care and support. An Operational Plan for the Action Framework was released in March 2010, to guide governments in addressing the specific needs of women, girls, and gender equality in the context of HIV at country level. The Operational Plan provides three recommendations to accelerate country action for women and girls in the three key areas: Figure 1: Key Recommendations of the UNDAIDS Action Framework Knowing, understanding and responding to the particular and various effects of the HIV epidemic on women and girls Translating political commitments into scaled-up action to address the rights and needs of women and girls in the context of HIV An enabling environment for the fulfillment of women s and girls human rights and their empowerment, in the context of HIV Jointly generate better evidence and increased understanding of the specific needs of women and girls in the context of HIV and ensure prioritized and tailored national AIDS responses that protect and promote the rights of women and girls Reinforce the translation of political commitments into scaled-up action and resources for policies and programs that address the rights and needs of women and girls in the context of HIV, with the support of all relevant partners, at the global, national, and community levels Champion leadership for an enabling environment that promotes and protects women s and girls human rights and their empowerment, in the context of HIV, through increased advocacy and capacity and adequate resources The Operational Plan calls upon to countries to develop four-year, time-bound and results-driven plans to ensure that HIV policies, programming, and budgetary allocations expressly address the needs of women and girls, and to make investments to address gender equality in the context of HIV. Countries are encouraged to root their plans in a broad-based human rights approach that reflects a number of key principles, including participation, evidenceinformed, partnership, the engagement of men and boys, leadership, and accountability. The needs, rights, and experiences of women and girls are to be incorporated and respected through women s active engagement and leadership in the development of the national plan. Creation of the National Accelerated Plan in Rwanda The release of the Agenda for Accelerated Country Action provides Rwanda with an opportunity to join its partners in the HIV response to address the specific needs of women and girls, and capitalize on the country s recent advances in both gender equality and the fight against HIV and AIDS. In June 2010, the Agenda for Accelerated Country Action was introduced to 200 participants at the 4th Partnership Forum for the Fight Against HIV and AIDS in Kigali. Since that time, the National AIDS Control Commission (CNLS), with support of the One UN Family, has engaged in developing a national plan to accelerate actions for women, girls, gender equality and HIV in Rwanda. The national plan is designed to complement Rwanda s National Gender Policy and its strategic development policies. Successful implementation of the plan will support the broader goals of the country s guiding strategy, Vision 2020, as well as the Economic Development and Poverty Reduction Strategy (EDPRS) and the National Strategic Plan on HIV and AIDS (NSP). Gender and HIV have been integrated as crosscutting issues in Vision 2020 and the EDPRS. In addition, gender is a key consideration in the country s national HIV policy. The national plan is intended to accelerate action for women, girls and gender equality in the context of HIV by addressing gaps and barriers specific to the needs and rights of women and girls. In this manner, the action plan supports the achievement of the NSP and contributes to the overall development of the country as outlined in the EDPRS and Vision 2020 (see Figure 2). 10

11 Figure 2: Alignment of the National Accelerated Plan to Rwanda s Development Strategies Rwanda s national plan was developed through a participatory process led by CNLS, with the support of the One UN Family, including the UN HIV Theme Group and the UN Gender Task Force. The first stage of development involved focus group discussions with members of CNLS and the One UN Family, followed by interviews with stakeholders involved in the HIV response, including the Ministry of Health (MOH), Ministry of Gender and Family Promotion (MIGEPROF), TRACPlus, the Rwanda Network of Associations of People Living with HIV (RRP+), and Profemmes Twese Hamwe, an umbrella organization representing over 4000 women. Additional focus group discussions and interviews were held with women living with HIV from each of the provinces, to further understand the needs of HIV-positive women and the barriers they face. During this process, gaps, barriers, and recommendations to address the needs and rights of women and girls in the national HIV response were identified. A two-day consultation workshop was convened with stakeholders involved in the HIV and/or gender response to obtain input and recommendations for accelerating action for women, girls, and gender equality in the context of HIV. The workshop, hosted by CNLS in collaboration with UNAIDS and UNIFEM, was held on the 22 and 23 of July 2010, at Sports View Hotel in Kigali. Over 100 participants from government institutions, the One UN family, multilateral and bilateral agencies, international organizations, and civil society organizations, including women s organizations and associations of women living with HIV attended. Participants in the workshop provided key recommendations to address the contributing factors to women and girls increased vulnerability to and risk of HIV infection in Rwanda. The resulting National Accelerated Plan for Women, Girls, Gender Equality and HIV , validated in a consultation meeting on 15th of October 2010, calls on all partners to prioritize the needs and rights of women and girls. The plan is human rights-based and evidence-informed, and reliant upon women and girls active participation and leadership to accelerate progress for gender equality in the context of HIV. The plan also highlights the importance of actively engaging men and boys to promote gender equality and protect the rights of women and girls. The plan is designed to intensify the impact of Rwanda s existing multisectoral, gender-sensitive development policies and HIV strategy, by guiding all stakeholders to align their programs and priorities to the needs and rights of women and girls. The National Accelerated Plan provides background evidence on Rwanda s progress towards gender equality and Universal Access to HIV prevention, care and treatment, and impact mitigation services for women and girls. The plan provides clear actions to reinforce the impact of Rwanda s HIV response on women and girls and overcome gaps and barriers in existing data, policies, and programs. The plan is designed to achieve three high-level impacts, corresponding to the three areas of focus outlined by the UNAIDS Action Framework. The achievement of each impact is supported by a set of outcomes, outputs, and activities. 11

12 02 GENDER EQUALITY & HIV IN RWANDA The ability to address the specific needs of women, girls, and gender equality in the context of HIV requires the presence of a strong national commitment to promote the rights of women and girls, a comprehensive national HIV response, and finally, the political will to integrate these two areas in a crosscutting, multisectoral response to gender and HIV. Rwanda is uniquely prepared to achieve this integration, with the existence of strong policies, institutions, and laws designed to promote both women s rights and Universal Access to HIV prevention, care, treatment and support services. The following section outlines Rwanda s key commitments and strategies in the areas of Gender Equality and HIV. The institutions and policies outlined in both sections are integral to the success of Rwanda s National Accelerated Plan for Women, Girls, Gender Equality and HIV. 12

13 National Commitment to Gender Equality Rwanda has strived to rebuild its society and institutions in a manner that respects the equal rights of all persons since the 1994 genocide, during which women and girls suffered grievous violations of their sexual and human rights. The government has taken great steps to advance gender equality and protect the rights of women and girls, alongside a culture that continues to promote male superiority. Today, Rwanda boasts the largest percentage of female parliamentarians in the world (at 56%), and has implemented a considerable number of laws and policies to promote gender equality across all sectors. The 2003 Rwandan Constitution establishes equal rights for all citizens and prohibits discrimination of any kind based on ethnic origin, tribe, clan, colour, sex, region, social origin, religion or faith, opinion, economic status, culture, language, social status, physical or mental disability or any other form of discrimination (Article 11). The Constitution further promotes equality between women and men, establishing that women are granted at least thirty percent of posts in the country s decision-making organs at all levels (Article 9). Significant effort has been made to mainstream gender equity as a crosscutting component in national development policies and strategies, including Vision 2020 and the Economic Development and Poverty Reduction Strategy (EDPRS). In addition, the government is now guided by a National Gender Policy and has established a Gender Monitoring Office to ensure that its commitment to gender equality and non-discrimination is achieved. A number of national bodies and institutions promote women and girls engagement in economic and political life, including: the Ministry of Gender and Family Promotion (MIGEPROF); the National Women s Council; the National Youth Council; the National Human Rights Commission; and the Forum for Women Parliamentarians. Women and girls active participation in these bodies has led to the adoption of laws and policies that protect and support women s rights, including a law against gender-based violence adopted in The government is also committed to the Millennium Development Goals (MDGs) and the Political Declaration on HIV and AIDS, both of which provide a strong foundation for supporting the rights of women and girls in the context of HIV. In addition, Rwanda has signed or ratified a number of international and regional instruments designed to promote and protect the rights of women and girls: the Convention on the Elimination of all forms of Discrimination Against Women (CEDAW) (see Annex 2); the Beijing Platform; the Protocol to the African Charter of Human and People s Rights on the Rights of Women in Africa; and the International Convention on the Rights of the Child. The HIV Response in Rwanda Since 2009, Rwanda has scaled-up its HIV response and aligned interventions to a new results-based National Strategic Plan on HIV and AIDS that sets ambitious targets for the provision of HIV prevention, treatment, care and support services. Rwanda has further adopted a multisectoral approach and mainstreamed HIV, like gender, throughout all public sectors in the EDPRS and Vision The country has also consolidated coordination of the HIV response and engaged all stakeholders in the fight against HIV and AIDS through the National AIDS Control Commission (CNLS). The NSP acts as a reference document for all partners in the HIV response, providing well defined impacts, outcomes and outputs, results and targets, as well as outlining the contribution of all the different stakeholders in the fight against HIV and AIDS. Three overarching results drive the NSP with regard to prevention, care and treatment, and impact mitigation by 2012: 1. To halve the incidence of HIV in the general population; 2. To reduce morbidity and mortality of people living with HIV; and 3. To ensure people infected and affected by HIV have the same opportunities as the rest of the population The adoption of an evidence-driven, results-based National Strategic Plan for HIV and AIDS reflects the Government of Rwanda s commitment to 13

14 achieving real impact that is measurable through improved health outcomes. The NSP supports the country s commitment to achieving Universal Access and the MDGs, particularly MDG 6. Together, these instruments provide a strong foundation for addressing women, girls, and gender equality in the context of HIV in Rwanda. The results outlined in the NSP cannot be achieved without improving HIV prevention, care, treatment, and support for women and girls, who constitute the majority of those impacted by HIV in Rwanda. Several overarching principles frame the NSP, including the promotion of equity and human rights, and the rights of women and girls. The plan, which is human rights-based, incorporates gender as a crosscutting component, recognizing that gender inequality is a major challenge, with women and girls commonly having less power to insist on safer sex, and with norms continuing to favor high rates of partner exchange among men. The importance of addressing barriers to gender equality, such as violence against women, access to justice for women, and problems with the current land laws, are also highlighted. As a result, several gender-specific outcomes, outputs, and results are contained within the country s guiding HIV policy. The creation of the National Accelerated Plan for Women, Girls, Gender Equality and HIV is an opportunity to accelerate action by identifying the factors, gaps, and barriers that contribute to women and girls increased vulnerability to HIV, therefore presenting a challenge to successful implementation of the NSP. Despite significant progress towards both gender equality and Universal Access, barriers to providing women and girls with prevention services, equal access to antiretroviral therapy (ART), and social, economic, and other supports continue to hamper the response. The National Accelerated Plan will help Rwanda to fulfill the mandate of the NSP , achieve Universal Access, and reach the MDGs. 14

15 03 HIV AMONG WOMEN & GIRLS IN RWANDA Women and girls are disproportionately impacted by the HIV epidemic in Rwanda. In 2008, women comprised 59% of adults infected with HIV. At nearly all age levels, women have significantly higher HIV prevalence than their male counterparts. This is particularly striking for young women aged whose 2.5% prevalence rate is five times higher than that of young men of the same age [Source: RDHS 2005]. Despite significant progress towards improving access to HIV prevention, care, treatment, and support services in recent years, the country is still far behind many of its 2012 targets where women and girls are concerned (see Figure 3). This section provides the most recent data available on the status of women and girls in the areas of HIV prevention, care and treatment, and impact mitigation, to highlight the areas where action must be accelerated for women and girls in the context of HIV. 15

16 HIV Prevention Women s access to services to prevent mother-to-child transmission (PMTCT) The provision of quality services to prevent motherto-child transmission of HIV is essential to prevent mothers from dying and babies from becoming infected with HIV. Through coordinated efforts, Rwanda has made substantial progress in scalingup the availability of PMTCT services, as well as integrating services and increasing women s attendance at antenatal consultations (ANC). By 2009, 76% of health facilities offered PMTCT services (372 out of 517), up from only 55% coverage in 2006 (234 out of 424) [Source: TRACPlus]. As a result, 68% of HIV-positive pregnant women in need of antiretrovirals (ARVs) to reduce the risk of mother-to-child transmission received them in 2009 (7,030 HIV+ women / 10,300 estimated women in need of ART). This figure represents an increase from 56% coverage in 2008 and a significant step towards the 2012 target of 90% coverage identified in the NSP In addition, two-thirds of pregnant women eligible for highly active antiretroviral therapy (HAART) during pregnancy received it in In 2009, 1,160 HIV-negative women in sero-discordant couples also received ART to prevent the transmission of HIV [Source: TRACPlus]. In 2009, 294,457 pregnant women were tested for HIV at ANC, and nearly all of those tested received their results [Source: TRACPlus]. The percentage of women being tested at ANC has risen dramatically in recent years, and there has been significant progress in promoting male involvement in PMTCT. In 2009, 84% of male partners accompanying women to ANC also agreed to be tested for HIV [Source: TRACPlus]. In addition, nearly all pregnant women reported attending at least one antenatal care visit in 2009, although less than 25% attended all four recommended visits. More children are receiving prophylaxis at birth, reaching 6,684 infants, or 86% of all notified births from HIV-positive mothers in In the same year, 70% of PMTCT sites were equipped to provide Early Infant Diagnosis of HIV (EID). However, estimates indicate that only 28% of children actually received EID in 2008 [Source: TRACPlus]. HIV screening for exposed children is currently done at 6-8 weeks and 18 months after birth. In 2009, the percentage of HIVpositive children born to known HIV-positive mothers was 4.1% at 18 months, compared to 7.1% in 2008 [Source: TRACPlus]. The NSP aims to reduce this percentage to 2% (measured at 18 months) by Women s knowledge of and access to PMTCT services can still be improved through ongoing community sensitization. In 2005, only 73% of women knew that taking drugs during pregnancy treatment could reduce mother-to-child transmission of HIV, compared with 80% of men [Source: RDHS 2005]. This figure was even lower for young women (61.6% for those aged 15-19), those with less education, and those in rural areas. In 2009, the Stigma Index found that 13.2% of HIV-positive women did not know they could take ARVs during pregnancy. The challenge for the PMTCT program is to ensure that success can be sustained and expanded to reach its target of 90% coverage by This necessitates increasing the number of: health facilities offering PMTCT; women attending ANC; pregnant women receiving HIV testing; women giving birth in health facilities; and women receiving ART to prevent mother-to-child transmission. Ensuring the quality of the treatment being provided is also important, increasing the number of PMTCT sites providing all four items from the minimum PMTCT package (currently at 73% of a target of 90% of all PMTCT sites) and integrating services, including OI and STI screening and treatment, family planning, and nutritional counseling and support [Source: TRACPlus]. Key Recommendation Scale-up efforts to increase women s knowledge of and access to PMTCT, including increasing the number of sites providing integrated PMTCT services. HIV testing and counseling among women, girls, and most-at-risk populations Ensuring that women, girls, and most-at-risk populations have access to HIV testing and counseling services is integral to HIV prevention, care, and treatment. In recent years, Rwanda has improved the availability of HIV testing, increasing the number 16

17 Figure 3: Progress Towards 2012 Targets for Women and Girls [Source: UNGASS 2010] of sites providing voluntary testing and counseling (VCT) and incorporating mobile VCT to increase access for people in rural areas. Through IEC/BCC campaigns Rwanda has also increased knowledge of and demand for HIV testing. The NSP aims for 35% of the general population aged to have received an HIV test in the past 12 months and know their results. Recent statistics show a substantial increase in HIV testing and counseling among women, particularly young women. Baseline data from 2005 indicated that only 11.6% of women aged had received an HIV test in the last 12 months and knew their results, compared with 11% of men [Source: RDHS 2005]. The rate of testing was higher among women aged (16.6%) and (12.5%). Rates were also higher among women from urban areas, and those with greater levels of education and wealth. Recent data shows an increase in the number of women and men receiving HIV testing at VCT sites. Since 2005, evidence indicates a substantial increase in the number of girls aged having received an HIV test in the past 12 months and knowing their results. In that year, only 4.8% of year old girls had received an HIV test in the last 12 months and knew their results, compared with 3.6% of boys of the same age [Source: RDHS 2005]. By 2006, this figure had reached 12.6%, and 54.8% by 2009 [Source: BSS 2006, 2009]. Although, by 2009, the number of boys aged having received an HIV test and knowing their results had reached 57.7%, surpassing that of girls. By increasing the number of health facilities offering youth-friendly services, in conjunction with ongoing HIV education, more girls and young women can be facilitated to access to VCT. Data also suggest that substantial improvements in HIV testing rates have been made among certain mostat-risk populations, including female sex workers. The BSS 2000 found that 35.9% of sex workers interviewed had received an HIV test and knew their results (at any point, not necessarily in the previous 12 months). By 2006, this figured had nearly doubled to 65.3% of sex workers having received an HIV test and knowing their results [Source: BSS 2006]. Comprehensive data for men who have sex with men (MSM) is not available. However, an exploratory study on MSM in Kigali in 2009 found that 57 out of 98 respondents had previously taken an HIV test (42 in the last 12 months), 96% of whom had obtained the results. Key Recommendation Scale-up the provision of youth-friendly services at health facilities, to facilitate girls and young women to access VCT, condoms, and family planning services. Women and girls access to and use of condoms Women and girls access to condoms and ability to negotiate their use with sexual partners is essential for effective HIV prevention. In recent years, Rwanda has accelerated condom distribution through both the public sector and social marketing. In 2009, a total of 17

18 18,312,708 condoms were distributed, a 21% increase from the previous year [Source: RHC quantification data 2009]. Female condoms accounted for only 52,290, or 0.2%, of the total number of condoms distributed. The government aims to increase the total number of male and female condoms distributed to 26 million by Cultural norms, lack of availability, and the higher cost of the female condom have limited its success and support for the product in Rwanda. However, the government is striving to make condoms geographically available and easily accessible, with male and female condoms theoretically available in all health facilities free of charge. Other distribution networks have also been utilized to distribute free condoms, including a community health basket of basic reproductive health commodities for community-based distribution. Women and girls continue to face barriers to accessing condoms, especially when compared to men. In 2005, only 37% of young women aged reported being able to obtain condoms on their own, compared to 73% of young men [Source: RDHS 2005]. The NSP aims to raise this to 60% of women aged by Several factors contribute to girls inability to access and use condoms, including long-standing stigma and cultural association between condoms and promiscuity. A school policy that prohibits condom provision in secondary schools presents another challenge, increasing girls vulnerability to HIV infection and inability to negotiate safe sex while in school. In addition, improved distribution of condoms and mass campaigns to increase societal acceptance have yet to correlate with greater condom use among both women and men. In 2005, RDHS found that only 19% of women aged reported condom use at last high-risk sexual intercourse with a non married, noncohabitating partner. This is considerably less than the 25% of men aged who reported condom use at last high-risk sexual intercourse, suggesting girls and women are at a disadvantage in both access to and use of condoms. The country has set an ambitious target of increasing this figure to 60% of women reporting use of a condom during their last high risk sexual intercourse by It is likely that stigma attached to condoms plays a strong role in reducing individuals likelihood of asking a partner to use a condom, as well as the likelihood of reporting its use. Recent successes need to be expanded to increase condom supply and societal acceptance, and ensure women and key populations, including girls and young women in secondary schools and female sex workers, have improved access to condoms. This includes advocacy among religious leaders and faith-based organizations, which operate a sizable proportion of Rwanda s health facilities, to ensure women and girls can access condoms at health facilities. In addition, stigma surrounding condom use must continue to be addressed via mass media and social campaigns, while prevention programs emphasize the importance of correct and consistent condom use. Key Recommendations Identify and address barriers to women and girls access to and use of condoms, including stigma and discrimination. Advocate against policies and practices that constrain women and girls access to condoms, e.g. prohibition of condoms in secondary schools. Prevention and behavior change among young women and girls Comprehensive prevention programs that educate and empower women and girls with sexual and reproductive health knowledge are key to reducing the sexual transmission of HIV. Sexual health education has been prioritized for youth in Rwanda, and HIV issues are increasingly being integrated into the teaching curricula. A modified behavior change strategy, called EABC has been adopted: Education, Abstinence, Be faithful, use a Condom. In addition, schools across the country have created anti-aids clubs to support education among youth. In 2008, 98% of 689 secondary schools in Rwanda had a functioning anti-aids club, with an average of 95% of schools in each district covered [Source: MINEDUC]. Delaying sexual debut for young women is an important prevention strategy. In recent years, slight improvement has been made in delaying the age of sexual debut for young women aged 15-19, especially compared to young men. The 2006 BSS found that 7% of girls aged had had sexual intercourse 18

19 before the age of 15, compared to 16% of boys. By 2009, this figure had been reduced to 6.1% of girls, compared to 14.7% of boys aged The overall percentage of youth aged who had their first sexual intercourse before the age of 15 was 9% in 2009 [Source: BSS 2009]. The same study found the average age of sexual debut among young girls to be 14 years of age. However, data indicates that young women s comprehensive knowledge of HIV transmission and prevention is declining. In 2005, 50.9% of women aged could correctly identify ways of preventing the sexual transmission of HIV and reject major misconceptions about HIV transmission [Source: RDHS 2005]. By 2009, BSS data indicate that only 10.3% of women aged could mention three methods of preventing HIV and reject two misconceptions in relation to HIV transmission. Additional data shows a decline among women aged 15-19, from 12.9% in 2006 to 9.4% in 2009 [Source: BSS 2006, 2009]. These statistics show a serious gap in girls and young women s HIV knowledge compared to the NSP target of 70% of women aged having comprehensive knowledge of HIV prevention and transmission by Also significant is that in all three studies (RDHS 2005, BSS 2006, BSS 2009) girls knowledge of HIV transmission and prevention was seen to consistently lag behind that of their male peers. Further disparities were demonstrated among those without education, from rural areas, or those from the poorest quintile [Source: BSS 2006]. Greater effort must be made to understand and address the vulnerabilities of young women to HIV infection, especially those aged Sexual and reproductive health education should prioritize improved knowledge of HIV and safe sexual practices among young women, while empowering them to better access condoms and negotiate their use. The Ministry of Education has outlined a plan of introducing girls safe spaces and clubs in at least 600 schools by 2011, to improve girls access to sexual education in a safe, conducive environment [Source: EDPRS ]. The number of schools thus far having implemented safe spaces in not yet known. Prevention programs should also ensure that young women aged have equal access to HIV testing, family planning, and STI screening and treatment and no girl be denied access to condoms because of her age. Key Recommendation Conduct study to understand the unique determinants of HIV among girls and young women aged Prevention and behavior change in mostat-risk populations Sex Workers The nature of sex work puts female sex workers at increased risk of and vulnerability to HIV infection. Stigma, discrimination, and threats of violence often make it harder to reach female sex workers with comprehensive prevention services. In Rwanda, stigma and difficulty in measuring the magnitude of the sex industry have presented challenges to effective prevention efforts targeted to sex workers. In 2009, the NSP prioritized prevention among sex workers and called for increased data on HIV prevalence and risk behavior, to enable evidence-based planning and implementation. Preliminary data from BSS 2010 indicates an HIV prevalence of 59% among female sex workers in Kigali city [Source: TRACPlus]. The study found a prevalence of 37% among those aged 15-19, 64% in year olds, and 94% for those aged Previous data suggests that 70% of sex workers in Rwanda are between the ages of 20 and 29 [Source: BSS 2006]. In 2009, a minimum of 5,028 female sex workers were identified in Rwanda, representing only those women engaged in the most easily identifiable forms of sex work (e.g. in bars, restaurants, on the street) [Source: BSS 2009]. Additional information is needed to ascertain the role transactional sex may play in HIV transmission among women and girls. In 2006, 65.3% of sex workers reported ever having had an HIV test and received their results [Source: BSS 2006]. While in 2008, PSI estimated that only 18.9% of sex workers were accessing VCT [Source: UNGASS 2008]. However, data does indicate improvements in risk behavior among female sex workers. In 2006, 86.6% of sex workers reported using a condom with their most recent client, an increase from 81.8% condom use in 2000 [Source: BSS 2006]. A slight increase was also found in comprehensive knowledge of HIV, rising from only 26.8% in 2000 to 32.6% in 2006 [Source: BSS 2000, BSS 2006]. 19

20 The NSP has set ambitious goals of reaching 60% of sex workers with prevention programs, increasing condom use to 93%, and raising comprehensive knowledge of HIV to 70% by However, substantial barriers continue to present a challenge to achieving these goals. Currently, the government is proposing to criminalize sex work through passage of Article 221 of the draft penal code. The article, currently at the level of the Senate, has the potential to halt HIV prevention, care and treatment among sex workers by discouraging implementers from working with sex workers, and driving this most-atrisk population further underground. HIV Sero-Discordant Couples Cross-generational sex and multiple concurrent relationships have been identified as contributing factors to women and girls higher rates of HIV prevalence in Rwanda. Prevention among HIV serodiscordant couples is therefore of great concern for women, who are often infected via relationships with older men. In 2005, RDHS found 2.2% of heterosexual couples in Rwanda to be HIV sero-discordant. Recent VCT data suggests this rate is higher, at 3.7% nationwide and 7.1% of cohabiting couples in Kigali city [Source: TRACPlus 2009]. The proportion of discordant couples with an HIV positive man was almost the same as that of discordant couples with an HIV positive woman. Knowledge of discordance is the key to reducing the risk of HIV infection for women and girls, enabling prevention with positives (PwP). Integrating couples voluntary testing and counseling (CVCT) into HIV services and increasing male involvement in PMTCT are important ways of reaching both partners with prevention, care, and treatment services. In 2009, approximately 84% of partners of pregnant women testing for HIV also agreed to be tested, an increase from only 52% in 2006 [Source: TRACPlus]. However, greater effort to reach discordant couples is necessary to reduce women s vulnerability to HIV infection. Reducing the number of sexual partners is also key to reducing the risk of infection. CVCT and other efforts aimed at reaching discordant couples can reduce women s vulnerability to infection, by informing male partners of the risk involved in having multiple concurrent relationships. While only 0.3% of women aged reported having sexual intercourse with more than one partner in the last 12 months in 2005, 2.7% of men aged reported doing so [Source: RDHS 2005]. Among men aged 25-49, this figure rises to 4.5%, and only 25% of those men reported using a condom during their last sexual intercourse. This is of particular concern for young women in relationships with older men, who may be unable to negotiate condom use with their partners due to economic and power differentials. Men who have Sex with Men Men who have sex with men (MSM) are a mostat-risk population for HIV infection that is also negatively impacted by stigma, gender norms, and gender inequality. In addition, many MSM report having sex with both men and women, and may act as a bridge to the general population. In 2009, Rwanda included MSM for the first time in its national HIV strategy, identifying homosexual transmission as responsible for 15% of predicted new infections [Source: NSP ]. The first behavioral study of MSM was carried out in Kigali using a snowball (non-representative) sampling strategy between The study found that MSM are at elevated risk of HIV infection, have wide sexual networks, and relatively low levels of condom use. Forty-two percent of respondents had never had an HIV test, and 34 out of 98 respondents reported never having previously used a condom with a male or female sexual partner. In addition, only one-third of respondents reporting sex with a female partner in the past 12 months used a condom during their last sexual intercourse with a female partner. MSM also reported engaging in sex work or transactional sex with both men and women, with one out of ten respondents exchanging sex for money in the previous year. Stigma, discrimination, and denial linked to strong cultural and gender norms continue to pose significant barriers to HIV prevention efforts targeted to MSM in Rwanda. The NSP aims for 60% of MSM to be reached by prevention programs by 2012, yet between 2008 and 2009, no prevention programs targeted this population. Greater evidence and understanding 20

21 of MSM is necessary to ensure this most-at-risk population has equal access to HIV prevention, care, treatment, and support services. Key Recommendations Conduct further studies to understand HIV prevalence and determinance among most-at-risk populations. Advocate against punitive laws and policies that promote stigma or hinder HIV prevention among most-at-risk populations. Prevention among survivors of gender-based violence Gender-based violence significantly increases women and girls vulnerability to and risk of HIV infection. The timely provision of HIV post-exposure prophylaxis (PEP) to survivors of GBV is integral to prevent HIV infection and ensure a comprehensive response to violence against women. In 2009, Rwanda adopted a law against gender-based violence (GBV) and recognized violence against women as a contributing factor to the spread of HIV. The government aims to ensure that all women who report a rape receive PEP to prevent HIV infection by The NSP prioritizes the prevention of HIV as a result of sexual or gender-based violence, identifying increased community awareness and strengthened referral systems between the community, police, and health facilities as key strategies to respond to GBV. The referral of women and girls experiencing GBV to health facilities is essential to ensure that PEP is administered within the required 72 hours. However, the availability of PEP remains a significant challenge to preventing HIV for women and girls experiencing GBV. In 2007, only 28% of health facilities, mainly hospitals, were equipped to provide PEP. While 95% of staff at district hospitals had access to PEP, only 27% of health center staff had access [Source: SPA 2007]. The NSP aims to increase PEP availability to 100% of all health facilities by Improving availability of PEP is essential to prevent HIV among survivors of GBV. It is important that health centers operating at the community level are equipped with PEP and the link between police, health facilities, and community leaders responsible for responding to GBV be strengthened. Referral and access to health facilities is also essential to ensure that women and girls experiencing GBV access services for the diagnosis, care and treatment of sexually transmitted infections (STIs), which can increase their vulnerability to HIV infection. In July 2009, the ISANGE One-Stop Center was opened at Kacyiru Hospital to provide a full range of services to meet the health, psychosocial, and legal needs of survivors of sexual and gender-based violence in one location. The center aims to enable a comprehensive response to GBV, linking police and health care providers in one location to overcome challenges in reporting and referral of GBV cases. The government and implementing partners are currently devising a strategy for duplication and rollout of One- Stop Centers throughout the country. Key Recommendations Scale-up the availability of HIV post-exposure prophylaxis at health facilities to prevent HIV among GBV survivors. Accelerate the creation of One-Stop Centers to enable comprehensive, integrated health, psychosocial, and legal services for GBV survivors. Integration of HIV and Family Planning services for HIV-positive women HIV care that incorporates family planning services is important for addressing the reproductive health needs of HIV-positive women and girls. In addition, integrated services should be able to address to needs of women experiencing gender-based violence. Rwanda aims to empower HIV-positive women to make informed reproductive heath decisions by integrating services and increasing male involvement in family planning (FP). Yet, in 2009, 18% of women of reproductive age attending HIV care and treatment services reported an unmet need for family planning, against a target of less than 10% by 2012 [Source: TRACPlus and FHI 2009]. Effort has been made to increase the number of health facilities offering integrated HIV and FP services, but only 30% of health facilities offered integrated FP services as part of ART in 2009 [Source: TRACPlus]. The country aims to increase this figure to 80% by A challenge to integration is that no single approach to integrated HIV and FP services currently exists. In addition, in 2009 FHI found that while over one-half of providers of HIV services in Rwanda had 21