7

Effects on Human Resources for Health and Quality of Care

OVERALL EFFECT OF THE HUMAN RESOURCES FOR HEALTH PROGRAM

Rwanda made substantial progress to reach the Joint United Nations Programme on HIV/AIDS (UNAIDS) 90-90-90 targets prior to the Human Resources for Health (HRH) Program, which was facilitated by the Government of Rwanda’s commitment to confronting its HIV epidemic. The development of national strategic plans on HIV/AIDS, the decentralization of the Rwandan health system, and the movement toward community-based health insurance and performance-based financing facilitated the country’s achievements and remarkable progress toward expanding access to HIV services and toward achieving HIV epidemic control (MOH, 2009a,b, 2018). Rwanda had also made substantial progress in achieving Millennium Development Goal (MDG) 5 (improve maternal health), with the maternal mortality ratio decreasing dramatically, from 1,160 deaths per 100,000 live births in 2000 to 373 in 2010, and to 275 in 2015 (WHO, 2017). There has been notable progress in all five provinces in Rwanda since 2005 in births attended by a skilled health professional, increasing from 31 percent in 2000 to 69 percent in 2010 (MDG Monitor, 2015). By 2015, 91 percent of deliveries were reportedly assisted by a skilled provider, most often by a nurse or medical student, followed by deliveries attended by a doctor, and then by a midwife (NISR et al., 2016).

In this respect, this context created an opportunity to make a broader impact in Rwanda’s HIV program. The third Health Sector Strategic Plan (2012–2018) called for the integration of HIV services at a decentralized level, the need to improve quality, and the need to maintain trained and adequate numbers of staff at all facilities (MOH, 2012). The result of decentralization has been a rapid increase in the number of facilities offering antiretroviral therapy (ART) services, from 4 facilities in 2002 to 552 in 2016, as reported in the Rwanda Integrated Health Management Information System. The increase in output and distribution of high-quality trained health professionals across Rwanda as a result of the HRH Program was seen by all respondent groups in this evaluation as having a positive impact on the quality of care as an outcome of increased access, although that is not explicitly noted in the overall design of the Program.

THE HIV EPIDEMIC IN RWANDA

With the first National Strategic Plan on HIV/AIDS in 2009, the Government of Rwanda cemented its commitment to tackling HIV by calling for universal access to HIV treatment and establishing goals of reducing infections, morbidity, and mortality, as well as ensuring equal opportunities for people living with HIV (PLHIV) (MOH, 2009b). In addition, the plan stated

that all PLHIV should receive prophylaxis for opportunistic infections. Even before the plan’s release, in 2008 national policy had eased the cluster of differentiation 4 (CD4) count threshold for ART treatment to less than or equal to 350 cells/mm³ from 200 cells/mm³ (Nsanzimana et al., 2015). Further changes in the CD4 count threshold for ART initiation were made in 2013. By 2014, Rwanda was fully implementing Option B+ in which HIV-positive pregnant women are enrolled on lifelong ART regardless of CD4 count. This expansion included anyone with tuberculosis co-infection, hepatitis B or C, and all children under 5 years old (MOH, 2013; Ross et al., 2019). On July 1, 2016, the Government of Rwanda rolled out the Treat All plan that required treatment of all HIV-positive patients regardless of CD4 count, age, comorbidities, or clinical staging (Nsanzimana et al., 2017; Ross et al., 2019).

As Figure 7-1 shows, HIV prevalence among adults age 15–49 in Rwanda, as reported by both the President’s Emergency Plan for AIDS Relief (PEPFAR) and UNAIDS, has been steadily decreasing since its peak at around 6 percent between 1994 and 1995, when sexual violence was used as a mechanism of terror and a means to spread HIV following the genocide against the Tutsi (Donovan, 2002; Nsanzimana et al., 2015).

The 2019 Rwanda Population-Based HIV Impact Assessment (RPHIA) estimated HIV prevalence among adults aged 15–49 as 2.6 percent and 3 percent among adults aged 15–64 years, totaling approximately 210,200 adults in Rwanda living with HIV (RPHIA, 2019). These are in line with the UNAIDS 2018 estimates of 2.5 percent of adults aged 15–49 living with HIV, totaling 210,000 people (UNAIDS, 2018b).

As discussed below, the RPHIA estimated that the annual incidence of HIV among adults was approximately 5,400 new cases per year, higher than the UNAIDS estimate of 3,600 total new infections per year and PEPFAR’s estimate of 4,409, although the confidence intervals for both

estimates overlap. The variation between the RPHIA and UNAIDS estimates likely point to methodological differences (PEPFAR Rwanda, 2019; RPHIA, 2019; UNAIDS, 2018b).

In the past decade, Rwanda has made steady improvements in increasing access to and coverage of ART (see Figure 7-2), although there is some discrepancy in the data. PEPFAR and UNAIDS reported ART coverage as 66 percent and 58 percent, respectively, in 2013, while elsewhere it was reportedly 92 percent in the same year (Binagwaho et al., 2016). Additionally, both PEPFAR and UNAIDS data present an approximately 8 percent differential, likely due to methodological differences. PEPFAR collects programmatic data from select core indicators, whereas UNAIDS compiles estimated HIV data produced by host countries. The Ministry of Health (MOH) 2016 Annual Statistics Booklet indicated ART coverage was 83 percent in 2016 (MOH, 2016a). In 2014, mortality was estimated to be greatest among those who were untested (35.4 percent) and those on ART (34.1 percent)—reflective of the increased and aging population on ART—followed by patients lost to follow up (11.8 percent) (Bendavid et al., 2016). More information about care and treatment services for PLHIV is covered in the subsequent sections about the health system and human resources for health in Rwanda.

HIV/AIDS Outcomes

The RPHIA and UNAIDS both estimate that approximately 74 percent of PLHIV have achieved viral suppression (RPHIA, 2019; UNAIDS, 2018b); however, estimates of the three 90-90-90 elements are different (see Table 7-1). Results from the RPHIA show that 76 percent of HIV-positive

adults (aged 15–64) and almost 80 percent of HIV-positive women have achieved viral load suppression, a key indicator of effective HIV treatment in a population (RPHIA, 2019). Overall, the RPHIA found that approximately 84 percent of adults living with HIV knew their status, 98 percent of adults who knew their status were on ART, and 90 percent of those on ART achieved viral suppression.

Impact on Quality of Care

Dimensions of Quality

The landmark 2001 Crossing the Quality Chasm report from the Institute of Medicine (IOM) presents six dimensions of high-quality health care (IOM, 2001), which were adapted in 2018 for application in global health (NASEM, 2018):

1. Safety: avoiding harm to patients from the care that is intended to help them.
2. Effectiveness: providing services based on scientific knowledge to all who could benefit and refraining from providing services to those not likely to benefit (that is, avoiding both overuse of inappropriate care and underuse of effective care).
3. Person-centeredness: providing care that is respectful of and responsive to individual preferences, needs, and values and ensuring that people’s values guide all clinical decisions. Care transitions and coordination should not be centered on health care providers, but on recipients.

4. Accessibility, timeliness, and affordability: reducing unwanted waits and harmful delays for both those who receive and those who give care; reducing access barriers and financial risk for patients, families, and communities; and promoting care that is affordable for the system.
5. Efficiency: avoiding waste, including waste of equipment, supplies, ideas, and energy, and including waste resulting from poor management, fraud, corruption, and abusive practices; existing resources should be leveraged to the greatest degree possible to finance services.
6. Equity: providing care that does not vary in quality because of personal characteristics such as gender, ethnicity, race, geographic location, and socioeconomic status.

Impact on HIV/AIDS Care

The design of the HRH Program emphasized developing a quality health care system through an increased output and cadre of high-quality trained health professionals who would in turn increase the quality of care. As mentioned above, the increase in output and distribution across Rwanda was seen to have had a positive impact on the quality of care as an outcome of increased access, although that is not explicitly noted in the overall design of the program. HRH Program trainees gained skills and knowledge that were seen as having a positive effect on the quality of care for all Rwandans, including PLHIV. With highly trained health workers distributed across Rwanda, the management of patients with HIV was seen to be improving. Most notably, the HRH Program was credited with bringing specialties that PLHIV required for comprehensive care, including treatment for people with advanced HIV disease or in need of specialized care:

A respondent from a PLHIV group noted that specialized care was particularly relevant for HIV-positive pregnant women, as “residents’ level has improved as they have been well taught to minimize [the] risks” of mother-to-child transmission (30, Former Government of Rwanda Program Administrator and PLHIV Representative). Exposure to U.S. institution (USI) faculty was also seen as contributing to reduced stigma and improved treatment of HIV-positive women presenting with cervical cancer:

Another respondent commented that “as more internal medicine residents go out to districts, I think that will help with the management of more advanced opportunistic infections and some of those things” (12, International NGO Representative). Here, it is important to note that not enough time had lapsed between the graduation of internal medicine doctors under the HRH Program and this evaluation to assess this type of impact. However, it was also observed that some specialties required for providing comprehensive services to PLHIV (notably, nephrology) were absent from the HRH Program. As combination ART has led to substantial improvements in opportunistic-disease associated mortality among PLHIV, comorbid noncommunicable diseases have become increasingly common in HIV management, in part as a natural consequence of longevity, but compounded by dysmetabolism associated with antiretroviral drugs (Koethe, 2017). Thus, HIV care must also focus on prevention and management of these illnesses, and on the complexity that arises in caring for an aging PLHIV population with multimorbidity, polypharmacy, and frailty (Guaraldi and Palella, 2017).

For program administrators, the impact on HIV was observed through the increases in the quality of care and management at health facilities by HRH trainees, reinforcing the integrated HIV service delivery Rwanda had been working toward since 2009. This was facilitated by the existing structures of HIV service delivery, which included doctors and nurses at hospitals who functioned as infectious disease specialists (including for HIV and tuberculosis), and received ongoing training from the MOH outside of the HRH Program.

One program administrator from the MOH drew a direct link between the improvements in HIV-related indicators and the increase in clinicians’ skills and knowledge as a result of the HRH Program:

After declining from a high of more than 30,000 per year in the early 1990s, the number of new infections reported by PEPFAR leveled off to approximately 7,500 new infections per year in 2018 (see Figure 7-3). In 2019, this number was reported to be 4,409 in PEPFAR’s Country Operational Plan 2019 using the UNAIDS Estimation and Projection Package Spectrum estimate (PEPFAR Rwanda, 2019). However, UNAIDS HIV incidence data suggests a gradual decline in the number of new HIV infections, reportedly estimated at 3,600 new infections per year in 2018.

Furthermore, annual incidence reported by the RPHIA in 2019 was 0.08 percent, which corresponds to approximately 5,400 new cases (RPHIA, 2019). Although the incidence rate has continued to decline since 2008 and is reflective of a successful national HIV program, the discrepancies in these data are notable, with implications for assessing the nature of the HIV epidemic in Rwanda even with methodological differences. Other indicators, such as the prevention of mother-to-child transmission (PMTCT) coverage,

estimated a decline in coverage from 113.1 percent in 2011 to 80.9 percent in 2016 for PEPFAR (see Table 7-2). UNAIDS estimates of PMTCT coverage have increased significantly, from 58 percent in 2010 to a leveling of around or above 95 percent. The estimated increases in coverage were seen throughout the years of the HRH Program implementation, although its estimations of coverage vary significantly in comparison to PEPFAR, likely pointing to methodological differences. This drop in coverage percentage occurred as the estimated need for PMTCT coverage rose from 9,416 pregnant women in 2011 to 11,000 in 2016, while the number of pregnant women who were provided antiretrovirals (ARVs) dropped from 10,646 to 8,900 (see Figure 7-4).

Impact on Other Clinical Areas

The HRH Program was also seen as having a positive impact on other clinical areas. The Program’s production of obstetricians/gynecologists was viewed as contributing to Rwanda’s 2015 achievement of MDG 5—to

reduce the maternal mortality ratio by three quarters between 1990 and 2015—which decreased from 1,160 deaths per 100,000 live births in 2000 to 373 in 2010, and to 275 in 2015 (WHO, 2017). More broadly, improvements around hand hygiene and use of personal protective equipment were observed and contributed to improved patient outcomes.

Other aspects of quality care were seen to have improved. Many respondents noted patient flow as having been positively influenced by interactions between USI and Rwandan faculty and students. Improving clinicians’ time management, triage practices, and scheduling rosters, and improved clinical guidelines (although the ever-changing HIV-related clinical guidelines were seen as challenging) were all seen as contributing to reduced patient waiting times and flow through the hospitals (30, Former Government of Rwanda HRH Program Administrator; 58 and 59, University of Rwanda Former Students in Nursing). This interaction also enhanced Rwandan faculty and student awareness and implementation of evidence-based medicine, which respondents saw as directly related to improved quality of care:

Impact of Other Quality Improvement Activities

Quality improvement activities supported by concurrent projects and initiatives also contributed to improved quality of care. In Bushenge Hospital, for example, which was included in this evaluation’s in-depth facility microsystem examination, a quality improvement project supported by a United States Agency for International Development implementing partner to reduce postsurgical infections was seen as improving care, although there was also an interactive effect with the HRH Program, as specialists produced by the Program and working in Bushenge Hospital “will make it easier for those hospitals to improve” (05, International NGO Representative).

Other activities that affected the health workforce and the provision of care include identifying gaps in service delivery, in-service training on HIV service delivery, continuing professional development and mentorship programs, external provision of ARVs, and results-based financing. A strong program of community-based HIV service delivery by community health workers was seen as having an impact on patient-level outcomes (Abbott et al., 2017). Similarly, the Centre Hospitalier Universitaire de Butare/University Teaching Hospital, Butare (CHUB), also included in the facility microsystem in-depth examination, received support from the U.S. Centers for Disease Control and Prevention (CDC) to provide comprehensive pediatric HIV services, which could have had a plausible impact on HIV outcomes.

Although these improvements in quality of care were observed in tertiary care facilities, such as CHUK (Centre Hospitalier Universitaire de Kigali/University Teaching Hospital, Kigali) or CHUB, for example, it was recognized that most Rwandans did not seek services from these hospitals; rather, they accessed care in health centers and district hospitals, which were not as affected by the HRH Program:

Related was the purchase and distribution of equipment for clinical teaching, which predominantly went to CHUK and, to a lesser extent, CHUB (see Chapter 6). This respondent, however, did not take into account

the nurses whose skills were upgraded from A2 to A1¹ as a result of the e-learning platform developed under the HRH Program, or other efforts and investments made in upgrading nurses’ skills. Although shifting HIV care tasks to nurses had occurred in 2009,

Hospital-level leadership was also seen as influencing quality of care. Although management processes were well defined, quality improvement tended not to be institutionalized at the leadership level for ongoing improvement. Additionally, 2017 saw a significant “shake up of the system” in which hospital directors were moved or removed, causing “huge management instability” (12, International NGO Representative). Simultaneously, however, more team-based approaches to decision making were installed, in part due to the HRH Program, which was seen as a forward step.

Other factors also affected health workers’ ability to provide quality of care. At the facility level, the absence of infrastructure and equipment impaired their work. Conditions in rural and remote areas made them undesirable locales to work and live, impeding health worker retention and contributing to a situation in which there were insufficient human resources for health at the facility level, creating a more burdensome workload for health workers who stayed.

Linking Quality of Care to Patient Outcomes

Data from this evaluation suggest revisions to the theoretical causal pathway that guided the evaluation design, presented in Chapter 1, that more clearly link HRH Program activities and outputs to the domains of quality presented in Figure 7-5. Through building awareness and use of evidence-based medicine and quality improvement methodologies, the safety and effectiveness of clinical interventions were seen as improving. The HRH Program was seen as building a cadre of physician specialists, including in specialties for which there previously were no providers, thereby increasing access; however, the geographic distribution of some specialties was an ongoing barrier.

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¹ A2 nurses have completed secondary school education, and A1 nurses receive a diploma after 3 years of training at a higher education institute (Uwizeye et al., 2018).

Beyond building clinical skills, the Program also was seen to have an effect on time management and patient flow, thereby improving the timeliness of services. Although this view was not widespread, one USI faculty member noted that there had been some improvements in treatment for and reduction in stigmatization of HIV-positive cervical cancer patients, which may point to small inroads in improving equity.

Therefore, the committee revised the causal pathway to highlight the role of improved quality of care as a longer-term outcome that is required to effectively impact health outcomes for all and HIV-related outcomes. Investments in human resources and other health systems strengthening blocks need to evolve over time as the context and needs of the population change; however, ongoing investments are required to continue to improve the health outcomes of Rwandans.

Measuring Impact

The committee did not have sufficient data to provide a quantitative assessment of the HRH Program’s impact on health outcomes. That said, the design of the Program, in principle, would have allowed a quantitative assessment of changes in outcomes following implementation. The clear outset of the Program, its defined set of training activities, and the distribution of HRH trainees across Rwanda mean that a quantitative assessment of impact with reasonable potential for causal attribution could, in principle, be carried out as follows: The design would conceptualize Rwandan districts that received HRH trainees as independent units with their own trajectories of health outcomes such as HIV testing, treatment, and viral suppression rates. The new infusion of HRH trainees would then be tested as an “intervention” that is applied to each district at a unique “dose” that is represented by the quantity and type of HRH trainees who enter each district, ideally characterizing dose in relation to population or disease burden. Designs such as regression discontinuity, interrupted time series, or difference-in-difference could then use district-level fixed effects to estimate the pooled effect of the Program on the outcomes of interest.

The information needed for such an analysis would allow the creation of panel data for districts, with two central pieces of data: (1) repeat observations over time (e.g., monthly or quarterly) of the health outcomes of interest, before and after the implementation of the HRH Program; and (2) detailed information on the trajectory of HRH trainees in districts, including the timing, type of health professional, and any ancillary information about the types and intensity of clinical services provided by the trainee. These two data elements could provide minimal but sufficient foundation for a quantitative assessment of impact. Unfortunately, neither of these key data elements was available to the committee. The committee posits that future HRH efforts could fill key knowledge gaps around the potential for impact on a range of individual and population health outcomes by conceptualizing, a priori, a rigorous evaluation design that fits with the planned HRH intervention. Such evaluations would ideally be designed with input from implementers and stakeholders, but executed by independent teams who are separate from those implementing the program.

SUSTAINABILITY AND INSTITUTIONALIZATION

Continuing the HRH Program

Government of Rwanda program administrators shared that the HRH Program continued, following the end of PEPFAR investments, as there was an ongoing need to generate specialists in medicine and nursing. Referring

to the 2011–2019 period as phase one, one of these respondents declared, “the HRH Program will never end. That is our motto” (03, Government of Rwanda HRH Program Administrator). The HRH Program was seen as being “Rwandan owned, where Rwandans decide what they want to do and decide who they want to hire” (13, Government of Rwanda HRH Program Administrator). The end of PEPFAR funding was seen as causing “a kind of unbalance” in terms of sustainability, but the Program continued with government commitment and resources from the Global Fund to Fight AIDS, Tuberculosis and Malaria (20, Government of Rwanda HRH Program Administrator).

There was general interest in continuing the HRH Program and making “longer-term investments” to facilitate USI faculty members’ staying for longer periods at the University of Rwanda to continually build capacity and “give the residents a lot more security and faith in the program when they don’t just see people coming and going all the time” (16, USI Faculty in Obstetrics and Gynecology). There was a perceived need to continue building physician specialists and subspecialists and

University of Rwanda and USI respondents alike expressed confusion about the future of the HRH Program. University of Rwanda respondents were unclear as to whether additional USI faculty would be coming and were concerned about being able to continue their programs without the support:

USIs had differing understandings, with one respondent reporting he had not heard from the MOH about continuing to support the surgery program and another who had only recently heard from the MOH that her institution would be issued a memorandum of understanding for another year to support the nursing program.

Additional partnerships with other USIs were reportedly being formed directly with the University of Rwanda, which was motivating to Rwandan faculty:

Sustaining HRH Program Outputs

Investments in the University of Rwanda, both in faculty and in postgraduate training, were key to sustaining the HRH Program’s gains. For Government of Rwanda program administration respondents, the fact that university departments were all headed by Rwandans was an indication that the Program had been institutionalized:

That the health workers trained under the HRH Program brought higher skill levels and qualifications to the health sector was viewed as another measure of sustainability. Similarly, the experience of being twinned with USI faculty was viewed as contributing to Rwandan faculty members’ professional development and growth:

One respondent external to the HRH Program (12, International NGO Representative) expressed that some of the products of the Program, such as curricula and formal degree programs, could be sustained, but it was unclear whether there would be faculty to continue delivering these programs.

Sustaining the Institutional Capacity to Train Health Workers

As indicated in the design phase, the MOH did not engage the Ministry of Education in the design of the HRH Program; however, throughout implementation, the relationship between the two ministries grew. Building the capacity of new and existing faculty at the University of Rwanda was seen as contributing to the sustainability of the Program:

Another Government of Rwanda respondent expressed that having a university capable of producing more health workers was an unplanned benefit of the Program, making it “even more sustainable than what we believe” (18, Former Government of Rwanda HRH Program administrator). An HRH trainee who went on to work as a physician specialist at CHUB and joined the faculty at the university felt that the transition from USI faculty to Rwandan faculty was successful, facilitating the university’s sustained capacity to educate future health workers:

USI faculty perspectives contrasted with this view. The notion that they trained Rwanda faculty “to become better teachers in a specific area … didn’t work that way” (15, USI Twinned Faculty in the Master of Hospital and Healthcare Administration Program). Another USI faculty member who had four consecutive contracts with the MOH to provide teaching, twinning, and direct services for complex gynecology oncology cases in Kigali noted:

For example, a sustainability plan in the gynecology/oncology program was developed, driven by USI faculty, but did not come to fruition, partly due to a lack of flexibility in the planning:

The midterm review also reported there were no formal planning exercises to facilitate the phasing out of USI faculty and ensure a permanent faculty pipeline for a sustainable health system as the HRH Program time lines evolved (MOH, 2016b). A general practitioner working at CHUB observed that

Finally, building local ownership over the HRH Program as a means of continuing it after the end of PEPFAR or other external funding was viewed as being hampered by changes in MOH leadership and leaders’ accompanying management style:

CONCLUSIONS

Program Impact

Using the IOM dimensions of quality as a frame, the HRH Program investment had a qualitative impact on the safety, effectiveness, timeliness, and accessibility of services for PLHIV and beyond. A small amount of qualitative data indicates that there may have been some contributions to improving equity in care and reducing stigmatization for PLHIV. The HRH Program was seen by those in both health professional education and health service delivery roles as contributing to improving quality of care for all Rwandans, including PLHIV, through direct and indirect pathways (greater provider availability, basic skills, HIV care-specific skills, and skills to address HIV-related complications).

The relationship between HRH training and patient-level outcomes is well documented in newborn survival, postpartum hemorrhage, surgical outcomes, and health care–associated infections (Aiken et al., 2003; Gomez et al., 2018; Grayson et al., 2018; Nelissen et al., 2017). For example, in critical care and emergency services, the presence of advanced practice nurses has been shown to have a positive impact on patient outcomes and may improve efficiencies (Woo et al., 2017). In HIV, there is less evidence linking the relationship between health professional education and PLHIV outcomes. However, there is evidence pointing to community health workers’ role in the provision of HIV care and improved outcomes for PLHIV, including psychosocial support and viral load suppression, yet these were not a part of the HRH Program (Han et al., 2018; Kenya et al., 2013).

As noted in the revised causal pathway (see Figure 7-3), the potential for health professional education and increased production of providers to improve quality of care is limited by other systems factors that affect quality (such as overall health worker density, infrastructure and diagnostics, and geographic and transportation-related barriers) (Farahani et al., 2016;

Lankowski et al., 2014; Mashamba-Thompson et al., 2017). For example, research from Tanzania found that at the facility level, increased loss to follow-up was associated with delays in testing and laboratory results, limited access to nutritional services, and poor patient flow (Rachlis et al., 2016).

Rwanda had made notable achievements in HIV service provision prior to the HRH Program. Successes included high rates of ART initiation, low loss to follow-up and mortality prior to initiation, and high retention rates (Teasdale et al., 2015). The implementation of the Treat All approach for HIV-infected children in 2012, in which all HIV-positive children under 5 years were initiated on combination ART, has positively affected pediatric outcomes in Rwanda, including growth, retention, and viral load suppression (Arpadi et al., 2019). The Treat All approach for all HIV-positive patients was implemented in 2016. Given these gains, the HRH Program’s contribution to HIV outcomes was relatively small. Considering that HIV services were integrated in the health system, as per health-sector policies and plans, disentangling the Program’s impact on HIV outcomes is further complicated.

Long-Term HRH Needs for PLHIV

The potential impact of the HRH Program on other health outcomes for PLHIV, including noncommunicable diseases, could not be determined by this evaluation. Although the Program invested in building a cadre of specialists, there did not appear to be an expansion of specialist cadres skilled to address the noncommunicable disease needs of PLHIV on long-term treatment, such as cardiologists or nephrologists. Evidence points to the need for future HRH planning to ensure the evolving health needs of an HIV population are met.

Recent population-based surveys from Tanzania and Uganda have shown that cardiovascular risk factors, including hypertension and other components of metabolic syndrome, are at least as prevalent in HIV populations as in the general population (Gaziano et al., 2017; Kavishe et al., 2015). Benjamin and colleagues (2016) demonstrated a double burden in Malawi, with traditional risk factors contributing to higher stroke risk in older PLHIV, while HIV status conferred higher risk among younger persons, especially those initiating ART within the 6 months prior to stroke onset. This finding suggests that immune reconstitution after immunodeficiency may require different clinical management strategies than those associated with traditional vascular risk factors for stroke (Benjamin et al., 2017).

Furthermore, PLHIV are at increased risk of kidney disease. With the widespread use of ART, HIV-associated nephropathy has become less

common, but the prevalence of other kidney diseases has increased, and long-term exposure to ART has the potential to cause or exacerbate kidney injury (Swanepoel et al., 2018). Among adult PLHIV initiated on ART in Zambia, renal insufficiency, even when mild, has been associated with increased mortality risk (Mulenga et al., 2008). A number of subsequent studies have assessed the prevalence of renal dysfunction among PLHIV in Africa starting ART, most of which show improvement in renal function after ART initiation for those with baseline renal dysfunction, including those initiating tenofovir disoproxil fumarate (TDF), which has known nephrotoxicity and is a common component of first-line ART for many countries in the region (Chikwapulo et al., 2018; De Waal et al., 2017; Deckert et al., 2017; Mulenga et al., 2014). Yet, studies with 12–24 months’ follow-up have shown small but steady declines in estimated glomerular filtration rates for some patients exposed to TDF, particularly those with initial normal renal function (Chikwapulo et al., 2018; De Waal et al., 2017; Mulenga et al., 2014). As national ART guidelines across the region adapt to World Health Organization recommendations for earlier ART initiation, the increased duration of exposure to ART may shift the risk–benefit balance for kidney health (Swanepoel et al., 2018).

The resources and services needed for monitoring and managing renal and cardiovascular diseases among PLHIV in sub-Saharan Africa are, to date, insufficient. Preventative and treatment strategies for addressing these and other chronic diseases are needed, particularly among aging populations. The successful integration of HIV care in sub-Saharan Africa may offer critical insights into leveraging improvements in primary health care services, either through horizontal integration or within HIV health care delivery.

Sustainability and Institutionalization

Sustainability and institutionalization of the HRH Program were significantly hampered by the Program’s design and implementation, and by PEPFAR’s changes in funding priorities. There was general agreement among respondents that prolonged engagement of USI faculty in an intensive twinning program was not the desired outcome, but there was also recognition that there had been insufficient time to institutionalize the ability to continually update curricula and teaching methodologies at the University of Rwanda. The HRH Program’s midterm review also pointed to the need for improved sustainability planning, but PEPFAR’s decision to end funding before the planned end of the Program limited the MOH’s ability to act on this recommendation.

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