Under-two child mortality according to maternal HIV status in Rwanda: assessing outcomes within the National PMTCT Program
Identifieur interne : 001537 ( Ncbi/Merge ); précédent : 001536; suivant : 001538Under-two child mortality according to maternal HIV status in Rwanda: assessing outcomes within the National PMTCT Program
Auteurs : Placidie Mugwaneza [Rwanda] ; Nadine Wa Shema Umutoni [Rwanda] ; Hinda Ruton [Rwanda] ; Alphonse Rukundo [Rwanda] ; Alexandre Lyambabaje [Rwanda] ; Jean De Dieu Bizimana [États-Unis] ; Landry Tsague [Rwanda] ; Claire M. Wagner [États-Unis] ; Elévanie Nyankesha [Rwanda] ; Jane Muita [Rwanda] ; Vincent Mutabazi [Rwanda] ; Jean Pierre Nyemazi [Rwanda] ; Sabin Nsanzimana [Rwanda] ; Corine Karema [Rwanda] ; Agnes Binagwaho [États-Unis, Rwanda]Source :
- The Pan African Medical Journal [ 1937-8688 ] ; 2011.
Abstract
We sought to compare risk of death among children aged under-2 years born to HIV positive mother (HIV-exposed) and to HIV negative mother (HIV non-exposed), and identify determinants of under-2 mortality among the two groups in Rwanda.
In a stratified, two-stage cluster sampling design, we selected mother-child pairs using national Antenatal Care (ANC) registers. Household interview with each mother was conducted to capture socio-demographic data and information related to pregnancy, delivery and post-partum. Data were censored at the date of child death. Using Cox proportional hazard model, we compared the hazard of death among HIV-exposed children and HIV non-exposed children.
Of 1,455 HIV-exposed children, 29 (2.0%; 95% CI: 1.3%-2.7%) died by 6 months compared to 18 children of the 1,565 HIV non-exposed children (1.2%; 95% CI: 0.6%-1.7%). By 9 months, cumulative risks of death were 3.0% (95%; CI: 2.2%-3.9%) and 1.3% (96%; CI: 0.7%-1.8%) among HIV-exposed and HIV non-exposed children, respectively. By 2 years, the hazard of death among HIV-exposed children was more than 3 times higher (aHR:3.5; 95% CI: 1.8-6.9) among HIV-exposed versus non-exposed children. Risk of death by 9-24 months of age was 50% lower among mothers who attended 4 or more antenatal care (ANC) visits (aHR: 0.5, 95% CI: 0.3-0.9), and 26% lower among families who had more assets (aHR: 0.7, 95% CI: 0.5-1.0).
Infant mortality was independent of perinatal HIV exposure among children by 6 months of age. However, HIV-exposed children were 3.5 times more likely to die by 2 years. Fewer antenatal visits, lower household assets and maternal HIV seropositive status were associated with increased mortality by 9-24 months.
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PubMed: 22145068
PubMed Central: 3215559
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wicri:level="1"><nlm:aff id="AF0001">Center for Treatment and Research on AIDS, Malaria, Tuberculosis and Other Epidemics, Kigali, Rwanda</nlm:aff><country xml:lang="fr">Rwanda</country><wicri:regionArea>Center for Treatment and Research on AIDS, Malaria, Tuberculosis and Other Epidemics, Kigali</wicri:regionArea><wicri:noRegion>Kigali</wicri:noRegion></affiliation></author><author><name sortKey="Ruton, Hinda" sort="Ruton, Hinda" uniqKey="Ruton H" first="Hinda" last="Ruton">Hinda Ruton</name><affiliation wicri:level="1"><nlm:aff id="AF0001">Center for Treatment and Research on AIDS, Malaria, Tuberculosis and Other Epidemics, Kigali, Rwanda</nlm:aff><country xml:lang="fr">Rwanda</country><wicri:regionArea>Center for Treatment and Research on AIDS, Malaria, Tuberculosis and Other Epidemics, Kigali</wicri:regionArea><wicri:noRegion>Kigali</wicri:noRegion></affiliation></author><author><name sortKey="Rukundo, Alphonse" sort="Rukundo, Alphonse" uniqKey="Rukundo A" first="Alphonse" last="Rukundo">Alphonse Rukundo</name><affiliation wicri:level="1"><nlm:aff id="AF0001">Center for Treatment and Research on AIDS, Malaria, Tuberculosis and Other Epidemics, Kigali, Rwanda</nlm:aff><country xml:lang="fr">Rwanda</country><wicri:regionArea>Center for Treatment and Research on AIDS, Malaria, Tuberculosis and Other Epidemics, Kigali</wicri:regionArea><wicri:noRegion>Kigali</wicri:noRegion></affiliation></author><author><name sortKey="Lyambabaje, Alexandre" sort="Lyambabaje, Alexandre" uniqKey="Lyambabaje A" first="Alexandre" last="Lyambabaje">Alexandre Lyambabaje</name><affiliation wicri:level="1"><nlm:aff id="AF0002">Department of Applied Mathematics, National University of Rwanda, Butare, Rwanda</nlm:aff><country xml:lang="fr">Rwanda</country><wicri:regionArea>Department of Applied Mathematics, National University of Rwanda, Butare</wicri:regionArea><wicri:noRegion>Butare</wicri:noRegion></affiliation></author><author><name sortKey="Bizimana, Jean De Dieu" sort="Bizimana, Jean De Dieu" uniqKey="Bizimana J" first="Jean De Dieu" last="Bizimana">Jean De Dieu Bizimana</name><affiliation wicri:level="3"><nlm:aff id="AF0003">Development Research Group, World Bank, Washington DC, USA</nlm:aff><country xml:lang="fr">États-Unis</country><wicri:regionArea>Development Research Group, World Bank, Washington DC</wicri:regionArea><placeName><settlement type="city">Washington (district de Columbia)</settlement><region type="state">District de Columbia</region></placeName></affiliation></author><author><name sortKey="Tsague, Landry" sort="Tsague, Landry" uniqKey="Tsague L" first="Landry" last="Tsague">Landry Tsague</name><affiliation wicri:level="1"><nlm:aff id="AF0004">UNICEF Rwanda, Kigali, Rwanda</nlm:aff><country xml:lang="fr">Rwanda</country><wicri:regionArea>UNICEF Rwanda, Kigali</wicri:regionArea><wicri:noRegion>Kigali</wicri:noRegion></affiliation></author><author><name sortKey="Wagner, Claire M" sort="Wagner, Claire M" uniqKey="Wagner C" first="Claire M" last="Wagner">Claire M. Wagner</name><affiliation wicri:level="3"><nlm:aff id="AF0005">Department of Global Health and Social Medicine, Harvard Medical School, Boston, USA</nlm:aff><country xml:lang="fr">États-Unis</country><wicri:regionArea>Department of Global Health and Social Medicine, Harvard Medical School, Boston</wicri:regionArea><placeName><settlement type="city">Boston</settlement><region type="state">Massachusetts</region></placeName></affiliation></author><author><name sortKey="Nyankesha, Elevanie" sort="Nyankesha, Elevanie" uniqKey="Nyankesha E" first="Elévanie" last="Nyankesha">Elévanie Nyankesha</name><affiliation wicri:level="1"><nlm:aff id="AF0004">UNICEF Rwanda, Kigali, Rwanda</nlm:aff><country xml:lang="fr">Rwanda</country><wicri:regionArea>UNICEF Rwanda, Kigali</wicri:regionArea><wicri:noRegion>Kigali</wicri:noRegion></affiliation></author><author><name sortKey="Muita, Jane" sort="Muita, Jane" uniqKey="Muita J" first="Jane" last="Muita">Jane Muita</name><affiliation wicri:level="1"><nlm:aff id="AF0004">UNICEF Rwanda, Kigali, Rwanda</nlm:aff><country xml:lang="fr">Rwanda</country><wicri:regionArea>UNICEF Rwanda, Kigali</wicri:regionArea><wicri:noRegion>Kigali</wicri:noRegion></affiliation></author><author><name sortKey="Mutabazi, Vincent" sort="Mutabazi, Vincent" uniqKey="Mutabazi V" first="Vincent" last="Mutabazi">Vincent Mutabazi</name><affiliation wicri:level="1"><nlm:aff id="AF0001">Center for Treatment and Research on AIDS, Malaria, Tuberculosis and Other Epidemics, Kigali, Rwanda</nlm:aff><country xml:lang="fr">Rwanda</country><wicri:regionArea>Center for Treatment and Research on AIDS, Malaria, Tuberculosis and Other Epidemics, Kigali</wicri:regionArea><wicri:noRegion>Kigali</wicri:noRegion></affiliation></author><author><name sortKey="Nyemazi, Jean Pierre" sort="Nyemazi, Jean Pierre" uniqKey="Nyemazi J" first="Jean Pierre" last="Nyemazi">Jean Pierre Nyemazi</name><affiliation wicri:level="1"><nlm:aff id="AF0001">Center for Treatment and Research on AIDS, Malaria, Tuberculosis and Other Epidemics, Kigali, Rwanda</nlm:aff><country xml:lang="fr">Rwanda</country><wicri:regionArea>Center for Treatment and Research on AIDS, Malaria, Tuberculosis and Other Epidemics, Kigali</wicri:regionArea><wicri:noRegion>Kigali</wicri:noRegion></affiliation></author><author><name sortKey="Nsanzimana, Sabin" sort="Nsanzimana, Sabin" uniqKey="Nsanzimana S" first="Sabin" last="Nsanzimana">Sabin Nsanzimana</name><affiliation wicri:level="1"><nlm:aff id="AF0001">Center for Treatment and Research on AIDS, Malaria, Tuberculosis and Other Epidemics, Kigali, Rwanda</nlm:aff><country xml:lang="fr">Rwanda</country><wicri:regionArea>Center for Treatment and Research on AIDS, Malaria, Tuberculosis and Other Epidemics, Kigali</wicri:regionArea><wicri:noRegion>Kigali</wicri:noRegion></affiliation></author><author><name sortKey="Karema, Corine" sort="Karema, Corine" uniqKey="Karema C" first="Corine" last="Karema">Corine Karema</name><affiliation wicri:level="1"><nlm:aff id="AF0001">Center for Treatment and Research on AIDS, Malaria, Tuberculosis and Other Epidemics, Kigali, Rwanda</nlm:aff><country xml:lang="fr">Rwanda</country><wicri:regionArea>Center for Treatment and Research on AIDS, Malaria, Tuberculosis and Other Epidemics, Kigali</wicri:regionArea><wicri:noRegion>Kigali</wicri:noRegion></affiliation></author><author><name sortKey="Binagwaho, Agnes" sort="Binagwaho, Agnes" uniqKey="Binagwaho A" first="Agnes" last="Binagwaho">Agnes Binagwaho</name><affiliation wicri:level="3"><nlm:aff id="AF0005">Department of Global Health and Social Medicine, Harvard Medical School, Boston, USA</nlm:aff><country xml:lang="fr">États-Unis</country><wicri:regionArea>Department of Global Health and Social Medicine, Harvard Medical School, Boston</wicri:regionArea><placeName><settlement type="city">Boston</settlement><region type="state">Massachusetts</region></placeName></affiliation><affiliation wicri:level="1"><nlm:aff id="AF0006">Ministry of Health of Rwanda, Kigali, Rwanda</nlm:aff><country xml:lang="fr">Rwanda</country><wicri:regionArea>Ministry of Health of Rwanda, Kigali</wicri:regionArea><wicri:noRegion>Kigali</wicri:noRegion></affiliation></author></analytic><series><title level="j">The Pan African Medical Journal</title><idno type="eISSN">1937-8688</idno><imprint><date when="2011">2011</date></imprint></series></biblStruct></sourceDesc></fileDesc><profileDesc><textClass></textClass></profileDesc></teiHeader><front><div type="abstract" xml:lang="en"><sec id="S0001"><title>Introduction</title><p>We sought to compare risk of death among children aged under-2 years born to HIV positive mother (HIV-exposed) and to HIV negative mother (HIV non-exposed), and identify determinants of under-2 mortality among the two groups in Rwanda.</p></sec><sec id="S0002"><title>Methods</title><p>In a stratified, two-stage cluster sampling design, we selected mother-child pairs using national Antenatal Care (ANC) registers. Household interview with each mother was conducted to capture socio-demographic data and information related to pregnancy, delivery and post-partum. Data were censored at the date of child death. Using Cox proportional hazard model, we compared the hazard of death among HIV-exposed children and HIV non-exposed children.</p></sec><sec id="S0003"><title>Results</title><p>Of 1,455 HIV-exposed children, 29 (2.0%; 95% CI: 1.3%-2.7%) died by 6 months compared to 18 children of the 1,565 HIV non-exposed children (1.2%; 95% CI: 0.6%-1.7%). By 9 months, cumulative risks of death were 3.0% (95%; CI: 2.2%-3.9%) and 1.3% (96%; CI: 0.7%-1.8%) among HIV-exposed and HIV non-exposed children, respectively. By 2 years, the hazard of death among HIV-exposed children was more than 3 times higher (aHR:3.5; 95% CI: 1.8-6.9) among HIV-exposed versus non-exposed children. Risk of death by 9-24 months of age was 50% lower among mothers who attended 4 or more antenatal care (ANC) visits (aHR: 0.5, 95% CI: 0.3-0.9), and 26% lower among families who had more assets (aHR: 0.7, 95% CI: 0.5-1.0).</p></sec><sec id="S0004"><title>Conclusion</title><p>Infant mortality was independent of perinatal HIV exposure among children by 6 months of age. However, HIV-exposed children were 3.5 times more likely to die by 2 years. Fewer antenatal visits, lower household assets and maternal HIV seropositive status were associated with increased mortality by 9-24 months.</p></sec></div></front><back><div1 type="bibliography"><listBibl><biblStruct></biblStruct><biblStruct><analytic><author><name sortKey="Newell, Ml" uniqKey="Newell M">ML Newell</name></author><author><name sortKey="Brahmbhatt, H" uniqKey="Brahmbhatt H">H Brahmbhatt</name></author><author><name sortKey="Ghys, Pd" uniqKey="Ghys P">PD Ghys</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Newell, Ml" uniqKey="Newell M">ML Newell</name></author><author><name sortKey="Coovadia, H" uniqKey="Coovadia H">H Coovadia</name></author><author><name sortKey="Cortina Borja, M" uniqKey="Cortina Borja M">M Cortina-Borja</name></author><author><name sortKey="Rollins, N" uniqKey="Rollins N">N Rollins</name></author><author><name sortKey="Gaillard, P" uniqKey="Gaillard P">P Gaillard</name></author><author><name sortKey="Dabis, F" 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<front><journal-meta><journal-id journal-id-type="nlm-ta">Pan Afr Med J</journal-id><journal-id journal-id-type="publisher-id">PAMJ</journal-id><journal-title-group><journal-title>The Pan African Medical Journal</journal-title></journal-title-group><issn pub-type="epub">1937-8688</issn><publisher><publisher-name>The African Field Epidemiology Network</publisher-name></publisher></journal-meta><article-meta><article-id pub-id-type="pmid">22145068</article-id><article-id pub-id-type="pmc">3215559</article-id><article-id pub-id-type="publisher-id">PAMJ-09-37</article-id><article-categories><subj-group subj-group-type="heading"><subject>Research</subject></subj-group></article-categories><title-group><article-title>Under-two child mortality according to maternal HIV status in Rwanda: assessing outcomes within the National PMTCT Program</article-title></title-group><contrib-group><contrib contrib-type="author"><name><surname>Mugwaneza</surname><given-names>Placidie</given-names></name><xref ref-type="aff" rid="AF0001">1</xref><xref ref-type="corresp" rid="cor1">&</xref></contrib><contrib contrib-type="author"><name><surname>Umutoni</surname><given-names>Nadine Wa Shema</given-names></name><xref ref-type="aff" rid="AF0001">1</xref></contrib><contrib contrib-type="author"><name><surname>Ruton</surname><given-names>Hinda</given-names></name><xref ref-type="aff" rid="AF0001">1</xref></contrib><contrib contrib-type="author"><name><surname>Rukundo</surname><given-names>Alphonse</given-names></name><xref ref-type="aff" rid="AF0001">1</xref></contrib><contrib contrib-type="author"><name><surname>Lyambabaje</surname><given-names>Alexandre</given-names></name><xref ref-type="aff" rid="AF0002">2</xref></contrib><contrib contrib-type="author"><name><surname>Bizimana</surname><given-names>Jean de Dieu</given-names></name><xref ref-type="aff" rid="AF0003">3</xref></contrib><contrib contrib-type="author"><name><surname>Tsague</surname><given-names>Landry</given-names></name><xref ref-type="aff" rid="AF0004">4</xref></contrib><contrib contrib-type="author"><name><surname>Wagner</surname><given-names>Claire M</given-names></name><xref ref-type="aff" rid="AF0005">5</xref></contrib><contrib contrib-type="author"><name><surname>Nyankesha</surname><given-names>Elévanie</given-names></name><xref ref-type="aff" rid="AF0004">4</xref></contrib><contrib contrib-type="author"><name><surname>Muita</surname><given-names>Jane</given-names></name><xref ref-type="aff" rid="AF0004">4</xref></contrib><contrib contrib-type="author"><name><surname>Mutabazi</surname><given-names>Vincent</given-names></name><xref ref-type="aff" rid="AF0001">1</xref></contrib><contrib contrib-type="author"><name><surname>Nyemazi</surname><given-names>Jean Pierre</given-names></name><xref ref-type="aff" rid="AF0001">1</xref></contrib><contrib contrib-type="author"><name><surname>Nsanzimana</surname><given-names>Sabin</given-names></name><xref ref-type="aff" rid="AF0001">1</xref></contrib><contrib contrib-type="author"><name><surname>Karema</surname><given-names>Corine</given-names></name><xref ref-type="aff" rid="AF0001">1</xref></contrib><contrib contrib-type="author"><name><surname>Binagwaho</surname><given-names>Agnes</given-names></name><xref ref-type="aff" rid="AF0005">5</xref><xref ref-type="aff" rid="AF0006">6</xref></contrib></contrib-group><aff id="AF0001"><label>1</label>Center for Treatment and Research on AIDS, Malaria, Tuberculosis and Other Epidemics, Kigali, Rwanda</aff><aff id="AF0002"><label>2</label>Department of Applied Mathematics, National University of Rwanda, Butare, Rwanda</aff><aff id="AF0003"><label>3</label>Development Research Group, World Bank, Washington DC, USA</aff><aff id="AF0004"><label>4</label>UNICEF Rwanda, Kigali, Rwanda</aff><aff id="AF0005"><label>5</label>Department of Global Health and Social Medicine, Harvard Medical School, Boston, USA</aff><aff id="AF0006"><label>6</label>Ministry of Health of Rwanda, Kigali, Rwanda</aff><author-notes><corresp id="cor1"><label>&</label>Corresponding author: Placidie Mugwaneza, TRAC Plus, Boulevard de la Revolution, BP 2717, Kigali, Rwanda</corresp></author-notes><pub-date pub-type="epub"><day>03</day><month>8</month><year>2011</year></pub-date><pub-date pub-type="collection"><year>2011</year></pub-date><volume>9</volume><elocation-id>37</elocation-id><history><date date-type="received"><day>18</day><month>5</month><year>2011</year></date><date date-type="accepted"><day>26</day><month>7</month><year>2011</year></date></history><permissions><copyright-statement>© Placidie Mugwaneza et al.</copyright-statement><copyright-year>2011</copyright-year><license license-type="open-access" xlink:href="http://creativecommons.org/licenses/by/2.0"><license-p>The Pan African Medical Journal - ISSN 1937-8688. This is an Open Access article distributed under the terms of the Creative Commons Attribution License which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.</license-p></license></permissions><abstract><sec id="S0001"><title>Introduction</title><p>We sought to compare risk of death among children aged under-2 years born to HIV positive mother (HIV-exposed) and to HIV negative mother (HIV non-exposed), and identify determinants of under-2 mortality among the two groups in Rwanda.</p></sec><sec id="S0002"><title>Methods</title><p>In a stratified, two-stage cluster sampling design, we selected mother-child pairs using national Antenatal Care (ANC) registers. Household interview with each mother was conducted to capture socio-demographic data and information related to pregnancy, delivery and post-partum. Data were censored at the date of child death. Using Cox proportional hazard model, we compared the hazard of death among HIV-exposed children and HIV non-exposed children.</p></sec><sec id="S0003"><title>Results</title><p>Of 1,455 HIV-exposed children, 29 (2.0%; 95% CI: 1.3%-2.7%) died by 6 months compared to 18 children of the 1,565 HIV non-exposed children (1.2%; 95% CI: 0.6%-1.7%). By 9 months, cumulative risks of death were 3.0% (95%; CI: 2.2%-3.9%) and 1.3% (96%; CI: 0.7%-1.8%) among HIV-exposed and HIV non-exposed children, respectively. By 2 years, the hazard of death among HIV-exposed children was more than 3 times higher (aHR:3.5; 95% CI: 1.8-6.9) among HIV-exposed versus non-exposed children. Risk of death by 9-24 months of age was 50% lower among mothers who attended 4 or more antenatal care (ANC) visits (aHR: 0.5, 95% CI: 0.3-0.9), and 26% lower among families who had more assets (aHR: 0.7, 95% CI: 0.5-1.0).</p></sec><sec id="S0004"><title>Conclusion</title><p>Infant mortality was independent of perinatal HIV exposure among children by 6 months of age. However, HIV-exposed children were 3.5 times more likely to die by 2 years. Fewer antenatal visits, lower household assets and maternal HIV seropositive status were associated with increased mortality by 9-24 months.</p></sec></abstract><kwd-group><kwd>HIV</kwd><kwd>PMTCT</kwd><kwd>maternal HIV infection</kwd><kwd>infant mortality</kwd><kwd>child mortality</kwd><kwd>under-five mortality</kwd><kwd>Rwanda</kwd></kwd-group></article-meta></front></pmc><affiliations><list><country><li>Rwanda</li><li>États-Unis</li></country><region><li>District de Columbia</li><li>Massachusetts</li></region><settlement><li>Boston</li><li>Washington (district de Columbia)</li></settlement></list><tree><country name="Rwanda"><noRegion><name sortKey="Mugwaneza, Placidie" sort="Mugwaneza, Placidie" uniqKey="Mugwaneza P" first="Placidie" last="Mugwaneza">Placidie Mugwaneza</name></noRegion><name sortKey="Binagwaho, Agnes" sort="Binagwaho, Agnes" uniqKey="Binagwaho A" first="Agnes" last="Binagwaho">Agnes Binagwaho</name><name sortKey="Karema, Corine" sort="Karema, Corine" uniqKey="Karema C" first="Corine" last="Karema">Corine Karema</name><name sortKey="Lyambabaje, Alexandre" sort="Lyambabaje, Alexandre" uniqKey="Lyambabaje A" first="Alexandre" last="Lyambabaje">Alexandre Lyambabaje</name><name sortKey="Muita, Jane" sort="Muita, Jane" uniqKey="Muita J" first="Jane" last="Muita">Jane Muita</name><name sortKey="Mutabazi, Vincent" sort="Mutabazi, Vincent" uniqKey="Mutabazi V" first="Vincent" last="Mutabazi">Vincent Mutabazi</name><name sortKey="Nsanzimana, Sabin" sort="Nsanzimana, Sabin" uniqKey="Nsanzimana S" first="Sabin" last="Nsanzimana">Sabin Nsanzimana</name><name sortKey="Nyankesha, Elevanie" sort="Nyankesha, Elevanie" uniqKey="Nyankesha E" first="Elévanie" last="Nyankesha">Elévanie Nyankesha</name><name sortKey="Nyemazi, Jean Pierre" sort="Nyemazi, Jean Pierre" uniqKey="Nyemazi J" first="Jean Pierre" last="Nyemazi">Jean Pierre Nyemazi</name><name sortKey="Rukundo, Alphonse" sort="Rukundo, Alphonse" uniqKey="Rukundo A" first="Alphonse" last="Rukundo">Alphonse Rukundo</name><name sortKey="Ruton, Hinda" sort="Ruton, Hinda" uniqKey="Ruton H" first="Hinda" last="Ruton">Hinda Ruton</name><name sortKey="Tsague, Landry" sort="Tsague, Landry" uniqKey="Tsague L" first="Landry" last="Tsague">Landry Tsague</name><name sortKey="Umutoni, Nadine Wa Shema" sort="Umutoni, Nadine Wa Shema" uniqKey="Umutoni N" first="Nadine Wa Shema" last="Umutoni">Nadine Wa Shema Umutoni</name></country><country name="États-Unis"><region name="District de Columbia"><name sortKey="Bizimana, Jean De Dieu" sort="Bizimana, Jean De Dieu" uniqKey="Bizimana J" first="Jean De Dieu" last="Bizimana">Jean De Dieu Bizimana</name></region><name sortKey="Binagwaho, Agnes" sort="Binagwaho, Agnes" uniqKey="Binagwaho A" first="Agnes" last="Binagwaho">Agnes Binagwaho</name><name sortKey="Wagner, Claire M" sort="Wagner, Claire M" uniqKey="Wagner C" first="Claire M" last="Wagner">Claire M. 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