Children’s right to health in the context of the HIV epidemic: a case study of Rwanda

Abstract

Background: After the 1994 genocide, Rwanda based its development on pro-poor policies, promoting the equity and rights of children. The objective of this current research was to assess obstacles encountered by children living with human immunodeficiency virus (HIV) in exercising their rights to health. Design: Mixed methods were used to respond to four main research questions on the right to information and participation, quality of prevention, physical and mental development, and financial management of the pediatric HIV response. Qualitative research and field assessment were applied to analyse access to primary prevention among marginalised groups. The quality of World Health Organization (WHO) and United Nations Children’s Fund (UNICEF) policies, and the right to information and participation, were assessed by desk reviews. An assessment of non-governmental organization (NGO) reports and analysis of the cost-effectiveness of different prevention services - Prevention of Mother to Child Transmission (PMTCT) and male circumcision (MC) - were carried out. The validation of the Child Depression Index (CDI) was performed to assess its accuracy for the screening of depression in Rwandan HIV-positive children. Results: Marginalised parents do not have their primary prevention needs granted at 100% due to law, stigmatization and criminalisation. The analysis of PMTCT regimens and the total cost calculation of lifelong care and treatment showed that Short-course Highly Active Antiretroviral Therapy (Sc-HAART), with 12 months breastfeeding, allows more children to be alive and HIV-negative at 18 months old. The neonatal MC is the most cost- effective, has a better potential to achieve universal coverage, and is associated with greater acceptability, safety, and feasibility. The rights of children to information and participation were not being fulfilled. The CDI cut-off is six – sensitivity 97%, specificity 72%; and 25% of children living with HIV in the study have depression. NGOs lack transparency in their financial management. Conclusion: Legal framework improvement, better management by NGOs, timely scientific guidance from governing institutions coupled with primary prevention, and a cost-effective approach would have a higher financial return and lead to improved health outcomes.