How Rwanda, once torn by genocide, became a global anti-AIDS leader

JUDY WOODRUFF: Now our series "The End of AIDS?" turns from America's epidemic to the one in sub-Saharan Africa. That's where the virus first emerged, and it remains the hardest-hit region, with an estimated 70 percent of all HIV infections worldwide.

The small nation of Rwanda, which many learned about decades ago because of a genocide there, has now mounted one of the most impressive HIV/AIDS responses in the world.

Correspondent William Brangham and producer Jason Kane continue our series, with support from the Pulitzer Center on Crisis Reporting.

WILLIAM BRANGHAM: At this hospital in a remote northern area of Rwanda, a small medical miracle is unfolding. This district, still in the grips of an HIV epidemic, has not recorded a single case of mother-to-child HIV transmission for three years.

Similar progress has been happening throughout Rwanda, outpacing many other places in the world, even many in the U.S.

DR. JEAN NEPO UTUMATWISHIMA: We sat down with local leaders. We sat down with the Ministry of Health team of supervisors. We discussed, "How can we make — how can we do better? Just to have zero case?"

Dr. Jean Nepo Utumatwishima says they did it with a creative mix of medicine, technology and what you might call aggressive neighborliness.

DR. JEAN NEPO UTUMATWISHIMA, Kinihira Provincial Hospital: Rwandans, they tend to hear much to their peers, to the people they live with.

WILLIAM BRANGHAM: You listen to who you know.

DR. JEAN NEPO UTUMATWISHIMA: You listen to who you know, and sometimes to who you share the situation.

WILLIAM BRANGHAM: To achieve this success, a fleet of influential women were recruited from local villages, and these women visited every pregnant woman in their area to make sure each one was educated and tested for HIV.

If untreated, an HIV-positive woman will often pass the virus to her baby at birth, or through breast-feeding. But HIV treatment can stop that. Using simple texting, the workers transmit results and information to the local health center, which then relays it to the main hospital.

DR. JEAN NEPO UTUMATWISHIMA: When the SMS reaches the central server, it goes directly to these computers.

WILLIAM BRANGHAM: Dr. Utumatwishima says working with infected pregnant women who are so consistently giving birth to babies free of the virus has been a huge source of pride for the nation's health care providers.

DR. JEAN NEPO UTUMATWISHIMA: We need a generation of kids who will never blame us. Who will never blame the country.

WILLIAM BRANGHAM: It's a remarkable success for a country many learned about through tragedy.

In 1994, one of the two main ethnic groups in Rwanda, the Hutus, turned on their neighbor Tutsis and slaughtered hundreds of thousands of them, often killing them with machetes. Millions more were displaced.

Government agencies, including much of the nation's health infrastructure, were left in shambles — a ripe opening for HIV.

Jon Cohen has covered the HIV/AIDS epidemic for more than 25 years for "Science" magazine, and he traveled with us for this series.

JON COHEN, "Science" Magazine: When I was here in 2000, they were trying to restart an AIDS program that had been completely destroyed.

WILLIAM BRANGHAM: So they had a good program prior to the genocide?

JON COHEN: They had one of the leading programs in sub-Saharan Africa in the early 1990s. And it was all destroyed.

WILLIAM BRANGHAM: Destroyed at the very moment HIV rates were spiking throughout the region.

DR. SABIN NSANZIMANA, Rwanda Biomedical Center: Everything was completely down, so it had to be built from zero.

WILLIAM BRANGHAM: Dr. Sabin Nsanzimana was in medical school during the rebuilding. He says he hated going to the AIDS wards, because all his training felt useless, the death so overwhelming.

DR. SABIN NSANZIMANA: Could not do anything to help them. What you could do only was to see people suffering without any help.

WILLIAM BRANGHAM: But Nsanzimana is now leading his nation's HIV/AIDS response, and he says everything has changed.

Today, health officials say 86 percent of HIV-positive Rwandans know their status, that 80 percent of those have started treatment, and 82 percent of those have now have fully suppressed the virus, making them far less likely to infect others.

Hitting 90 percent in each of those categories is what global health experts say will be a major step towards ending the epidemic, and Rwanda is almost there. Of course, the success of Rwanda's effort relies in large part on people actually adhering to their treatment plans.

Josiane Mukanyandwi is HIV-positive, but she's alive and well, and the virus is undetectable in her blood. That's what prevented her young son, Prince, from getting infected when he was born. But that diligence isn't easy. It involves long treks to the clinic, time she has to take off work. She's got checkups and treatment, long stretches of waiting and counseling, managing her meds. All of this even though Mukanyandwi feels perfectly fine.

JOSIANE MUKANYANDWI, Rwanda (through translator): It took one month to accept my status. I talked with my family, my parents, and I decided to come. Now I'm coming every month, and there is not a problem.

WILLIAM BRANGHAM: As Josiane leaves, a long line of moms follow through the clinic. They're all HIV-positive, their babies all negative.

DR. SABIN NSANZIMANA: Now it's time where we can say, "No more loss. Shouldn't lose any other life anymore. Because this country will be only be rebuilt by its own people."

WILLIAM BRANGHAM: The mother-to-child HIV transmission rate has fallen so sharply in Rwanda that, when the rare transmission does occur…

DR. PLACIDIE MUGWANEZA:, Rwanda Biomedical Center: She refused initially to start on treatment.

WILLIAM BRANGHAM: … health officials conduct a forensic examination of each case to see why it happened and how to prevent it next time.

DR. SABIN NSANZIMANA: We still have new infections. We still have people dying because of AIDS. And we still have children who are getting HIV from their mothers, so we shouldn't sleep.

WILLIAM BRANGHAM: Jon Cohen says that, in the aftermath of Rwanda's genocide, the nation built an even stronger HIV response.

JON COHEN: They had a chance to rebuild from the bottom up and to build a sturdy structure in terms of a health response, and they're starting to see the payoff of that.

WILLIAM BRANGHAM: So they seized an opportunity.

JON COHEN: Yes. I hate to be Pollyannish about any of this stuff. It's hard to sustain this sort of response they have today. And the place they want to go to next is really difficult to get to.

WILLIAM BRANGHAM: The last and most difficult steps to end the epidemic involve finding those who don't know they're infected, as well as helping those who are on medication stay the course.

WOMAN: When they give me pills, I started to refuse.

WILLIAM BRANGHAM: These young people, part of a local support group, are all HIV-positive. They were infected at birth by the virus that has also made most of them orphans. Most say they didn't learn their status until they developed AIDS as kids, and nearly died.

WOMAN: Like me, the first time I know it, I — I want to kill myself.

WILLIAM BRANGHAM: Compared to adults, adolescents are twice as likely to skip their meds, take them incorrectly or stop treatment altogether.

This can hurt their own health, and make them more likely to infect others. So, keeping these young people consistently on treatment is a crucial goal for the country.

JEAN-PAUL: It was a hard task for me to take my pills.

WILLIAM BRANGHAM: Why?

JEAN-PAUL: For the first thing, I would go off, play, and then forget the good time of taking medicine.

WILLIAM BRANGHAM: Eighteen-year-old Jean-Paul — that's not his real name — is one of those who needs help.

JEAN-PAUL: You're going to, like, need someone to, like, remind you. You're going to need a parent or a family member or a relative.

WILLIAM BRANGHAM: Like all these young people, Jean-Paul has been paired with another young man from the group, Alexis Nshimiyimana. Alexis is older than Jean-Paul. He's also HIV-positive, and he's been more consistent with his meds. His job now is to help Jean-Paul do the same.

The two hang out. They swap stories. They commiserate.

ALEXIS NSHIMIYIMANA: He asks some things. "What can I do?" I say, this is your life. It is not mine. You know? You may take medicine in order to live.

JEAN-PAUL: They're talking from experience, so we're open to them. He told me, "This is what you're going to do. You're going to change your time that you used to take your drugs to a time that is not going to be an obstacle to you."

WILLIAM BRANGHAM: But there are logistical obstacles as well. His mom and dad are both dead. He splits his time between his aunt's house and an uncle's across town. Jean-Paul still misses pills now and then, he said. But he's trying.

It's a lot of difficult things to deal with for someone your age.

JEAN-PAUL: That's part of life.

WILLIAM BRANGHAM: Part of life for an entire nation, as well. One that's striving to keep up its newfound progress against this epidemic.

For the "PBS NewsHour," I'm William Brangham in Kigali, Rwanda.

JUDY WOODRUFF: Some remarkable reporting.

And, tomorrow, our team reports on an innovative treatment program that's happening on a remote island in Kenya, and how they have figured out how to reach fishermen there.

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