Sustaining Rwanda's HIV response after elimination of PEPFAR funding: a modelling analysis of HIV epidemic and care continuum outcomes

Abstract Introduction HIV prevention and treatment supported by the United States President's Emergency Plan for AIDS Relief (PEPFAR) have saved millions of lives. Rwanda is among the most successful countries worldwide in achieving global targets with PEPFAR support. Abrupt PEPFAR funding uncertainty raises concerns about continued HIV epidemic control. We projected the impact of the Government of Rwanda's (GoR's) capacity to offset PEPFAR funding elimination on adult HIV epidemic and care continuum outcomes over 10 years. Methods Using an HIV policy model calibrated to Rwanda, we assessed capacity to sustain HIV services at: 50% (with no capacity by GoR to cover the PEPFAR funding gap), 75%, 90% and 100% (with full capacity by GoR to cover the gap). Scenarios involved reducing the number on antiretroviral therapy (ART), immediately discontinuing ART and proportionally decreasing HIV diagnosis, ART initiation, and care re‐engagement. We projected epidemic outcomes (HIV prevalence, HIV incidence, number with HIV, new HIV infections, deaths) and care continuum outcomes (percentage diagnosed, percentage on ART among those diagnosed, percentage virally suppressed among those on ART). We calculated differences in projected outcomes for partial or no capacity versus full capacity. Secondary analyses assessed the timing of the GoR's response. Results Compared to full capacity at 10 years, the model projected a 13.9%–38.7% increase in HIV prevalence and 69.0%–246.7% increase in HIV incidence across coverage capacity scenarios. This translated to 29,000–64,000 additional adults with HIV and 20,000–92,000 cumulative new adult HIV infections. Cumulative projected deaths increased by 10,000–51,200. The model projected continual reductions in percentage diagnosed at 10 years; percentage virally suppressed among those on ART was similar across scenarios. Higher, and more delayed, coverage capacity had projected outcomes similar to lower, and less delayed, coverage capacity. Outcomes for gradual increases in coverage capacity were generally similar to or better than full, but delayed, coverage capacity. Conclusions Even in countries like Rwanda that have achieved epidemic control, abrupt and persistent elimination of PEPFAR funding could drastically reverse critical gains. Evidence quantifying the consequences of different capacities to sustain HIV services underscores the high stakes of rapid and sufficient action.