The achievement of universal HIV coverage in one African country, Rwanda, has resulted in HIV diagnoses more than halving and annual incidence falling by 90%, the 2014 Treatment as Prevention workshop in Vancouver heard earlier this month.
Edward Mills of the British Columbia Centre for Excellence in HIV/AIDS, which runs a clinic in Rwanda, told the workshop that Rwanda was one of the first countries – in Africa or anywhere – to achieve universal coverage of HIV treatment under the World Health Organization (WHO) guidelines of 2009, which recommended treatment for people with CD4 counts below 350 cells/mm3. It is estimated that, as of this year, 93% of people living with diagnosed HIV with CD4 counts below 350 are on antiretroviral therapy (ART), and about 40% of all people with HIV, diagnosed and undiagnosed. The median CD4 count at diagnosis was 300 cells/mm3, which compares favourably with the median count in UK heterosexuals (about 275 cells/mm3).
Coverage is still patchy, with some centres reporting 80% coverage of all diagnosed people and others only 20%; one particularly challenging area is the slums and informal settlements on the outskirts of the capital, Kigali, where there are high levels of migrant workers and refugees from the war in the neighbouring Democratic Republic of Congo.
HIV prevalence in Rwanda is 2.9% of the adult population, or about 210,000 people: of these, more than half (123,317 at the last count) are taking ART.
This is already having a dramatic effect on HIV diagnoses and incidence. About 37,000 people tested positive for HIV in 2007: by 2011 diagnoses were down to 23,000 and last year they declined to 13,000. This is despite the number of HIV tests going up, and would be even more dramatic if it reflected true incidence: annual incidence of HIV in fact declined nearly tenfold from 0.25% a year in 2004 to 0.03% in 2012.
It is estimated that the current ART coverage level of 40% of the entire HIV-positive population is bringing down incidence at a year-on-year rate of 23%.
Rwanda is considering moving to treating people with CD4 counts under 500 cells/mm3, in accordance with the 2013 WHO guidelines. A second paper presented to the Treatment as Prevention workshop (Nsanzimana) calculated the costs and benefits of doing this.
It found that the increased coverage would cost $US12.7 million over five years, but that it would save $27.3 million because of fewer deaths and infections, a net gain of $14.6 million. There would be 6400 fewer AIDS-related deaths and 7586 fewer new HIV infections.
Mills M Nation-wide evaluation of HIV/AIDS prevention strategies in Rwanda: a multisectoral time-trend analysis. 2014 Treatment as Prevention Workshop, Vancouver, abstract 6027, 2014.
Nsanzimana S Benefits of the implementation of the 2013 WHO guidelines on HIV treatment in combination with test-and-treat strategy for key populations in Rwanda. 2014 Treatment as Prevention Workshop, Vancouver, abstract 6029, 2014.