Linkage to and retention in HIV care and treatment in the Rwanda national HIV program

Sub Saharan Africa (SSA) region carries the highest burden on HIV globally, with more than 75% of people living with HIV and 65% of global new HIV infections according to UNAIDS. Despite tremendous efforts made over the last decade to control HIV, especially with rapid scale up of Anti-Retroviral Therapy (ART), AIDS remain the main cause of deaths among youth 15-24 years old and only 50% of people living with HIV (PLHIV) in SSA access ART. The UNAIDS has recently recommended that 90% of people living with HIV get tested, 90% of them receive ART and 90% of those on ART suppress viral load with the ambition to end IDS by 2030.This goal could be only achieved with strong testing services, linkage to care and retention on sustainable and well tolerated regimen.
We systematically studied these questions using data from the entire Rwanda national HIV program and presented different studies and examples of successful policy implementation. Our first study assessed the HIV incidence from a longitudinal cohort study, the first ever implemented in Rwanda. Previously the country relied heavily on mathematical modelling to estimate incidence with several limitations. Findings suggested an estimated national incidence of 0.27 infections per 100 person-years, 50% higher than the UNAIDS Spectrum/EPP model estimated incidence; however, our study suggested that incidence was characterized by multiple breakouts. To understand the linkage and retention in care, we conducted two studies on HIV continuum of care and predictors of lost to follow up and mortality in Rwanda. We found a high proportion of patients entering care in Rwanda’s HIV program retained with a low mortality and high proportion of PLHIV achieving viral suppression rates. Nonetheless, older age, low CD4 count at initiation and male sex were associated with disengagement from care and mortality on ART. The two studies also provided new evidence that cascade of care is a non-linear pathway wherein patients have multiple opportunities to leave and re-engage in care. In line with the new era of treating all HIV+ regardless of CD4 count, we assess a phased approach implementation of the new policy in Rwanda and what is required to move from evidence to policy change and implementation considerations. We also assessed political, and financial implications especially required to implement the new HIV guidelines. The second part of this thesis evaluated treatment outcome for patients who failed first and second line ART available regimens, suggesting that overall, 92.5% of patients on second line ART in Rwanda were retained in care and 83% achieved viral suppression. Defaulting from care was significantly associated with more recent initiation of ART- PI based regimen, low CD4 cell count and HIV viral load at initiation of ART while Viral failure was associated with younger age, advanced disease and low CD4 count at initiation. Our study on outcomes from Rwanda’s first national cohort of third-line ART indicated that, over 90% of all 55 patients ever started on third line ART achieved VL suppression. Only one patient died and all were retained in care; however, raised concerns of 10% of multi-drug resistant patients who have no other treatment options after failing third line ART. Finally, we assessed the magnitude of HIV among female sex workers (FSW), a group with alarming high prevalence (46%) and considered to be the bridge of HIV transmission in Rwanda. The study analysed a projected incidence of HIV among female sex workers and their male partners in Rwanda using a Markov model examining intervention effects. The study found significant success of current program interventions (ART, condom use) to reduce HIV incidence among FSW and also estimated that introduction of Prep expected in Rwanda in 2019, could prevent more new infections among FSW by 0.24%.