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PROBLEM: Although it is highly preventable and treatable, cervical cancer is the most common and most deadly cancer among women in Rwanda. APPROACH: By mobilizing a diverse coalition of partnerships, Rwanda became the first country in Africa to develop and implement a national strategic plan for cervical cancer prevention, screening and treatment. LOCAL SETTING: Rwanda - a small, landlocked nation in East Africa with a population of 10.4 million - is well positioned to tackle a number of "high-burden" noncommunicable diseases. The country's integrated response to infectious diseases has resulted in steep declines in premature mortality over the past decade. RELEVANT CHANGES: In 2011-2012, Rwanda vaccinated 227,246 girls with all three doses of the human papillomavirus (HPV) vaccine. Among eligible girls, three-dose coverage rates of 93.2% and 96.6% were achieved in 2011 and 2012, respectively. The country has also initiated nationwide screening and treatment programmes that are based on visual inspection of the cervix with acetic acid, testing for HPV DNA, cryotherapy, the loop electrosurgical excision procedure and various advanced treatment options. LESSONS LEARNT: Low-income countries should begin to address cervical cancer by integrating prevention, screening and treatment into routine women's health services. This requires political will, cross-sectoral collaboration and planning, innovative partnerships and robust monitoring and evaluation. With external support and adequate planning, high nationwide coverage rates for HPV vaccination and screening for cervical cancer can be achieved within a few years.

BackgroundOperational effectiveness of large‐scale national programmes for the prevention of mother to child transmission (PMTCT) of HIV in sub‐Saharan Africa remains limited. We report on HIV‐free survival among nine‐ to 24‐month‐old children born to HIV‐positive mothers in the national PMTCT programme in Rwanda.MethodsWe conducted a national representative household survey between February and May 2009. Participants were mothers who had attended antenatal care at least once during their most recent pregnancy, and whose children were aged nine to 24 months. A two‐stage stratified (geographic location of PMTCT site, maternal HIV status during pregnancy) cluster sampling was used to select mother‐infant pairs to be interviewed during household visits. Alive children born from HIV‐positive mothers (HIV‐exposed children) were tested for HIV according to routine HIV testing protocol. We calculated HIV‐free survival at nine to 24 months. We subsequently determined factors associated with mother to child transmission of HIV, child death and HIV‐free survival using logistic regression.ResultsOut of 1448 HIV‐exposed children surveyed, 44 (3.0%) were reported dead by nine months of age. Of the 1340 children alive, 53 (4.0%) tested HIV positive. HIV‐free survival was estimated at 91.9% (95% confidence interval: 90.4‐93.3%) at nine to 24 months. Adjusting for maternal, child and health system factors, being a member of an association of people living with HIV (adjusted odds ratio: 0.7, 95% CI: 0.1‐0.995) improved by 30% HIV‐free survival among children, whereas the maternal use of a highly active antiretroviral therapy (HAART) regimen for PMTCT (aOR: 0.6, 95% CI: 0.3‐1.07) had a borderline effect.ConclusionsHIV‐free survival among HIV‐exposed children aged nine to 24 months is estimated at 91.9% in Rwanda. The national PMTCT programme could achieve greater impact on child survival by ensuring access to HAART for all HIV‐positive pregnant women in need, improving the quality of the programme in rural areas, and strengthening linkages with community‐based support systems, including associations of people living with HIV.

Two decades ago, the genocide against the Tutsis in Rwanda led to the deaths of 1 million people, and the displacement of millions more. Injury and trauma were followed by the effects of a devastated health system and economy. In the years that followed, a new course set by a new government set into motion equity-oriented national policies focusing on social cohesion and people-centred development. Premature mortality rates have fallen precipitously in recent years, and life expectancy has doubled since the mid-1990s. Here we reflect on the lessons learned in rebuilding Rwanda's health sector during the past two decades, as the country now prepares itself to take on new challenges in health-care delivery.