Predictors of sustained human immunodeficiency virus viral-load suppression before and after the adoption of Treat All policy in Rwanda.

Abstract

Background: Sustained viral load (VL) suppression is an important indicator of successful treatment among people living with human immunodeficiency virus (HIV).

Aim: To assess trends of different VL outcomes before and after adoption of the Treat All policy among people living with HIV in Rwanda.

Methods: Between 2014 and 2017, VL suppression [VL suppression (VLS) < 200 copies/mL] was measured among people living with HIV from 28 healthcare facilities in Rwanda. Participant VL was measured at 6 months, 18 months, and 30 months. The unit of analysis was visit-pair, with subjects across four visit-pair categories: (1) Sustained VL suppression (VL < 200 copies/mL at two consecutive visits); (2) Persistent viremia (VL ≥ 200 copies/mL at two consecutive visits); (3) Viral rebound (VL < 200 copies/mL at prior visit only); and (4) Newly suppressed (VL < 200 copies/mL at subsequent visit only). Poisson regression models with generalized estimating equations were used to estimate adjusted incidence risk ratio (aIRR) and 95% confidence intervals (CIs) for factors associated with sustained VLS. To handle missing data, multiple imputations was performed.

Results: A total of 634 participants contributed 973 visit-pairs (295 single pairs and 339 double pairs). The median age was 37 years (interquartile range: 32-43 years). The incidence rates of sustained VLS, persistent viremia, viral rebound, and new suppression were 85.2%, 4.3%, 4.6%, and 5.7%, respectively. Young individuals aged 18-24 years had higher incidence of viral rebound compared to those 25 years or older (14.8% vs 4.3%; P = 0.011). Of the visit-pairs that had sustained VLS during the first two visits (49.8%; n = 485), 56.7% exhibited sustained VLS throughout follow-up. Compared to having no education, having at least primary education was associated with an increased likelihood of sustained VLS (aIRR = 1.09; 95%CI: 1.01-1.17). Those who presented with advanced HIV disease at baseline had a 12% reduced likelihood of sustained VLS (aIRR = 0.88; 95%CI: 0.79-0.99). Achieving sustained VLS did not differ before or after adoption of the Treat All policy. When the analysis was repeated on imputed datasets, similar results were found.

Conclusion: Although most people living with HIV have sustained VLS in Rwanda, individuals without formal education, those presenting with advanced HIV, and younger individuals were lagging on multiple outcomes. Interventions tailored to these individuals would improve treatment outcomes to achieve epidemic control.