CDC in Rwanda

The Centers for Disease Control and Prevention (CDC) established an office in Rwanda in 2002 to support HIV/AIDS prevention and control through the Global Aids Program and later through the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR). CDC’s support expanded in 2007 under the U.S. President’s Malaria Initiative (PMI). CDC continues to work with the government of Rwanda to build laboratory and workforce capacity, support health systems strengthening for HIV and tuberculosis, and leverage existing resources to respond to the COVID-19 pandemic and other emerging health threats.

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CDC Impact in Rwanda

Global Health Security

Countries with strong public health systems can quickly prevent, detect, and respond to infectious disease threats before they become epidemics. Rwanda began participating in the Global Health Security Agenda (GHSA) in 2015. CDC supports the Ministry of Health (MOH) with strategic planning, national outbreak preparedness, establishment of national and provincial Emergency Operations Centers (EOCs), and emergency management trainings for MOH staff.

Health Systems Strengthening

CDC supports the MOH to establish innovative and robust electronic health information systems to prevent, detect, treat, and report cases of HIV, TB, and other diseases. To increase understanding of HIV transmission, program performance, and individual health outcomes, Rwanda used data from multiple electronic systems to establish a case-based surveillance system (CBS) to identify patients during clinic visits and link health records from multiple visits and across health facilities. A digital platform for CBS is currently being tested before deployment to health facilities. Investments in electronic health information systems contribute to:

• Enhanced quality and availability of timely data for clinical decisions and evidence-based programs and policies
• Enhanced data analysis and use of strategic information
• Mentorship and continuous quality improvement that strengthens health services and programs

Laboratory Capacity

CDC supports enhanced laboratory infrastructure and workforce development. CDC also promotes local expertise in continuous quality improvement (CQI) and helps increase testing capacity to quickly deliver high-quality services. Specific to HIV, CDC works with Rwanda’s National Reference Laboratory (NRL) to coordinate the testing network and strengthen key laboratory functions including:

• Sample referral, diagnostics, and electronic information systems
• Quality management systems and strengthening laboratory management towards accreditation (SLMTA)
• External quality assurance programs, including local production, acquisition, and distribution of proficiency testing panels for HIV-related testing
• Workforce capacity strengthening in laboratory testing techniques
• Investigation and surveillance of recent HIV infection and other disease outbreaks
• Operational research, surveys, and evaluations of novel testing technologies

Since 2017, CDC has supported advanced and cost-effective HIV genotyping for routine surveillance and to monitor drug resistance in clinical settings

Since 2018, CDC supports the NRL to establish local diagnostic capabilities for Ebola and other viral hemorrhagic fevers

After achieving medical laboratory accreditation (ISO15189:2012) in 2020, Rwanda’s NRL leads local efforts to advance quality management systems throughout the laboratory network

In 2021, the Rwanda Military hospital laboratory, one of the viral load (VL) testing hubs, achieved international accreditation

With CDC support, Rwanda expanded a laboratory information system for HIV testing services to all regional VL hubs since 2017. The paperless system saves resources and increased testing coverage (from less than 80% to 90%) among people living with HIV

CDC helped strengthen local laboratory capabilities to produce and distribute proficiency testing (PT) panels to over 6,000 testers annually

CDC also established an electronic PT data management system at the NRL to monitor test performance, reporting, and feedback in real-time

Since 2018, CDC has supported introduction of HIV recency testing in Rwanda, continued supply of test kits, and training of trainers

Field Epidemiology Training Program

With CDC support, the Rwanda Field Epidemiology Training Program (FETP) trains local epidemiologists and public health leaders to use public health surveillance data to address priority public health challenges and respond to emergencies. In 2009, CDC began supporting FETP by conducting needs assessments and trainings in disease surveillance and outbreak response. CDC expanded support in 2010 to include FETP-Advanced, a two-year course that awards a master’s degree course in applied epidemiology and laboratory management. An FETP-Frontline was established in 2020.

As of July 2022, 64 trainees from six cohorts graduated from Rwanda’s Advanced FETP

182 trainees from 27 districts have completed FETP-Frontline

More than 80% of FETP-Advanced graduates work at government institutions

Since 2010, FETP residents led and supported more than 60 outbreak responses, including COVID-19, measles, cholera, malaria, epidemic typhus fever, Rift Valley fever, typhoid fever, and gastroenteritis

FETP trainees conducted more than 20 disease surveillance assessment projects and more than 60 protocol-based studies to guide prevention and control of priority diseases like HIV, TB, and malaria

COVID-19

The first case of COVID-19 was confirmed in Rwanda in March 2020. Since the pandemic was declared, CDC has provided technical and financial support to Rwanda partners for emergency management, disease surveillance, laboratory diagnostics, trainings and workforce development, outbreak response, clinical care, and vaccination. Previous CDC and MOH partnership and investments related to PEPFAR, Ebola, global health security, and laboratory systems were critical to Rwanda’s COVID-19 response. RFETP graduates are instrumental to the country’s COVID-19 response as they conduct case investigations and contact tracing, monitor home-based care, implement randomized testing events, and respond to outbreaks.

CDC supported Rwanda to leverage existing resources and systems to build a strong workforce and efficiently roll-out COVID-19 vaccines, national community-level diagnostic testing plans, and clinical care protocols

HIV and Tuberculosis (TB)

HIV and TB are two of the world’s leading causes of death. HIV and TB are interconnected, with TB ranked as the leading cause of death for people living with HIV. Through PEPFAR, CDC works with Rwanda’s MOH to:

• Strengthen clinical HIV prevention and treatment services, such as counseling and testing at government-run facilities, distribution of self-test kits, index testing, voluntary medical male circumcision, and prevention of mother-to-child transmission
• Support interventions such as pre-exposure prophylaxis (PrEP) among focus populations, including female sex workers, men who have sex with men, and adolescent girls and young women (ages 15-24)
• Scale-up of antiretroviral treatment (ART)
• Integrate TB and HIV services at MOH testing and treatment facilities
• Support TB and HIV informatics, surveillance, monitoring and evaluation, and population-based impact assessment surveys

More than 106,200 (52%) of adults and children living with HIV in Rwanda receive ART through PEPFAR

Rwanda’s national ART coverage is 92.4%, treatment retention is 92.3%, and overall viral load suppression is 91%

Successful treatment of TB increased from 58% in 2003 to 88% in 2018

In 2020, Rwanda began implementing TB preventive therapy to reduce TB and HIV coinfection and deaths among people living with HIV. As of 2022, 66% of all people living with HIV are enrolled in TB preventive therapy. The TB treatment completion rate is 94%

CDC’s implementing partners performed nearly 244,000 voluntary medical male circumcisions in 2020

Due to prevention of mother-to-child transmission, 5% of infants born to mothers living with HIV do not have HIV at 2 years of age

CDC supported the launch of the Rwanda population-based HIV impact assessment survey in 2018 to assess Rwanda’s progress toward UNAIDS 90-90-90 goals

Malaria

Malaria is a leading cause of death and disease in many countries, and young children and pregnant women are among the most affected populations. In 2007, CDC began co-implementing malaria prevention and control activities through the U.S. President’s Malaria Initiative (PMI). CDC’s PMI activities support the Rwanda MOH’s National Malaria Control Program to:

• Provide long-lasting insecticide-treated nets and antimalarial medication
• Support indoor residual spraying in districts with high malaria incidence and prevalence
• Prevent malaria in pregnancy
• Enhance malaria diagnostics, case management, and disease surveillance
• Monitor and evaluate malaria-related activities to inform decision-making

Cases of malaria in Rwanda decreased substantially from 8 million cases in 2016 to 1.2 million cases in 2021. Malaria incidence also decreased by 79% between 2016 and 2021

Severe malaria cases decreased from 18,000 cases in 2016 to less than 2,000 cases in 2021. Deaths due to malaria also decreased from 715 in 2016 to 69 in 2021

CDC/PMI helped scale-up indoor residual spraying (IRS) from 5 districts to 12 out of 15 districts with high malaria incidence and prevalence

As of 2020, 66% of households in Rwanda own at least one insecticide-treated bed net

CDC’s support led to expansion of community-based malaria case management (diagnosis and treatment). The percentage of cases treated at the community level increased from 13% in 2016 to 57% in 2021