Sustaining Rwanda's HIV response after elimination of PEPFAR funding: a modeling analysis

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 around the world in achieving global targets with PEPFAR support. However, abrupt funding uncertainty around PEPFAR raises concerns about continued HIV epidemic control. We projected the impact of the Government of Rwanda's (GoR's) capacity to offset the elimination of PEPFAR funding 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 PEPFAR funding gap). Scenarios were operationalized by reducing the number on antiretroviral therapy (ART), with immediate ART discontinuation and proportional decreases in HIV diagnosis, ART initiation, and care re-engagement. We projected HIV epidemic outcomes (HIV prevalence, HIV incidence, number with HIV, new HIV infections, deaths) and care continuum outcomes (percent diagnosed, percent on ART among those diagnosed, percent virally suppressed among those on ART). We calculated differences in projected outcomes for partial or no capacity versus full capacity. Secondary analyses assessed delayed coverage capacity by 1 and 3 years. 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 percent diagnosed at 10 years; percent 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. 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.