Prevalence, impact and management of postmenopausal symptoms among postmenopausal women in Rwanda.

OBJECTIVE: This study aimed at evaluating the prevalence and management of postmenopausal symptoms among Rwandan women. METHODS: A descriptive cross-sectional study was conducted at the four largest Rwandan referral hospitals from August 2017 to March 2018 among postmenopausal women. Data on postmenopausal symptoms were collected using the Modified Blatt-Kupperman Menopausal Index and score ranges of 0-6, 7-15, 16-30 and >30 were used to rate the degree of severity as none, mild, moderate, and severe, respectively. RESULTS: Six hundred participants were recruited. The mean age at natural menopause was 51.7 ± 5.6 years. Common symptoms were hot flushes (82%), sexual complaints (66%) and headache (61%). The mean Blatt-Kupperman index score was 21.2 (1-58). Participants' symptoms were classified as severe (35.8%), moderate (49.0%), mild (11.3%) and none (3.8%). Among 41.2% who had sought medical care, 1.7% were given hormonal replacement and 36% were given only pain medications. Age >50 years and lack of a male partner were significantly associated with higher scores. CONCLUSIONS: Postmenopausal symptoms remain a burden among Rwandan women and little consideration is given for optimal management. There is a need for health managers to consider this inevitable phase of life on the health policy agenda for equitable healthy aging.

Oncology Training in Rwanda: Challenges and Opportunities for Undergraduate Medical Students (The EDUCAN Project).

A critical shortage of trained cancer specialists is one of the major challenges in addressing the increasing cancer burden in low- and middle-income countries. Inadequate undergraduate cancer education in oncology remains a major obstacle for both task shifting to general practitioners and for training of specialists. We provide the first report of cancer education in Rwanda's undergraduate program to survey how new graduates are prepared to provide care for cancer patients. Anonymous online survey was sent January to June 2017 to medical students in their senior clinical years (years 5 and 6). Questions related to the demographics, medical curriculum, and general oncology exposure were included in the survey. Of 192 eligible students, 42% (n = 80) completed the survey and were analyzed. The majority were 25 to 29 years of age and 41% were female. Internal medicine was cited to provide the most exposure to cancer patients (50%) and cancer bedside teaching (55%). Close to a half (46%) have been taught oncology formally in addition to bedside teaching. A tenth (11%) of the participants felt comfortable in attending a cancer patient, and a fifth (21%) of the students felt comfortable while addressing multimodality treatment approach. The majority (99%) of the participants preferred having a formal oncology rotation. Of particular interest, 61% of the students are interested in pursuing an oncology career path. There is a need to modify the current oncology undergraduate curriculum to prepare future physicians for delivering cancer care in Rwanda. Raising the profile of oncology in undergraduate medical education will complement the on-going efforts to increase the country's capacity in task shifting and in training of cancer specialists.

Persistence rate of cervical human papillomavirus infections and abnormal cytology in Rwanda.

OBJECTIVES: In this study, we determined the incidence and persistence of human papillomavirus (HPV) strains and of squamous intraepithelial lesions (SIL) or worse cytology in 237 HIV-positive and HIV-negative Rwandan women and whether the interleukin (IL)-28B single nucleotide polymorphism (SNP) at rs12979860 correlated with susceptibility to and persistence of HPV infection. METHODS: Cervical samples were collected at baseline and after 9, 18 and 24 months for a 40-HPV DNA screening test and a ThinPrep Pap test. Genotyping of the IL-28B SNP rs12979860 was performed using real-time polymerase chain reaction (PCR). RESULTS: Chronic high-risk (HR) HPV infections occurred in 56% of HIV-positive women, while no HIV-negative women developed HPV chronicity. High-grade SIL (HSIL) or cancer was diagnosed in 38% of HIV-positive women with persistent HR-HPV infections. HIV and HR-HPV positivity at baseline were factors associated with an increased risk of HPV persistence. Additionally, HR-HPV positivity at baseline was associated with an increased risk of developing HSIL or worse cytology. The unfavourable T/x genotype at rs12979860 is common among Africans, and women with this genotype were found to be more commonly infected with HPV. CONCLUSIONS: HPV screening in Rwanda may help to identify women at risk of developing cervical cancer and polymorphism in IL-28B may be associated with risk of contracting  HPV infection.

Sexual risk behaviour in a cohort of HIV-negative and HIV-positive Rwandan women.

Here we wanted to assess whether sexual risk behaviour differs dependent by human immunodeficiency virus (HIV) status by following 100 HIV- and 137 HIV+ women recruited at two university teaching hospitals in Rwanda. Women were tested for sexually transmitted infections (STIs; trichomoniasis, syphilis, hepatitis B and C) and for reproductive tract infections (RTIs; candidiasis, bacterial vaginosis (BV)) and were interviewed at baseline and 9 months later. BV was the most prevalent infection, while syphilis was the most common STI with a 9-month incidence of 10.9% in HIV+ women. Only 24.5% of women positive for any RTI/STI contacted their health facility and got treatment. More HIV- women than HIV+ women had had more than one sexual partner and never used condoms during the follow-up period. The use of condoms was affected neither by marital status nor by concomitant STIs besides HIV. Our data highlight the importance of public education regarding condom use to protect against STIs in an era when HIV no longer is a death sentence.

Screening for human papillomavirus, cervical cytological abnormalities and associated risk factors in HIV-positive and HIV-negative women in Rwanda.

OBJECTIVES: Cervical cancer is the major cause of death from cancer in Africa. We wanted to assess the prevalence of human papillomavirus (HPV) infections and associated risk factors and to determine whether HPV testing could serve as a screening method for squamous intraepithelial lesions (SILs) in Rwanda. We also wanted to obtain a broader understanding of the underlying risk factors for the establishment of HPV infection in Rwanda. METHODS: A total of 206 HIV-positive women, 172 HIV-negative women and 22 women with unknown HIV status were recruited at the University Teaching Hospitals of Kigali (UTHK) and of Butare (UTHB) in Rwanda. Participants underwent an interview, cervical sampling for a Thinprep Pap test and a screening test analysing 37 HPV strains. RESULTS: Only 27% of HIV-positive women and 7% of HIV-negative women had been screened for cervical cancer before. HPV16 and HPV52 were the most common HPV strains. HIV-positive women were more commonly infected with high-risk (HR) HPV and multitype HPV than HIV-negative women. The sensitivity was 78% and the specificity 87% to detect high-grade SIL (HSIL) with HPV screening. Among HIV-negative women, being divorced was positively associated with HR-HPV infection, while hepatitis B, Trichomonas vaginalis infection and HR-HPV infection were factors positively associated with SILs. Ever having had gonorrhoea was positively associated with HR-HPV infection among HIV-positive women. HR-HPV infection and the number of live births were positively associated with SILs. CONCLUSIONS: The currently used quadrivalent vaccine may be insufficient to give satisfactory HPV coverage in Rwanda. HPV Screening may be effective to identify women at risk of developing cervical cancer, particularly if provided to high-risk patients.

Point-of-care utrasound use over six-month training period in Rwandan district hospitals

Introduction: Point-of-care ultrasound (POCUS) is an effective diagnostic technology in resource-limited settings. There is increasing interest in introducing ultrasound training in such environments, but few reports describing long-term follow-up and impact of a POCUS program in a resource-limited setting. We introduced a POCUS program in Rwanda, and sought to determine the number and type of ultrasounds performed, the impact of a remote quality assurance (QA) program, and the effect of POCUS on patient management. Methods: Seventeen Rwandan physicians underwent a ten-day training course in POCUS in Kigali, Rwanda. Post-course, participants tracked the ultrasounds they performed using a cloud-based storage system, recorded clinical impressions,and received periodic QA with on-site proctoring over a six-month follow-up. Remote QA to evaluate image quality was performed by five emergency ultrasound fellowshiptrained clinicians. Images were graded on a scale of 0­4. (0=no meaningful image, 2= adequate, 4= outstanding). Trainees also documented how POCUS changed clinical management. Results: Over six months, 1158 ultrasounds were performed and logged by fifteen participants at eleven regional hospitals. 590(50.9%) had matched images and interpretations available for review. Abdominal ultrasound was the most frequently performed application (19.7%), followed by liver (14.6%), obstetrics (14.5%), renal (12.4%),and spleen (11%). Across all applications, the mean score was 2.5 (SD± 0.11, 95% confidence interval, 2.39­2.54). Ultrasound result in a management change in 84% of cases. Major changes in management related to medication choice (42.4%), admission (30%), transfer to a higher level of care (28.1%), and performance of procedures (23.3%). Conclusions: During this six-month training program in Rwanda, participants used POCUS for a range of applications. The remote QA process captured 51% of ultrasounds performed. Of scans with QA, the average score was adequate to good. POCUS routinely changed clinical management. This study demonstrates the impact of POCUS in a resource-limited setting

International medical graduates in the USA: a qualitative study on perceptions of physician migration.

Objectives Physician migration from low-income to high-income nations is a global concern. Despite the centrality of understanding the perspectives of international medical graduates (IMGs) who have experienced migration to understanding the causes and consequences of this phenomenon, empirical literature is limited. The authors sought to characterise the experiences of IMGs from limited resource nations currently practicing primary care in the USA, with a focus on their perspectives on physician migration. Design The authors conducted a qualitative study utilising in-depth, in-person interviews and a standardised interview guide. The sample comprised a diverse, purposeful sample of IMGs (n=25) from limited resource nations (defined as having ≤2 physicians per 1000 population). Results Analyses revealed four recurrent and unifying themes reflecting the perspectives of IMGs in the USA on physician migration: (1) decisions to migrate were pragmatic decisions made in the context of individual circumstance; (2) the act of migration ultimately affected participants' ability to return home in multiple, unpredictable ways; (3) the ongoing process of acclimation was coupled with inherent conflicts surrounding the decision to remain in the USA; and (4) the effects of policies in both the home country and in the USA occurred at multiple levels. Conclusion The perspectives of IMGs who have migrated to the USA are an important addition to the ongoing discussion surrounding the global health workforce. Our findings highlight the effects of workforce policies which are often developed and discussed in abstraction, but have real, measurable impacts on the lives of individuals. Future efforts to address physician migration will need to acknowledge the immediate needs of the health workforce as well as the long-term needs of individuals within health systems.