HIV control in Rwanda:

Lessons and challenges

Sabin Nsanzimana,MD Institute of HIV disease prevention& control

• Landlocked East Africa nation,

• 26,388Km2:

• ~11.5 M, highest pop.density in Africa: 416 ppl./km2

• Life expectancy at birth m/f (years, 2013): 64/67

• HIV prevalence :3%

Country Profile

A Hilly Terrain a.k.a ‘’A country of a Thousand Hills and

thousand solutions

HIV incidence (2004 to 2014) New infections reduced by 50%.

0

5000

10000

15000

20000

25000

30000

35000

197

5

197

6

197

7

197

8

197

9

198

0

198

1

198

2

198

3

198

4

198

5

198

6

198

7

198

8

198

9

199

0

199

1

199

2

199

3

199

4

199

5

199

6

199

7

199

8

199

9

200

0

200

1

200

2

200

3

200

4

200

5

200

6

200

7

200

8

200

9

201

0

201

1

201

2

201

3

201

4

201

5

201

6

201

7

201

8

201

9

Number of new HIV infections

Total PLHIV deaths*

Annual AIDS deaths

TODAY

HIV Related deaths (2014) 78% decline in overall AIDS related deaths (2004 to 2014)

New HIV infection & AIDS related deaths in Rwanda Source: UNAIDS epi spectrum & RBC annual reports

Few years ago … Saving lives with Free Treatment for HIV Infection and Tuberculosis

Kim JY, Farmer P. N Engl J Med 2006;355:645-647.

Before After

March 2003 September 2003

0

1

2

3

4

5

6

7

8

15-19 20-24 25-29 30-34 35-39 40-44 45-49

DHS 2005 0.5 1.6 2.9 5.2 4.9 6.6 4.6

DHS 2010 0.5 1.5 2.9 3.9 6.3 6.7 5.7

RAIHIS 2013 0.4 1.0 2.1 4.4 5.0 7.2 6.5

PER

CEN

T H

IV P

REV

ALE

NC

E

DHS 2005 DHS 2010

Reduction of

HIV Prevalence

among youth

Peak prevalence RAIHIS 2013

RAIHIS : Rwanda AIDS Indicators and HIV Incidence survey

HIV Prevalence

National Average: 3% Male: 2.3% Female: 3.6%

City of Kigali 7.3%

• Even in Kigali, disparity of

prevalence

• High pockets of HIV prevalence:

FSWs: 51% (BSS2010)

HIV prevalence in Rwanda is 3% , BUT…

Source: Rwanda Demography Health Survey (DHS), 2010

51% Core transmitters (Highest prevalence)

Bridging Population (Moderate prevalence)

General Population (Lowest prevalence)

FSW: HIV Core Transmitters in Rwanda

Source: RBC, HMIS 2015

Patients on ART & Patients tested HIV+

0

10000

20000

30000

40000

50000

60000

2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014

New HIV positive cases

Year over year reduction

associated with every 10%

increase in ART coverage

results into 6% incidence

reduction

Effect of ART coverage on HIV prevention

Source: S. nsanzimana, E. mills & al. abstract,feb. CROI 2015, Seattle ,USA

New infections ~ 10,000

a

Deaths:~ 5000

c All HIV Infected 210,000

b

Treatment as Prevention (TasP)

Global 90-90-90 Targets & Current Status

*McMahon et al. 2015, estimates for LMIC for intention-to-treat

Rwanda’s Progress Towards 90-90-90

208,497

1 Nsanzimana et al, The Lancet HIV feb 2015 2 Drug Resistance Monitoring in selected sites, 2013 3 HMIS , June 2015

210,000

86%

85%

82%

4%

5%

8%

0

50000

100000

150000

200000

HIV Positive people Diagnosed On ART VL suppressed

(< 40 copies /ml)

# o

f H

IV i

nfe

cte

d p

eop

le

Target coverage in HIV program

Sources: 1TracNET data on current program enrollment

90-90-90 Target of 90% of PLHIV

know their status

Under test and treat

Aim to enroll ~36,000 people on

ART, mainly from current Pre-ART

patients1

WHO recommends to treat all HIV+ What next ?

How much?

Can we afford?

How can we operationalize the new recommendations?

How can we retain patients in care (especially healthy

patients)?

How can we measure the benefits and impact?

Can Rwanda afford Test and Treat ?

What are the benefits?

-

50,000

100,000

150,000

200,000

250,000

2013Guidelines

UniversalTreatment

Patient Numbers in 2020 at 95% coverage

8%

256,522

257,842 5%

Early analysis shows in Rwanda, Test & Treat could bring an additional 8% of patients on treatment, with a 5% increase in funding need

Source: 1 Epi Estimate RBC,2014

ARVs

Lab

personel

Ind costs

Early analysis into Universal Treatment in Rwanda suggests a reduction in the number of PLHIV by 2020

2012 2013 2014 2015 2016 2017 20182019 2020 2021 2022 2023 2024 2025 2026 2027 2028 2029 2030

-

50

100

150

200

250

300

1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39 41 43 45 47 49 51 53 55 57

Tho

usa

nd

s

Epi Estimates of PLHIV under 2013 Guidelines vs Universal Treatment

2013 Guidelines 2013 Guidelines Universal Treatment Universal Treatment

Source: 1 Epi Estimates RBC,2014

By adopting Test and Treat, Rwanda may be able to avert 17,800 more infections than under the 2013 Guidelines

-

500

1,000

1,500

2,000

2,500

-

0.5

1.0

1.5

2.0

2.5

3.0

20

14

20

15

20

16

20

17

20

18

20

19

20

20

20

21

20

22

20

23

20

24

20

25

20

26

20

27

20

28

20

29

20

30

Ad

dit

ion

al In

fect

ion

s av

erte

d

Ad

dit

ion

al C

ost

of

AR

T

Mill

ion

s

Incremental Cost and Impact of Moving from 2013 Guidelines to Universal Treatment

Cost increase Infections averted

Average

additional annual

costs for ARVs

and labs

= $ 1.4 million p.a

Additional Infections Averted by Scaling Up

17,800

SAVING:

1st line ARV costs for

17,800 people

= $3.5 million a year

Challenges remaining Funding reduction to support programs:

~40% of external HIV funding declined in 4 years

mainly from the GF and PEPFAR is a major barrier

to end AIDS

It is possible to see the end of AIDS from Rwanda

-With strategic use of resources

-Simplifications of models of care

- Ending AIDS is no longer dream

“La bataille n ‘est pas encore finie”

Conclusion

Acknowledgements • Eric Remera,

• Jpaul Uwizihiwe,

• J Claude Ntirenganya

• Kirk Catherine

• Mary Dain

• Heiner Bucher

• Edward Mills,

• Sophie Hadder

• Agnes Binagwaho

10/1/2015 Rwanda HIV Continuum Care 21

The courage of our convictions