Rwanda’s HIV leadership on display at IAS 2025

The 13th International AIDS Society Conference on HIV Science (IAS 2025) is taking place this week in Rwanda, a country of just over 14 million people that has become a continental leader in HIV control, even as sub-Saharan Africa continues to bear over 60% of the global HIV burden.

Rwanda is one of only seven African countries to have achieved the UNAIDS 95-95-95 targets. Of the estimated 230,000 people living with HIV, 96% know their status, 98% of those are on treatment, and 98% are virally suppressed. Nearly 99% of HIV-positive pregnant women are receiving antiretroviral therapy, supporting the country’s efforts to eliminate mother-to-child transmission. In 2024, it recorded 3200 new HIV acquisitions.

Rwanda’s achievement is especially notable given its history. Just over three decades ago, the country’s health system collapsed following the 1994 genocide against the Tutsi.

“We have been building from scratch through leadership, partnerships, community-led approaches, and cross-sector innovation,” said Dr Sabin Nsanzimana, Rwanda’s Minister of Health. “Together, we met the UNAIDS 95-95-95 targets ahead of schedule and continue to harness cutting-edge science to deliver more targeted, integrated interventions.”

Building early systems of accountability and surveillance

Dr Kathryn Anastos, founder of Women's Equity in Access to Care and Treatment (WE ACTx), which provides medical and psychosocial services in Rwanda, told the conference that by 2004, the country’s HIV strategy already included structures not common in higher-income countries.

“There were required two-to-three-day educational sessions for patients so that they would understand the science and clinical importance,” she said. “Beyond providing antiretroviral therapy, there was a buddy system, every patient had a buddy who knew their status and would support them in adherence, and community health workers followed up with patients who did not return to health centres. Community health workers have remained central to Rwanda’s HIV response.”

Over the past two decades, the country has also maintained an Open Medical Record System (OpenMRS), allowing nationwide data sharing and continuous feedback to improve programme design. This infrastructure has supported not only the scale-up of HIV services but also enabled cohort-based research, a vital tool in guiding national strategies.

And when the World Health Organization recommended 'treat all' in 2016, Rwanda was among the first countries in the region to adopt the guidance. Comparative data from four east African countries showed that Rwanda experienced the most immediate increase in rapid antiretroviral therapy initiation (34%age points) with no decline in retention, compared to 26 points in Kenya and 18 in Burundi.

Since 2018, Rwanda has also partnered with ICAP at Columbia University to implement the Tracking with Recency Assays to Control the Epidemic (TRACE) initiative. The programme uses HIV recency testing, a method that helps identify whether a newly diagnosed infection is recent, to better understand where and among whom new infections are occurring.

Recency testing is offered to all newly diagnosed individuals, and their sexual contacts are reached through index testing and partner notification services. From August 2021 to October 2022, 1238 people newly diagnosed with HIV (aged 15 and older) were enrolled at 60 health facilities across Rwanda. Sexual contacts were offered HIV testing and recency testing if positive. Findings suggest this combined approach helps identify new infections earlier and supports more targeted responses.

A hallmark of Rwanda’s response is also its strong national co-ordination. All HIV-related partnerships are centrally managed to avoid duplication and optimise resource use.

“No implementing partner is allowed to provide services already being delivered by another,” added Dr Anastos.

Other additional enablers of Rwanda’s success presented to the conference include:

• strong political commitment and governance
• decentralised and free access to services
• community engagement and peer networks
• data-informed planning and surveillance
• broad coverage of viral load testing
• integrated services across HIV, tuberculosis, and sexual and reproductive health.

Challenges amidst the progress

Despite Rwanda’s progress, gaps remain. While national HIV prevalence is under 3%, it is far higher among key populations: 35% of female sex workers and 6% of men who have sex with men (MSM) are living with HIV.

Pre-exposure prophylaxis (PrEP) was introduced nationwide in 2019, prioritising key populations. However, at the end of 12 months, MSM had the highest retention, just under 60%, while female sex workers and adolescent girls and young women stabilised between 45 and 50%. The 'other' category fell to around 40%. These trends highlight the need for more supportive and tailored approaches to improve long-term PrEP adherence, especially in groups with lower retention.

Rwanda is also managing a shifting disease landscape. Since 2015, non-communicable diseases (NCDs) have caused more deaths than infectious diseases.

“It is now a double burden,” said Dr Nsanzimana. “We have managed to reduce HIV mortality, along with malaria, tuberculosis and other infectious diseases. But now we have people living longer with NCDs. That is why we are investing in systems. Strengthening health systems is going to be our mission going forward.”

Like many countries, Rwanda has had to adapt to the cut in global health funding. In response, it has prioritised essential programmes, delayed or restructured activities, and shifted in-person trainings and mentorship online. The government has also increased domestic financing through the national treasury.

“We need to continue funding and financing our programmes, it is an investment, not a cost. We have to make the science available to everyone. Long-acting tools must be brought to the community. We need to keep investing in community-led and differentiated service delivery because this works,” Dr Nsanzimana concluded.