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The 1994 genocide against the Tutsi destroyed the health system in Rwanda. It is impressive that a small country like Rwanda has advanced its health system to the point of now offering near universal health insurance coverage. Through a series of strategic structural changes to its health system, catalyzed through international assistance, Rwanda has demonstrated a commitment towards improving patient and population health indicators. In particular, the rapid scale up of antiretroviral therapy (ART) has become a great success story for Rwanda. The country achieved universal coverage of ART at a CD4 cell count of 200 cells/mm3 in 2007 and increased the threshold for initiation of ART to ≤350 cells/mm3 in 2008. Further, 2013 guidelines raised the threshold for initiation to ≤500 cells/mm3 and suggest immediate therapy for key affected populations. In 2015, guidelines recommend offering immediate treatment to all patients. By reviewing the history of HIV and the scale-up of treatment delivery in Rwanda since the genocide, this paper highlights some of the key innovations of the Government of Rwanda and demonstrates the ways in which the national response to the HIV epidemic has catalyzed the implementation of interventions that have helped strengthen the overall health system.

IntroductionAwareness and knowledge of treatment as prevention (TasP) was assessed among HIV‐positive and HIV‐negative gay, bisexual and other men who have sex with men (GBMSM) in Vancouver, Canada.MethodsBaseline cross‐sectional survey data were analyzed for GBMSM enrolled, via respondent‐driven sampling (RDS), in the Momentum Health Study. TasP awareness was defined as ever versus never heard of the term "TasP." Multivariable logistic regression identified covariates of TasP awareness. Among those aware of TasP, men's level of knowledge of TasP was explored through an examination of self‐perceived knowledge levels, risk perceptions and short‐answer definitions of TasP which were coded as "complete" if three TasP‐related components were identified (i.e. HIV treatment, viral suppression and prevention of transmission). Information source was also assessed. Analyses were stratified by HIV status and RDS adjusted.ResultsOf 719 participants, 23% were HIV‐positive, 68% Caucasian and median age was 33 (Interquartile range (IQR) 26,47). Overall, 46% heard of TasP with differences by HIV status [69% HIV‐positive vs. 41% HIV‐negative GBMSM (p<0.0001)]. In adjusted models: HIV‐positive GBMSM were more likely to have heard of TasP if they were Canadian born, unemployed, not using party drugs and had higher CD4 counts; HIV‐negative GBMSM were more likely to have heard of TasP if they were Caucasian (vs. Aboriginal), students, had higher education, a regular partner and multiple sexual partners. Among those aware of TasP 91% of HIV‐positive and 69% of HIV‐negative GBMSM (p<0.0001) felt they knew "a lot" or "a bit in general" about TasP; 64 and 41% (p=0.002) felt HIV treatment made the risk of transmission "a lot lower"; and 21 and 13% (p<0.0001) demonstrated "complete" TasP definitions. The leading information source was doctors (44%) for HIV‐positive GBMSM and community agencies (38%) for HIV‐negative GBMSM, followed by gay media for both populations (34%).ConclusionsNearly half of GBMSM in this study reported having heard of TasP, yet only 14% demonstrated complete understanding of the concept. Variations in TasP awareness and knowledge by HIV status, and key socio‐demographic, behavioural and clinical factors, highlight a need for health communication strategies relevant to diverse communities of GBMSM in order to advance overall TasP health literacy.