Second-line antiretroviral therapy success rates and predictors among people living with HIV in Rwanda, 2019–2023

BACKGROUND: Despite advances in HIV treatment, managing people living with HIV (PLHIV) on second-line antiretroviral therapy (ART) remains challenging. Globally, second-line ART achieves an average viral suppression rate (VLS) of 81.2%. In Rwanda, evidence is limited; the most recent national study in 2016 reported a 17% failure rate. This study assessed current VLS proportions and predictors of second-line ART success in Rwanda. METHODS: A retrospective cohort study was conducted at 277 health facilities across Rwanda, including PLHIV who initiated second-line ART between January 2019 and December 2023. The primary outcome was VLS, defined as a viral load of ≤ 1000 copies/mL at the most recent measurement recorded at least six months after second-line initiation. Data were abstracted from patient files using a standardized tool, and multivariate logistic regression identified independent predictors of VLS. RESULTS: Analysis included 726 individuals; overall VLS was 88.8% (645/726). Most participants were female (63.9%), aged 35-49 years (38.7%), on protease inhibitor-based regimens (78.7%), and on ART for 10 years or more (80.9%). Participants aged 15-24 years had lower odds of VLS compared with the 35-49 year reference group (aOR = 0.34; 95% CI: 0.13-0.92), and students had lower odds than participants (aOR = 0.18; 95% CI: 0.06-0.51). Residence in Kigali City (aOR = 2.47; 95% CI: 1.07-6.26), Northern (aOR = 3.57; 95% CI: 1.37-10.95), and Southern Province (aOR = 3.84; 95% CI: 1.58-10.53) was independently associated with higher odds of VLS compared with Eastern Province. PLHIV with poor or moderate ART adherence had 0.25 times the odds of VLS (aOR = 0.25; 95% CI: 0.14-0.44); alcohol or illicit drug use (aOR = 0.44; 95% CI: 0.22-0.94) and NCD comorbidity (aOR = 0.22; 95% CI: 0.06-0.80) were also independently associated with lower VLS. CONCLUSION: Rwanda's second-line VLS of 88.8% exceeds the global average and improves on the 2016 estimate but remains below the UNAIDS 95% target. Targeted interventions addressing adherence, substance use, and regional disparities, and integrated NCD services are needed. Tailored youth-friendly care, peer support, and integrated mental health services should be prioritized to improve outcomes among younger populations.