BackgroundGeneralizable data are needed on the magnitude and determinants of adherence and virological suppression among patients on antiretroviral therapy (ART) in Africa.MethodsWe conducted a cross-sectional survey with chart abstraction, patient interviews and site assessments in a nationally representative sample of adults on ART for 6, 12 and 18 months at 20 sites in Rwanda. Adherence was assessed using 3- and 30-day patient recall. A systematically selected sub-sample had viral load (VL) measurements. Multivariable logistic regression examined predictors of non-perfect (<100%) 30-day adherence and detectable VL (>40 copies/ml).ResultsOverall, 1,417 adults were interviewed and 837 had VL measures. Ninety-four percent and 78% reported perfect adherence for the last 3 and 30 days, respectively. Eighty-three percent had undetectable VL. In adjusted models, characteristics independently associated with higher odds of non-perfect 30-day adherence were: being on ART for 18 months (vs. 6 months); younger age; reporting severe (vs. no or few) side effects in the prior 30 days; having no documentation of CD4 cell count at ART initiation (vs. having a CD4 cell count of <200 cells/µL); alcohol use; and attending sites which initiated ART services in 2003–2004 and 2005 (vs. 2006–2007); sites with ≥600 (vs. <600 patients) on ART; or sites with peer educators. Participation in an association for people living with HIV/AIDS; and receiving care at sites which regularly conduct home-visits were independently associated with lower odds of non-adherence. Higher odds of having a detectable VL were observed among patients at sites with peer educators. Being female; participating in an association for PLWHA; and using a reminder tool were independently associated with lower odds of having detectable VL.ConclusionsHigh levels of adherence and viral suppression were observed in the Rwandan national ART program, and associated with potentially modifiable factors.

It is increasingly clear that resolution of complex global health problems requires interdisciplinary, intersectoral expertise and cooperation from governmental, non-governmental and educational agencies. ‘One Health’ refers to the collaboration of multiple disciplines and sectors working locally, nationally and globally to attain optimal health for people, animals and the environment. One Health offers the opportunity to acknowledge shared interests, set common goals, and drive toward team work to benefit the overall health of a nation. As in most countries, the health of Rwanda's people and economy are highly dependent on the health of the environment. Recently, Rwanda has developed a One Health strategic plan to meet its human, animal and environmental health challenges. This approach drives innovations that are important to solve both acute and chronic health problems and offers synergy across systems, resulting in improved communication, evidence-based solutions, development of a new generation of systems-thinkers, improved surveillance, decreased lag time in response, and improved health and economic savings. Several factors have enabled the One Health movement in Rwanda including an elaborate network of community health workers, existing rapid response teams, international academic partnerships willing to look more broadly than at a single disease or population, and relative equity between female and male health professionals. Barriers to implementing this strategy include competition over budget, poor communication, and the need for improved technology. Given the interconnectedness of our global community, it may be time for countries and their neighbours to follow Rwanda's lead and consider incorporating One Health principles into their national strategic health plans.

No abstract

Background: The paper examines external multiple job holding practices in public health training institutions based in prominent public universities in three sub-Saharan Africa countries (Rwanda, Ethiopia, Mozambique). Objective: The study aims to contribute to broadening understanding about multiple job holding (nature and scale, drivers and reasons, impact, and efforts to regulate) in public health training schools in public universities. Methods: A qualitative multiple case study approach was used. Data were collected through document reviews and in-depth interviews with 18 key informants. Data were then triangulated and analyzed thematically. Results: External multiple job holding practices among faculty of the three public health training institutions were widely prevalent. Different factors at individual, institutional, and national levels were reported to underlie and mediate the practice. While it evidently contributes to increasing income of academics, which many described as enabling their continuing employment in the public sector, many pointed to the negative effects as well. Similarities were found regarding the nature and drivers of the practice across the institutions, but differences exist with respect to mechanisms for and extent of regulation. Regulatory mechanisms were often not clear or enforced, and academics are often left to self-regulate their engagement. Lack of regulation has been cited as allowing excessive engagement in multiple job holding practice among academics at the expense of their core institutional responsibility. This could further weaken institutional capacity and performance, and quality of training and support to students. Conclusion: The research describes the complexity of external multiple job holding practice, which is characterized by a cluster of drivers, multiple processes and actors, and lack of consensus about its implication for individual and institutional capacity. In the absence of a strong accountability mechanism, the practice could perpetuate and aggravate the fledgling capacity of public health training institutions.