Exploring the Perspectives of Healthcare Providers on Providing HIV Prevention and Treatment Services for Key Populations in Rwanda: A Qualitative Study
Background: The overall HIV prevalence and incidence in Rwanda have decreased significantly in the past decade. However, opposite trends are seen among key populations (KP). The HIV prevalence among sex workers is as high as 51% and continues to rise. While the HIV prevalence among KP remains high, their adherence to treatment is low. Healthcare providers play a vital role in KP’s access and adherence to HIV treatment. This study aimed to explore the perspectives of healthcare providers on providing HIV services to key populations in Rwanda. Methods: An exploratory qualitative study was conducted with nurses, doctors, social workers, and psychologists who provide HIV services to KP in public health facilities in Rwanda. In-depth interviews were conducted using a semi-structured interview guide. All data were analyzed thematically using Dedoose. Results: Interviews were conducted with 18 healthcare providers. Three overarching themes emerged from the interviews: healthcare providers’ intrinsic feelings affect the ways they provide HIV services to key populations, key populations face a multitude of challenges related to accessing treatment and preventing the spread of HIV, and a more comprehensive and sensitive approach should be used to improve HIV services for key populations. Conclusion: Healthcare providers expressed difficulties in providing services to key populations and identified a lack of adherence to treatment and prevention guidelines, structural barriers, KP’s lack of trust in the healthcare system, and the discrimination and abuse KP face as challenges to effective HIV prevention and treatment. More comprehensive services including clinical, financial, and psychosocial support from trusted sources are needed. Some important policy changes are essential to facilitate access to HIV services for KP.
References
[1]
Rwanda Biomedical Center, NISR, PEPFAR, CDC, ICAP (2020) Rwanda Population-Based HIV Impact Assessment 2018-2019.
[2]
Kayirangwa, E., Hanson, J., Munyakazi, L. and Kabeja, A. (2006) Current Trends in Rwanda’s HIV/AIDS Epidemic. Sexually Transmitted Infections, 82, i27-i31. https://doi.org/10.1136/sti.2006.019588
[3]
Rwanda Biomedical Center (2014) Rwanda Global AIDS Response Progress Report (GARPR).
[4]
Binagwaho, A., Farmer, P.E., Nsanzimana, S., et al. (2014) Rwanda 20 Years on: Investing in Life. The Lancet, 384, 371-375. https://doi.org/10.1016/S0140-6736(14)60574-2
[5]
Ministry of Health (2015) National HIV/AIDS Targets 2018-2020-2030.
[6]
Joint United Nations Program on HIV/AIDS (UNAIDS) (2020) New HIV Infections Increasingly among Key Populations. https://www.unaids.org/en/resources/presscentre/featurestories/2020/september/20200928_new-hiv-infections-increasingly-among-key-populations
[7]
Dolan, K., Kite, B., Black, E., Aceijas, C. and Stimson, G.V. (2007) HIV in Prison in Low-Income and Middle-Income Countries. The Lancet Infectious Diseases, 7, 32-41. https://doi.org/10.1016/S1473-3099(06)70685-5
[8]
Mutagoma, M., Samuel, M,S., Kayitesi, C., Gasasira, A.R., Chitou, B., Boer, K., Hedt-Gauthier, B., Gupta, N., Ntaganira, J. and Nsanzimana, S. (2017) High HIV Prevalence and Associated Risk Factors among Female Sex Workers in Rwanda. International Journal of STD & AIDS, 28, 1082-1089. https://doi.org/10.1177/0956462416688137
[9]
Ntale, R.S., Rutayisire, G., Mujyarugamba, P., Shema, E., Greatorex, J., Frost, S.D.W. and Kaleebu, P. (2019) HIV Seroprevalence, Self-Reported STIs and Associated Risk Factors among Men Who Have Sex with Men: A Cross-Sectional Study in Rwanda, 2015. Sexually Transmitted Infections, 95, 71-74. https://doi.org/10.1136/sextrans-2017-053311
[10]
Twahirwa Rwema, J.O., Lyons, C.E., Herbst, S., et al. (2020) HIV Infection and Engagement in HIV Care Cascade among Men Who Have Sex with Men and Transgender Women in Kigali, Rwanda: A Cross-Sectional Study. Journal of the International AIDS Society, 23, e25604. https://doi.org/10.1002/jia2.25604
[11]
Twahirwa Rwema, J.O., Nizeyimana, V., Menezes, N.P., et al. (2021) Injection Drug Use Practices and HIV Infection among People Who Inject Drugs in Kigali, Rwanda. https://doi.org/10.1101/2021.08.05.21261564
[12]
United States Agency for International Development (2021) Key Populations: Achieving Equitable Access to End AIDS. https://www.usaid.gov/global-health/health-areas/hiv-and-aids/technical-areas/key-populations
[13]
Joint United Nations Program on HIV/AIDS (UNAIDS) (2018) The Need to Scale up HIV Programmes for Key Populations in Western and Central Africa. https://www.unaids.org/en/resources/presscentre/featurestories/2018/december/western-and-central-africa
[14]
Macdonald, V., Verster, A. and Baggaley, R. (2017) A Call for Differentiated Approaches to Delivering HIV Services to Key Populations. Journal of the International AIDS Society, 20, 21658. https://doi.org/10.7448/IAS.20.5.21658
[15]
World Health Organization (2016) Consolidated Guidelines on HIV Prevention, Diagnosis, Treatment and Care for Key Populations, 2016 Update. World Health Organization, Geneva.
[16]
Shumbusho, F., Griensven, J., Lowrance, D., Turate, I., Weaver, M.A., Price, J. and Binagwaho, A. (2009) Task Shifting for Scale-Up of HIV Care: Evaluation of Nurse-Centered Antiretroviral Treatment at Rural Health Centers in Rwanda. PLOS Medicine, 6, e1000163. https://doi.org/10.1371/journal.pmed.1000163
[17]
Franke, M.F., Kaigamba, F., Socci, A.R., et al. (2013) Improved Retention Associated with Community-Based Accompaniment for Antiretroviral Therapy Delivery in Rural Rwanda. Clinical Infectious Diseases, 56, 1319-1326. https://doi.org/10.1093/cid/cis1193
[18]
Nsanzimana, S., Prabhu, K., McDermott, H., Karita, E., Forrest, J.I., Drobac, P., Farmer, P., Mills, E.J. and Binagwaho, A. (2015) Improving Health Outcomes through Concurrent HIV Program Scale-Up and Health System Development in Rwanda: 20 Years of Experience. BMC Medicine, 13, Article No. 216. https://doi.org/10.1186/s12916-015-0443-z
[19]
Yannessa, J.F., Reece, M. and Basta, T.B. (2008) HIV Provider Perspectives: The Impact of Stigma on Substance Abusers Living with HIV in a Rural Area of the United States. AIDS Patient Care STDs, 22, 669-675. https://doi.org/10.1089/apc.2007.0151
[20]
Mutambo, C. and Hlongwana, K. (2019) Healthcare Workers’ Perspectives on the Barriers to Providing HIV Services to Children in Sub-Saharan Africa. AIDS Research and Treatment, 2019, e8056382. https://doi.org/10.1155/2019/8056382
[21]
Ingabire, R., Parker, R., Nyombayire, J., et al. (2019) Female Sex Workers in Kigali, Rwanda: A Key Population at Risk of HIV, Sexually Transmitted Infections, and Unplanned Pregnancy. International Journal of STD & AIDS, 30, 557-568. https://doi.org/10.1177/0956462418817050
[22]
Sidibe, T., Golin, C., Turner, K., Fray, N., Fogel, C., Flynn, P., Gould, M., Knight, K. and Wohl, D. (2015) Provider Perspectives Regarding the Health Care Needs of a Key Population: HIV-Infected Prisoners After Incarceration. Journal of the Association of Nurses in AIDS Care, 26, 556-569. https://doi.org/10.1016/j.jana.2015.05.001
[23]
Bashir, F., Ba Wazir, M., Schumann, B. and Lindvall, K. (2019) The Realities of HIV Prevention. A Closer Look at Facilitators and Challenges Faced by HIV Prevention Programmes in Sudan and Yemen. Glob Health Action, 12, Article ID: 1659098. https://doi.org/10.1080/16549716.2019.1659098
[24]
Stobo, J.D., Kohen, J.J., Kimball, H.R., LaCombe, M.A., Schechter, G.P., Blank, L.L. and Members of ABIM (2001) Project Professionalism. American Board of Internal Medicine, Philadelphia.
[25]
Matovu, J.K.B., Musinguzi, G., Kiguli, J., Nuwaha, F., Mujisha, G., Musinguzi, J., Arinaitwe, J. and Wanyenze, R.K. (2019) Health Providers’ Experiences, Perceptions and Readiness to Provide HIV Services to Men Who Have Sex with Men and Female Sex Workers in Uganda—A Qualitative Study. BMC Infectious Diseases, 19, Article No. 214. https://doi.org/10.1186/s12879-019-3713-0
[26]
Health Development Initiative (2015) Can Anybody Hear Us? Exploring the Realities of Being Lesbian, Gay or Bisexual in Rwanda. Kigali.
[27]
Adedimeji, A., Sinayobye, J., Asiimwe-Kateera, B., et al. (2019) Social Contexts as Mediator of Risk Behaviors in Rwandan Men Who Have Sex with Men (MSM): Implications for HIV and STI Transmission. PLOS ONE, 14, e0211099. https://doi.org/10.1371/journal.pone.0211099
[28]
Shangani, S., Naanyu, V., Operario, D. and Genberg, B. (2018) Stigma and Healthcare-Seeking Practices of Men Who Have Sex with Men in Western Kenya: A Mixed-Methods Approach for Scale Validation. AIDS Patient Care STDs, 32, 477-486. https://doi.org/10.1089/apc.2018.0101
[29]
Maleke, K., Daniels, J., Lane, T., Struthers, H., McIntyre, J. and Coates, T. (2019) How Social Stigma Sustains the HIV Treatment Gap for MSM in Mpumalanga, South Africa. Global Health Promotion, 26, 6-13. https://doi.org/10.1177/1757975917737509
[30]
Shangani, S., Naanyu, V., Mwangi, A., Vermandere, H., Mereish, E., Obala, A., Vanden Broeck, D., Sidle, J. and Operario, D. (2017) Factors Associated with HIV Testing among Men Who Have Sex with Men in Western Kenya: A Cross-Sectional Study. International Journal of STD & AIDS, 28, 179-187. https://doi.org/10.1177/0956462416638967
[31]
King, R., Sebyala, Z., Ogwal, M., Aluzimbi, G., Apondi, R., Reynolds, S., Sullivan, P. and Hladik, W. (2020) How Men Who Have Sex with Men Experience HIV Health Services in Kampala, Uganda. BMJ Global Health, 5, e001901. https://doi.org/10.1136/bmjgh-2019-001901
[32]
Lall, P., Lim, S.H., Khairuddin, N. and Kamarulzaman, A. (2015) Review: An Urgent Need for Research on Factors Impacting Adherence to and Retention in Care among HIV-Positive Youth and Adolescents from Key Populations. Journal of the International AIDS Society, 18, 19393. https://doi.org/10.7448/IAS.18.2.19393
[33]
Ogunbajo, A., Kershaw, T., Kushwaha, S., Boakye, F., Wallace-Atiapah, N.-D. and Nelson, L.E. (2018) Barriers, Motivators, and Facilitators to Engagement in HIV Care Among HIV-Infected Ghanaian Men Who have Sex with Men (MSM). AIDS and Behavior, 22, 829-839. https://doi.org/10.1007/s10461-017-1806-6
[34]
Bowring, A.L., Ketende, S., Rao, A., et al. (2019) Characterising Unmet HIV Prevention and Treatment Needs among Young Female Sex Workers and Young Men Who Have Sex with Men in Cameroon: A Cross-Sectional Analysis. The Lancet Child & Adolescent Health, 3, 482-491. https://doi.org/10.1016/S2352-4642(19)30123-3
[35]
Henderson, M. (2016) Case Examples of Programmes Serving the Needs of Key Populations. World Health Organization, Geneva.
[36]
Camlin, C.S., Cassels, S. and Seeley, J. (2018) Bringing Population Mobility into Focus to Achieve HIV Prevention Goals. Journal of the International AIDS Society, 21, e25136. https://doi.org/10.1002/jia2.25136
[37]
van der Elst, E.M., Smith, A.D., Gichuru, E., et al. (2013) Men Who Have Sex with Men Sensitivity Training Reduces Homoprejudice and Increases Knowledge among Kenyan Healthcare Providers in Coastal Kenya. Journal of the International AIDS Society, 16, 18748. https://doi.org/10.7448/IAS.16.4.18748
[38]
Bhattacharjee, P., Musyoki, H., Prakash, R., Malaba, S., Dallabetta, G., Wheeler, T., Moses, S., Isac, S. and Steen, R. (2018) Micro-Planning at Scale with Key Populations in Kenya: Optimising Peer Educator Ratios for Programme Outreach and HIV/STI Service Utilisation. PLOS ONE, 13, e0205056. https://doi.org/10.1371/journal.pone.0205056
[39]
Yadav, A., Sakthievel, S.P., Tayyaba, S., Shah, U. and Agarwal, A. (2016) Female Sex Workers and Their Association with Self Help Groups in Thane, Maharashtra, India: A Comparative Analysis in the Context of HIV Program Outcome. The World Journal of AIDS, 6, 186-196. https://doi.org/10.4236/wja.2016.64021
[40]
Zakumumpa, H., Rujumba, J., Kwiringira, J., Kiplagat, J., Namulema, E. and Muganzi, A. (2018) Understanding the Persistence of Vertical (Stand-Alone) HIV Clinics in the Health System in Uganda: A Qualitative Synthesis of Patient and Provider Perspectives. BMC Health Services Research, 18, Article No. 690. https://doi.org/10.1186/s12913-018-3500-4
[41]
Uebel, K., Guise, A., Georgeu, D., Colvin, C. and Lewin, S. (2013) Integrating HIV Care into Nurse-Led Primary Health Care Services in South Africa: A Synthesis of Three Linked Qualitative Studies. BMC Health Services Research, 13, Article No. 171. https://doi.org/10.1186/1472-6963-13-171
[42]
Bond, V., Nomsenge, S., Mwamba, M., et al. (2019) “Being Seen” at the Clinic: Zambian and South African Health Worker Reflections on the Relationship between Health Facility Spatial Organisation and Items and HIV Stigma in 21 Health Facilities, the HPTN 071 (PopART) Study. Health & Place, 55, 87-99. https://doi.org/10.1016/j.healthplace.2018.11.006
[43]
Topp, S.M., Chipukuma, J.M., Chiko, M.M., Matongo, E., Bolton-Moore, C. and Reid, S.E. (2013) Integrating HIV Treatment with Primary Care Outpatient Services: Opportunities and Challenges from a Scaled-Up Model in Zambia. Health Policy and Planning, 28, 347-357. https://doi.org/10.1093/heapol/czs065
[44]
Dapaah, J.M. and Senah, K.A. (2016) HIV/AIDS Clients, Privacy and Confidentiality; the Case of Two Health Centres in the Ashanti Region of Ghana. BMC Medical Ethics, 17, Article No. 41. https://doi.org/10.1186/s12910-016-0123-3
[45]
Ntirenganya, E. (2020) Where Do You Fall in the New Ubudehe Categories? The New Times. https://www.newtimes.co.rw/news/where-do-you-fall-new-ubudehe-categories
[46]
Bizimungu, J. (2020) New Ubudehe Categories: What You Need to Know. The New Times. https://www.newtimes.co.rw/news/new-ubudehe-categories-what-you-need-know
[47]
Ministry of Local Government (2018) NST-1 Social Protection Sector Strategic Plan (SP-SPP) 2018/19-2023/24.
[48]
Dushimimana, M.-A. (2019) Ubudehe Categories to Be Reviewed. The New Times. https://www.newtimes.co.rw/news/ubudehe-categories-be-reviewed