Esther Uwababyeyi’s journey with HIV began at a young age. "Since the age of three, I've been on HIV treatment due to mother-to-child transmission," she says. The 22-year-old who lives in Rwamagana district in Eastern province of Rwanda, has been a first-hand witness to the innovations of the HIV response in the country since the early days of the response.

During her adolescence, Uwababyeyi benefited from the most up to date evidence-based Rwanda national ARV treatment program, aligned with World Health Organization (WHO) treatment guidelines that recommended immediate treatment upon diagnosis for all people living with HIV (PLHIV). In 2015, WHO recommended that all PLHIVbe put on ARV therapy (ART) regardless of any other criteria to improve treatment outcomes and reduce HIV transmission. At that time, PLHIV had to visit health facilities monthly for clinical or laboratory follow-up, drug refills and psychosocial support.

For Uwababyeyi, visiting the clinic once monthly became a barrier during her high school years. “Challenges arose during my time in boarding school as I grappled with the stigma surrounding my HIV status. I hesitated to disclose my status, fearing discrimination. To adhere to my treatment schedule, I resorted to fabricating reasons for my absence every month to school authorities," she recalls.

In 2016, WHO recommended differentiated service delivery (DSD) models for more patient-centered care that took into account the contexts and need of all populations., including multi month dispensing (MMD) of ARVs. WHO Rwanda supported the country to adopt the strategy by providing global guidance through expert workshops, discussing in-country feasibility, defining implementation needs , adapting tools, and training the workforce. This led to the implementation of MMD in Rwanda, alleviating the burden of care on people like Uwababyeyi.

The Ministry of Health, through Rwanda Biomedical Centre, introduced a robust community-based peer education model alongside MMD, designed based on WHO global recommendations to ensure service quality. WHO supported the country in designing and adapting the peer education (PE) model to the local context, defining criteria for PE selection, developing training manuals, and conducting training with civil society organizations, mainly the network of PLHIV at all levels. The PE model includes support groups for PLHIV and is instrumental in providing follow up care and connecting people to health facilities. Coordinated by the Rwanda Network of People Living with HIV/AIDS, the model helps PLHIV to adhere to HIV treatment and improve viral load suppression. It also motivates peer educators to maintain their adherence to treatment.  

People living with HIV who had been on HIV treatment for at least 18 months and demonstrated good adherence to treatment with successful viral suppression were provided the option to refill their HIV treatment every three months, and were able to move to six monthly refills from 2020. This was a huge relief for Uwababyeyi. "In 2019, after demonstrated adherence to treatment as assessed by health professionals and successful viral load suppression, I was enrolled in a 3-month antiretroviral refill program while still attending boarding school. Throughout my final year in high school, my appointments were conveniently scheduled during end-of-term holidays, allowing me to complete my education without interruption," she says. Upon graduation in 2022, Uwababyeyi’s proven track record of adherence resulted in her clinic upgrading her refill schedule to six months.   

"MMD is a real patient-centered approach that has saved our patients time and money. Instead of monthly visits, many of our patients now visit health facilities every three to six months. This change saves them money on transportation and gives them more time to care for their families. This convenience has also enhanced treatment adherence and viral suppression" said Dr Simeon Tuyishime, the Director of HIV care and treatment within RBC.

The Power of Peer Educators

Havugimana Faustin started HIV treatment in 2006 at the age of 50, two years after being diagnosed with HIV. Almost a decade later in 2018, Faustin was enrolled in a 3-month refill program and became one of 4,900 people living with HIV trained as peer educators (PE). These PEs support their peers by promoting adherence, tracking people lost to follow-up, facilitating health facility referrals, and providing appointment reminders. WHO continues to support this robust PE model through training in follow up, reporting and supervision to ensure service quality. "I make monthly visits to check on people’s adherence and address any emerging issues, ensuring timely referral to healthcare facilities when necessary," says Faustin. "I am pleased to report that most of my peers exhibit good adherence and appreciate the benefits of the MMD program."
 

According to Dr Muhayimpundu Ribakare, HIV, STIs, Tuberculosis, and Hepatitis Programme Officer at WHO Rwanda, the MMD model greatly benefited to the HIV response. "MMD has been one of the differentiated service delivery strategies that improved recipients' adherence while alleviating the burden on the health care system by removing the need for monthly visits by all recipients," she says. 
Due to high-level political commitment and a multipronged and multisectoral approach, including innovations like Treat All and MMD model, Rwanda has made significant progress in the HIV response. New HIV infections have dropped by 56% between 2015 and 2022, from 6,900 to 3,000. The country has also made significant strides in reaching the UNAIDS 95‒95‒95 targets, wherein 95% of people living with HIV know their HIV status; 92% of people diagnosed with HIV are on treatment; and 90% of people on HIV treatment are virally suppressed. Uwababyeyi is testament to this success. Now a young adult and employed, the MMD model has made her journey with HIV easier. “The 6-month refill schedule has enabled me to seamlessly integrate my medical care into my professional life,” she says.