Rwanda’s Case for RH-HIV Integration

Lisa Schechtman

This year Rwanda's proposal to the Global Fund integrates HIV prevention with its National Reproductive Health Policy, setting an important precedent for other donors and countries.

Just about everyone knows Rwanda's sad history. What fewer people know is the hope that can be found inside that tiny African country. The streets are clean and many roads are well paved. It feels safer than most places, and there are fewer guns in sight than in lots of major cities. The quota for women to fill at least 30 percent of all decision-making posts has been exceeded, and Parliament is now approximately 50 percent women, making Rwanda the world's leader in this regard. And the Ministry of Health has created an outstanding reproductive health policy, which looks at the issue holistically and which may be about to get a big boost from an unexpected source—the Global Fund to Fight AIDS, Tuberculosis and Malaria.

To most people reading this, the important links between sexual and reproductive health (SRH) and HIV/AIDS are probably clear. Unfortunately, it's not always so clear that major global health donors see the links. The United States government has huge barriers for programs that fully integrate SRH and HIV/AIDS, such as the Global Gag Rule and the abstinence-until-marriage earmark in PEPFAR (President's Emergency Plan for AIDS Relief). Plus, even while U.S. funding for AIDS has gone up, money for family planning has gone down, making it hard to integrate programs with U.S. support. And, to this point, the Global Fund has supported essentially no proposals that integrate SRH and HIV/AIDS, despite its willingness to do so and the fact that it has none of the restrictions the U.S. has.

However, since the Global Fund is country driven and flexible and not prone to the ideologies that corrupt other AIDS-related efforts, it is the perfect vehicle for scaling up SRH-HIV programs. Once it's done in a country or two and the precedent is set, perhaps other countries will choose this approach and SRH-HIV/AIDS integration will become a lifesaving reality.

So, Rwanda is a test case as much as it is an example of innovation and commitment to its people's health. This year, Rwanda's Country Coordinating Mechanism for the Global Fund decided that the HIV prevention piece of its proposal would be based on the National Reproductive Health Policy. The policy focuses on six priority areas, which will all be integrated with HIV/AIDS programs if the Round 7 proposal is successful: safe motherhood and child health, family planning, prevention and treatment of STIs including HIV, adolescent reproductive health, prevention and management of sexual violence and social changes to increase women's decision-making power.

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I was especially excited to be able to incorporate dramatically increased services for survivors of sexual and gender-based violence, because all too often people don't see clearly the connections between violence, reproductive health, and HIV/AIDS. But there are many. And Rwanda's history is a piece of the evidence base that supports these connections. During the 1994 genocide, there was a policy that HIV-positive genocideres should rape women in order to spread the disease. Estimates suggest that as many as 500,000 women were raped in those 100 days and 75 percent acquired HIV as a result. But interpersonal violence in Rwanda certainly didn't end with the genocide, so the country's commitment to seeking funding for national programs to address the physical, mental and emotional consequences of rape—including on sexual and reproductive health and including HIV—is yet another of the hopeful signs I saw in Rwanda.

The two weeks I spent in Rwanda were not easy. The history of genocide is impossible to overlook; every time I drove past the Hotel des Milles Collines, where the film Hotel Rwanda took place, whoever was in the car with me would invariably point it out, assuming I knew what happened there. One of the first questions strangers asked was "Do you still have your mother," a terrible reflection of the loss suffered by the Rwandan people. But Rwanda is doing well overall, especially considering its post-conflict status. HIV prevalence is still relatively low, and the country has been successful at implementing the previous grants it has received from the Global Fund. I have high hopes that it will succeed again in Round 7. If it does, it will have been rewarded for its courage in submitting a proposal unlike any that the Fund has supported in the past. And millions of Rwandans stand to benefit. Keep your fingers crossed!

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