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 cross-sectional study was conducted across 277 health facilities, including PLHIV who transitioned to second-line ART between January 2019 and December 2023. Data were abstracted from patient files using a standardized tool. Descriptive statistics summarized profiles, and multivariate logistic regression identified predictors of VLS, defined as viral load < 1000 copies/mL. Ethical approval was obtained from the University of Rwanda Institutional Review Board. Results Analysis included 726 individuals. Overall, VLS was 88.8%. Time from first-line failure to second-line initiation ranged 0–14 months (median: 5; IQR: 3–9). Most were female (63.9%), aged 35–49 years (38.7%), on protease inhibitor-based regimens (78.7%), and over 10 years on ART (71.7%). At switch, 83.2% had viral load ≥ 10,000 copies/mL. Compared to < 15 years, individuals aged 35–49 (aOR = 3.07; 95% CI: 1.07–8.11) and ≥ 50 (aOR = 3.31; 95% CI: 1.08–9.52) had higher odds of VLS. Residence in Northern (aOR = 2.67; 95% CI: 1.15–6.94) and Southern Provinces (aOR = 2.82; 95% CI: 1.25–7.05) predicted greater suppression than Eastern Province. Poor/moderate adherence (20%) reduced odds by 74% (aOR = 0.26; 95% CI: 0.15–0.43), and substance use (13.4%) reduced odds by 60% (aOR = 0.40; 95% CI: 0.21–0.79). No significant difference was observed between PI-based (89.0%) and DTG-based regimens (88.4%; p = 0.953). Youth aged 15–24 (80.5%) and students (75.6%) had lower, though nonsignificant, suppression. 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 are needed. Tailored youth-friendly care, peer support, and integrated mental health services should be prioritized to improve outcomes among younger populations.