Non-surgical Adult Male Circumcision Using the PrePex Device: Task-Shifting from Physicians to Nurses

The Republic of Rwanda is implementing a program of voluntary male circumcision (MC) to reduce HIV transmission but lacks the infrastructure for conventional surgical MC on a nationwide scale. Nonsurgical MC using the PrePex device was first assessed in 5 subjects on an inpatient basis. Subsequent procedures were on an outpatient basis. Physicians performed 100 outpatient procedures (Phase 1 of this study) and trained nurses in the technique; the nurses then independently performed 47 procedures (Phase 2). All subjects achieved complete circumcision and healing within 6 weeks. There were no cases of infection or bleeding. In Phase 1, one case of transient moderate diffuse edema occurred. In Phase 2, no adverse events were reported. Thus, outcomes of MC performed by nurses using the PrePex device were not inferior to outcomes achieved by physicians, suggesting that task-shifting MC by this method from physicians to nurses is feasible in Rwanda. (Afr J Reprod Health 2014; 18[1]: 61-70).Keywords: Circumcision, device, nurses, Rwanda, safety, task-shiftin

Organic Geochemistry of Peat Deposits in southwest Rwanda

Rwanda hosts million tons of peat deposits and that of western province is of great importance as it close to Kivu Lake. The discovery of methane gas in Kivu Lake has attracted investors in methane gas utilization as source of power supply and Compressed Natural Gas (CNG). Researchers identified Kivu Lake and adjacent area as an area of interest for hydrocarbon exploration. However, organic geochemical prospecting for hydrocarbon and energy content assessment is inadequate for the identified areas. The study aimed at determining the organic geochemistry of peat deposits in southwest, Rwanda. Forty (40) subsurface peat samples (1 to 10 m depth) were collected, air-dried and pulverized and screened. Five (5) samples with high organic matter content were subjected to biomarkers analysis using GC-GCMS. The n-alkanes distribution comprised mainly n-C11 to n-C 37. The Pr/Ph ratios (3.3-10.4, the waxiness index (0.09-0.87), CPI (3.6-7.8), OEP (3.5-6.0), C29 steranes (63.0–100.0%), C28 (0.0–28.0%), C27 (0.0–18.0%) and C27/ C29 sterane ratios (0.0-0.28). The ββ/ (ββ + αα) and 20S/ (20S + 20R) are 0.5 and 0.46 respectively. The C30 -moretane/ C30 -hopane ratios ranged from 1.56 to 2.42, while the oleanane index ranged from 0.07 to 0.26. The Ts/ (Ts + Tm) ratios ranged from 0.13 to 1.05. The dominance of C-29 sterols and C29/C27 sterane ratio which ranged from 3.5 to 100 indicating derivation from terrigenous higher plant material. The Pr/Ph ratio (>3) reflect the oxic to sub-oxic environmental condition during peat deposition. The peat deposits in Western Province, Rwanda are very rich in organic matter of mainly terrestrial precursor deposited in dry and cold climate

Request for Antimalarial Medicines and Their Dispensing Without a Prescription in Community Pharmacies in Rwanda

Amon Nsengimana,1 Emmanuel Biracyaza,2,3 Joyce Isimbi,4 Charles Uwambajimana,4 Jean Claude Hategekimana,4 Vedaste Kagisha,4 Domina Asingizwe,5,6 Jean Baptiste Nyandwi4,6 1US Agency for International Development Global Health Supply Chain Program, Procurement and Supply Chain Management, Kigali, Rwanda; 2School of Rehabilitation, Faculty of Medicine, Université de Montréal, Québec, Canada; 3Centre for Interdisciplinary Research in Rehabilitation of Greater Montreal (CRIR), Montreal, Canada; 4Department of Pharmacy, University of Rwanda, Kigali, Rwanda; 5Department of Physiotherapy; University of Rwanda, Kigali, Rwanda; 6East African Community Regional Centre of Excellence for Vaccines, Immunization and Health Supply Chain Management, University of Rwanda, Kigali, RwandaCorrespondence: Amon Nsengimana, Email [email protected]: This study aimed to explore the request and dispensing of antimalarial medicines without a prescription in community pharmacies in Rwanda, as well as factors associated.Methods: We employed an embedded mixed-methods design that involved a convenience sample of 235 licensed community pharmacists between February and April 2022. To simultaneously collect qualitative and quantitative data, we used a self-administered questionnaire containing a combination of close and open-ended questions. Bivariate and multivariate regression analyses were performed to examine the relationship between dispensing antimalarial medicines without a prescription and the selected independent variables. Statistical significance was set at p< 0.05, and a 95% confidence interval was applied. The factors influencing the dispensing of antimalarial medicines without a prescription were analyzed using thematic content analysis as a qualitative analysis approach.Results: Most respondents (88.5%) were asked to dispense antimalarial medicines by clients without a prescription. More than half of them (54%) agreed, but 34.5% refused; instead, they referred clients to malaria diagnostic testing facilities. Those who had rapid diagnostic tests for malaria in stock (OR=2.08, 95% CI:1.1– 3.94), and thought that antimalarials were over-the-counter medicines (OR=7.03, 95% CI:2.01– 24.5) were more likely to dispense antimalarial medicines without prescriptions. The primary reasons reported by community pharmacists for dispensing antimalarial medicines without prescriptions included their prior knowledge of malaria diagnosis, client pressure, and fear of losing clients. However, non-adherence to negative results obtained from formal health facilities and long queues at these institutions have also been cited as additional factors driving clients to seek antimalarial medicines without prescriptions.Conclusion: Dispensing antimalarial medicines without prescriptions is a common practice in community pharmacies in Rwanda. The main factors contributing to this practice include lack of awareness regarding the classification of antimalarials as prescription medicines, the availability of malaria diagnostic tests, client pressure, and fear of losing clients.Keywords: request, antimalarial medicines, dispensing, community pharmacies, Rwand

Treatment of chronic myeloid leukemia in rural Rwanda: promising early outcomes

Purpose The burden of cancer is rising in low- and middle-income countries, yet cancer treatment requires resources that are often not available in these settings. Although management of chronic myeloid leukemia (CML) has been described in low- and middle-income countries, few programs involve patients treated in rural settings. We describe characteristics and early outcomes of patients treated for CML at rural district hospitals in Rwanda. Methods We conducted a retrospective review of patients with confirmed BCR-ABL–positive CML who were enrolled between July 1, 2009 and June 30, 2014. Types of data included patient demographics, diagnostic work up, treatment, clinical examination, laboratory testing, and death. Results Forty-three patients were included, with a maximum follow-up of 58 months. Of 31 patients who were imatinib-naïve at enrollment, 54.8% were men and the median age at diagnosis was 36.9 years (interquartile range: 29-42 years). Approximately two-thirds of patients (67.7%) were on the national public insurance scheme. The imatinib dose was reduced for 16 patients and discontinued for five. Thirty-two of the 43 patients continued to have normal blood counts at last follow-up. Four patients have died and four are lost to follow-up. Conclusion Our experience indicates that CML can be effectively managed in a resource-constrained rural setting, despite limited availability of on-site diagnostic resources or specialty oncology personnel. The importance of model public-private partnerships as a strategy to bring high-cost, life-saving treatment to people who do not have the ability to pay is also highlighted

Quality of Breast Cancer Treatment at a Rural Cancer Center in Rwanda

Purpose: As breast cancer incidence and mortality rise in sub-Saharan Africa, it is critical to identify strategies for delivery of high-quality breast cancer care in settings with limited resources and few oncology specialists. We investigated the quality of treatments received by a cohort of patients with breast cancer at Butaro Cancer Center of Excellence (BCCOE), Rwanda’s first public cancer center. Patients and Methods: We reviewed medical records of all female patients diagnosed with invasive breast cancer at BCCOE between July 2012 and December 2013. We evaluated the provision of chemotherapy, endocrine therapy, surgery, and chemotherapy dose densities. We also applied modified international quality metrics and estimated overall survival using interval-censored analysis. Results: Among 150 patients, 28 presented with early-stage, 64 with locally advanced, and 53 with metastatic disease. Among potentially curable patients (ie, those with early-stage or locally advanced disease), 74% received at least four cycles of chemotherapy and 63% received surgery. Among hormone receptor–positive patients, 83% received endocrine therapy within 1 year of diagnosis. Fifty-seven percent of potentially curable patients completed surgery and chemotherapy and initiated endocrine therapy if indicated within 1 year of biopsy. Radiotherapy was not available. At the end of follow-up, 62% of potentially curable patients were alive, 24% were dead, and 14% were lost to follow-up. Conclusion: Appropriate delivery of chemotherapy and endocrine therapy for breast cancer is possible in rural sub-Saharan African even without oncologists based on site. Performing timely surgery and ensuring treatment completion were key challenges after the opening of BCCOE. Further investigation should examine persistent quality gaps and the relationship between treatment quality and survival

Quality of Breast Cancer Treatment at a Rural Cancer Center in Rwanda

Purpose: As breast cancer incidence and mortality rise in sub-Saharan Africa, it is critical to identify strategies for delivery of high-quality breast cancer care in settings with limited resources and few oncology specialists. We investigated the quality of treatments received by a cohort of patients with breast cancer at Butaro Cancer Center of Excellence (BCCOE), Rwanda’s first public cancer center. Patients and Methods: We reviewed medical records of all female patients diagnosed with invasive breast cancer at BCCOE between July 2012 and December 2013. We evaluated the provision of chemotherapy, endocrine therapy, surgery, and chemotherapy dose densities. We also applied modified international quality metrics and estimated overall survival using interval-censored analysis. Results: Among 150 patients, 28 presented with early-stage, 64 with locally advanced, and 53 with metastatic disease. Among potentially curable patients (ie, those with early-stage or locally advanced disease), 74% received at least four cycles of chemotherapy and 63% received surgery. Among hormone receptor–positive patients, 83% received endocrine therapy within 1 year of diagnosis. Fifty-seven percent of potentially curable patients completed surgery and chemotherapy and initiated endocrine therapy if indicated within 1 year of biopsy. Radiotherapy was not available. At the end of follow-up, 62% of potentially curable patients were alive, 24% were dead, and 14% were lost to follow-up. Conclusion: Appropriate delivery of chemotherapy and endocrine therapy for breast cancer is possible in rural sub-Saharan African even without oncologists based on site. Performing timely surgery and ensuring treatment completion were key challenges after the opening of BCCOE. Further investigation should examine persistent quality gaps and the relationship between treatment quality and survival

Patient characteristics, early outcomes, and implementation lessons of cervical cancer treatment services in rural Rwanda

Purpose Low- and middle-income countries account for 86% of all cervical cancer cases and 88% of cervical cancer mortality globally. Successful management of cervical cancer requires resources that are scarce in sub-Saharan Africa, especially in rural settings. Here, we describe the early clinical outcomes and implementation lessons learned from the Rwanda Ministry of Health’s first national cancer referral center, the Butaro Cancer Center of Excellence (BCCOE). We hypothesize that those patients presenting at earlier stage and receiving treatment will have higher rates of being alive. Methods The implementation of cervical cancer services included developing partnerships, clinical protocols, pathology services, and tools for monitoring and evaluation. We conducted a retrospective study of patients with cervical cancer who presented at BCCOE between July 1, 2012, and June 30, 2015. Data were collected from the electronic medical record system and by manually reviewing medical records. Descriptive, bivariable and multivariable statistical analyses were conducted to describe patient demographics, disease profiles, treatment, and clinical outcomes. Results In all, 373 patients met the study inclusion criteria. The median age was 53 years (interquartile rage, 45 to 60 years), and 98% were residents of Rwanda. Eighty-nine percent of patients had a documented disease stage: 3% were stage I, 48% were stage II, 29% were stage III, and 8% were stage IV at presentation. Fifty percent of patients were planned to be treated with a curative intent, and 54% were referred to chemoradiotherapy in Uganda. Forty percent of patients who received chemoradiotherapy were in remission. Overall, 25% were lost to follow-up. Conclusion BCCOE illustrates the feasibility and challenges of implementing effective cervical cancer treatment services in a rural setting in a low-income country