Exploring what works in Rwanda Dr Sabin NSANZIMANA Head of HIV&AIDS, STIs & OBBI Division Institute of HIV Disease Prevention and Control RWANDA BIOMEDICAL CENTER

1.HIV program in Rwanda 2.Introduction to Sugar daddies project in Rwanda 3.Evidence from Kenya 4.Plan for piloting, evaluating and scaling in Rwanda 5.Preliminary program design details for Rwanda 6.Way forward Presentation Outline

M5 3 AIDS is Caused by HIV H H I I V V =Immunodeficiency =Human =Virus The Virus causing AIDS

M1 4 AIDS Defined A A I I D D S S =Acquired=Get HIV from someone who is infected =Immune=The body’s defense system which protects the body from disease =Deficiency=Not having enough of something =Syndrome=A group of symptoms associated with a particular disease

M1 5 Transmission

M1 6

Outline of NSP document – Strategic framework 7 B New HIV infections are reduced by 2/3 - from 6K to 2K - by June 2018 HIV related deaths are reduced by ½ from 5K to 2.5K by June 2018, and HIV morbidity is decreased PreventionCare and Treatment Impact Mitigation Health Support Systems, Coordination, and Strategic Information People infected and/or affected by HIV have the same opportunities as the general population

HIV prevalence in Rwanda is 3% Source: RDHS National Average: 3% Male: 2.3% Female: 3.6% City of Kigali 7.3% Even in Kigali, disparity of prevalence, high pockets of HIV prevalence: FSWs: 56% (BSS2010).

FSW: 51% (BSS SW 2010) Pregnant Women in Sentinel Sites: 3.3% (Sero-surveillance 2011) Youth aged Years: 1.6% ( DHS-2010) Men in uniform : 2,8% ( Rda Seroprev study, 2010) Prisoners 4,7% ( Mobile VCT, 2010) HIV Prevalence by Sex HIV Prevalence by Age Source: RDHS 2005 & RDHS 2010Source: RDHS 2010 HIV Prevalence in Other Populations: Epidemiological situation

Prevalence among population aged 15–24 years HIV among youth in Rwanda

Sugar Daddies Risk Information Program

1.Why is this program important in Rwanda? 2.Evidence from Kenya 3.Plan for piloting, evaluating and scaling in Rwanda 4.Preliminary program design details for Rwanda

Goal: Promote adolescents’ understanding of the role of cross-generational sex in the spread of HIV. Evidence : A randomized evaluation in Kenya found significant reductions in teenage childbearing as a result of the program. Why : Eliminating cross-generational sex could break transmission of HIV to youth populations – and thus end the disease. Sugar Daddies Risk Information Program

The Government of Rwanda has identified reducing cross- generational sex as critical to controlling the spread of HIV and keeping young people safe. Older men are more likely to have HIV than adolescent boys: 3.5% of year-old men have HIV in Rwanda vs. 0.3% of year-olds (Demographic and Health Survey 2010) One out of 10 girls has first sexual experience with a man ≥10 years older (Rwanda BSS 2009) Girls aged are five times more likely to have HIV than same age boys (RDHS 2010) Young girls appear to be getting infected by older men, rather than by boys of their own age (RDHS 2010) Eliminating cross-generational relationships could end HIV. Preventing Adolescent HIV: a national priority

Data source: RDHS 2010 Rwanda: HIV prevalence (%) by age & sex Preventing Adolescent HIV: a national priority (Cont’d)

Teenage childbearing in Rwanda (% of women ages who have had children or are pregnant) Data source: World Bank, World Development Indicators Teenage childbearing

Source: Rwanda Ministry of Education, In School Rapid Assessment on Unwanted Pregnancies, 2011 Unwanted pregnancies most common in s1-S3

Rwanda has made enormous strides in increasing access to education Primary school net enrollment is nearly universal, at 96% In lower secondary school, female enrollment exceeds that of males (MINEDUC Statistical Yearbook 2012) However, unintended pregnancies still cause girls to drop out of school Reducing teenage pregnancies can help young girls stay in school and improve their life outcomes. Teenage childbearing, a Barrier to Education

1.Why is this program important in Rwanda 2.Evidence from Kenya 3.Plan for piloting, evaluating and scaling in Rwanda 4.Preliminary program design details for Rwanda

Trained project officer visited schools and spoke to grade 8 students Students were shown a 10-minute educational video on “sugar daddies” An open discussion on the role of cross generational sex in the spread of HIV followed the video screening Students were given detailed information about local HIV prevalence rates, by gender and age group Evaluation: Sugar daddies campaign in Kenya J-PAL affiliated professor Pascaline Dupas (Stanford University) evaluated a “relative risk information campaign” in Kenyan primary schools

Girls reduced engagement in unprotected sex with older men » Teenage childbearing with older men fell by 61% » No offsetting increase in childbearing with same- age partners -> After the campaign, girls were more likely to use condoms with younger boys Most girls knew how HIV was spread but not that older men were much more risky Risk reduction campaigns have greater success than total risk avoidance campaigns in schools (i.e. abstinence only education) Girls responded to information on relative risk

1.Why is this program important in Rwanda 2.Evidence from Kenya 3.Plan for piloting, evaluating and scaling in Rwanda 4.Preliminary program design details for Rwanda

National priority to prevent adolescent HIV Compelling evidence from a program in East Africa shown to be effective Rwanda Biomedical Centre plans to evaluate & scale the “sugar daddies” program Plan for Piloting, Evaluating & Scaling

Phase 1: Visit a sample of schools to find out what girls already know about the relative risk of contracting HIV from older partners. Phase 2: Design the program for the Rwandan context Phase 3: A mini pilot to test the practical implementation of the program and the reaction of the community, teachers and students in order to best tailor the program to meet their needs Phase 4: Full scale randomized evaluation in several hundred schools to test impact in Rwanda Phase 5: If found to be effective, scale up to the rest of the country Plans

The Rwanda Biomedical Centre in the Ministry of Health is driving this process Imbuto Foundation have been selected as an implementing partner J-PAL will offer technical assistance in designing and implementing the pilot and evaluation. Partnerships

1.Why is this program important in Rwanda 2.Evidence from Kenya 3.Plan for piloting, evaluating and scaling in Rwanda 4.Preliminary program design details for Rwanda

Implementing in schools will reach the widest distribution of students while targeting students on the brink of making sexual decisions Holding the sessions during the school day would match the successful model from Kenya. An in-school program could target both boys and girls. The short 45 minute session including the educational video and discussion will not greatly impact class time. Implement in Lower Secondary School Students

The risk information program will be conducted during school hours by a trained facilitator. 40 minute program led by young, charismatic female facilitator To ensure an open discussion, the teacher will be asked to leave the room. Content : 10 minute video on sugar daddies Present info on the HIV rates by age and gender in that area Classroom discussion and Q&A on cross-generational sex Program Curriculum

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