Met and unmet palliative care needs of people living with HIV/AIDS in Rwanda

The rising number of people living with HIV/AIDS (PLWHA) worldwide has made health care professionals and policy makers search for accessible health care that will meet the needs of people who are suffering from the disease and enhance their quality of life (QoL). This study investigated met and unmet palliative care needs of PLWHA in selected areas in Rwanda. The study sample included 306 participants: PLWHA, health care professionals and coordinators of HIV/AIDS units. Quantitative and qualitative methodologies were used. The data were analysed separately and then triangulated. In the findings, over 50% of PLWHA had symptoms related to HIV/AIDS most of the time, with the most common symptom being pain. Participation in activities of daily living was significantly associated with the health status of PLWHA (p<0.001). The most common perceived palliative care needs of PLWHA were medical needs, psychosocial needs and the need for financial assistance (77%); home-based care (47%); nutritional support (44%); and pain relief and management of other symptoms (43%). Most PLWHA indicated these palliative care needs were unmet, in particular the need for pain relief, symptom management, financial assistance and nutritional support. Over 50% of health care professionals reported they were not trained in palliative care. They indicated that inadequate policy and resources were the main obstacles to the provision of optimal palliative care. Addressing unmet palliative care needs would enhance the QoL of PLWHA. In addition, developing policy related to the provision of palliative care and building the capacity of health care providers is essential for the provision of adequate palliative care services in Rwanda.     

Rwandan young people's perceptions on sexuality and relationships: Results from a qualitative study using the ‘mailbox technique’

Abstract

This study aimed to gain more insight into young Rwandans’ perceptions on sex and relationships, which is essential for formulating effective sexual and reproductive health (SRH) promotion interventions. Using a ‘mailbox technique’, this paper studies the spontaneous thoughts of Rwandan young people on sexuality. Mailboxes were installed in five secondary schools in the Bugesera district and students were invited to write about their ideas, secrets, wishes, desires and fears on sexuality and relationships. Of the 186 letters collected, 154 addressed SRH topics. The letters were analysed in NVivo 9 using a theoretical model on vulnerability. Two stereotypical sexual interactions co-exist: experimental sex, taking place unprepared, driven by desire among young people of the same age, and transactional sex, occurring after negotiation between older men/women and younger girls/boys in exchange for money or goods. Both types expose young people to poor, though different, SRH outcomes. Young people have little capacity to manage their vulnerability in these relationships: they have limited knowledge on SRH topics, lack adult guidance or support and have difficult access to condoms. They apply seemingly contradictory norms and behaviours concerning sexuality. In conclusion, we have formulated several recommendations for SRH interventions.     

卢旺达儿童疟疾406例临床分析

目的：了解中非国家卢旺达儿童疟疾现状，临床特征及治疗方法。方法：对406例确诊为疟疾的患儿流行病学特点和临床特征进行分析，对疗效进行观察。结果：全年住院患儿766例，其中疟疾患儿406例，患病率53．0％，各月疟疾患病人数间无明显差异。406例疟疾患儿学龄前303例，占74．6％；年长儿103例，占25．4％。不规则发热218例，占53．7％；稽留热109例，占26．8％；出现贫血者126例，占31．3％；有吐泻者199例，占49．0％；有呼吸道症状体征者106例，占26．1％；脾大123例，占30．3％；肝大86例，占21．2％；昏迷4例，占1．0％；死亡21例，占5．1％。406例经静脉滴注二盐酸奎宁及对症治疗5～7d，治愈385例，有效率94．8％。结论：卢旺达儿童疟疾患病率高，发病无明显季节性，恶性疟疾呈现高发病率，死亡率高。住院患儿以学龄前儿童居多，临床以不规则发热和稽留热占大多数。胃肠型、贫血和肝脾肿大发生率高，部分患儿有呼吸道症状体征是一特点，静脉用奎宁是抗疟疾治疗的主要方法。     

Ten-year clinical experience of humanitarian cardiothoracic surgery in Rwanda: Building a platform for ultimate sustainability in a resource-limited setting

Objective

Despite its near complete eradication in resource-rich countries, rheumatic heart disease remains the most common acquired cardiovascular disease in sub-Saharan Africa. With a ratio of physicians/population of 1 per 10,500, including only 4 cardiologists for a population of 11.4 million, Rwanda represents a resource-limited setting lacking the local capacity to detect and treat early cases of strep throat and perform lifesaving operations for advanced rheumatic heart disease. Humanitarian surgical outreach in this region can improve the delivery of cardiovascular care by providing sustainability through mentorship, medical expertise, training, and knowledge transfer, and ultimately the creation of a cardiac center.

Screening for human papillomavirus,cervical cytological abnormalities and associated risk factors in HIV‐positive and HIV‐negative women in Rwanda

Objectives

Cervical cancer is the major cause of death from cancer in Africa. We wanted to assess the prevalence of human papillomavirus (HPV) infections and associated risk factors and to determine whether HPV testing could serve as a screening method for squamous intraepithelial lesions (SILs) in Rwanda. We also wanted to obtain a broader understanding of the underlying risk factors for the establishment of HPV infection in Rwanda.

Methods

A total of 206 HIV‐positive women, 172 HIV‐negative women and 22 women with unknown HIV status were recruited at the University Teaching Hospitals of Kigali (UTHK) and of Butare (UTHB) in Rwanda. Participants underwent an interview, cervical sampling for a Thinprep Pap test and a screening test analysing 37 HPV strains.

Results

Only 27% of HIV‐positive women and 7% of HIV‐negative women had been screened for cervical cancer before. HPV16 and HPV52 were the most common HPV strains. HIV‐positive women were more commonly infected with high‐risk (HR) HPV and multitype HPV than HIV‐negative women. The sensitivity was 78% and the specificity 87% to detect high‐grade SIL (HSIL) with HPV screening. Among HIV‐negative women, being divorced was positively associated with HR‐HPV infection, while hepatitis B, Trichomonas vaginalis infection and HR‐HPV infection were factors positively associated with SILs. Ever having had gonorrhoea was positively associated with HR‐HPV infection among HIV‐positive women. HR‐HPV infection and the number of live births were positively associated with SILs.

Conclusions

The currently used quadrivalent vaccine may be insufficient to give satisfactory HPV coverage in Rwanda. HPV Screening may be effective to identify women at risk of developing cervical cancer, particularly if provided to high‐risk patients.

     

Delays in Breast Cancer Presentation and Diagnosis at Two Rural Cancer Referral Centers in Rwanda

Background.

Breast cancer incidence is increasing in low- and middle-income countries (LMICs). Mortality/incidence ratios in LMICs are higher than in high-income countries, likely at least in part because of delayed diagnoses leading to advanced-stage presentations. In the present study, we investigated the magnitude, impact of, and risk factors for, patient and system delays in breast cancer diagnosis in Rwanda.

Materials and Methods.

We interviewed patients with breast complaints at two rural Rwandan hospitals providing cancer care and reviewed their medical records to determine the diagnosis, diagnosis date, and breast cancer stage.

Results.

A total of 144 patients were included in our analysis. Median total delay was 15 months, and median patient and system delays were both 5 months. In multivariate analyses, patient and system delays of ≥6 months were significantly associated with more advanced-stage disease. Adjusting for other social, demographic, and clinical characteristics, a low level of education and seeing a traditional healer first were significantly associated with a longer patient delay. Having made ≥5 health facility visits before the diagnosis was significantly associated with a longer system delay. However, being from the same district as one of the two hospitals was associated with a decreased likelihood of system delay.

Conclusion.

Patients with breast cancer in Rwanda experience long patient and system delays before diagnosis; these delays increase the likelihood of more advanced-stage presentations. Educating communities and healthcare providers about breast cancer and facilitating expedited referrals could potentially reduce delays and hence mortality from breast cancer in Rwanda and similar settings.

Implications for Practice:

Breast cancer rates are increasing in low- and middle-income countries, and case fatality rates are high, in part because of delayed diagnosis and treatment. This study examined the delays experienced by patients with breast cancer at two rural Rwandan cancer facilities. Both patient delays (the interval between symptom development and the patient’s first presentation to a healthcare provider) and system delays (the interval between the first presentation and diagnosis) were long. The total delays were the longest reported in published studies. Longer delays were associated with more advanced-stage disease. These findings suggest that an opportunity exists to reduce breast cancer mortality in Rwanda by addressing barriers in the community and healthcare system to promote earlier detection.     

Profile of members and non members of mutual health insurance system in Rwanda: the case of the health district of Kabutare

The establishment of mutual health insurance systems is one of the priorities of the Rwandan government. Pilot studies have been conducted in three districts of the country. Nonetheless, after 4 years of implementation (1999-2003), the population coverage by these insurance systems remains relatively low. A cross-sectional study of 1042 households in the Kabutare health district allowed for a comparison of socio-economic and demographic variables, and the medical, surgical, gynaecological, and obstetrical history of health insurance scheme members and non-members. The results of the study demonstrate that the distribution of members and non-members is similar in terms of sex, marital status, professional status and medical history. However, larger households (more than five members) and those having a relatively higher income (more than USD 230 per annum) are more likely to be insured than other households. Members of the mutual health insurance use more the health services than non-members, spend less on health care and increasingly maintain membership. The study emphasizes the relevance to further promote mutual health insurance, but also points to the need for mechanisms to ensure financial access for the poor rural population.