title: Mortality along the continuum of HIV care in Rwanda: a model-based analysis.
abstract: HIV is the leading cause of death among adults in sub-Saharan Africa. However, mortality along the HIV care continuum is poorly described. We combine demographic, epidemiologic, and health services data to estimate where are people with HIV dying along Rwanda's care continuum.
  
  
  
  We calibrated an age-structured HIV disease and transmission stochastic simulation model to the epidemic in Rwanda. We estimate mortality among HIV-infected individuals in the following states: untested, tested without establishing care in an antiretroviral therapy (ART) program (unlinked), in care before initiating ART (pre-ART), lost to follow-up (LTFU) following ART initiation, and retained in active ART care. We estimated mortality among people living with HIV in Rwanda through 2025 under current conditions, and with improvements to the HIV care continuum.
  
  
  
  In 2014, the greatest portion of deaths occurred among those untested (35.4%), followed by those on ART (34.1%), reflecting the large increase in the population on ART. Deaths among those LTFU made up 11.8% of all deaths among HIV-infected individuals in 2014, and in the base case this portion increased to 18.8% in 2025, while the contribution to mortality declined among those untested, unlinked, and in pre-ART. In our model only combined improvements to multiple aspects of the HIV care continuum were projected to reduce the total number of deaths among those with HIV, estimated at 8177 in 2014, rising to 10,659 in the base case, and declining to 5,691 with combined improvements in 2025.
  
  
  
  Mortality among those untested for HIV contributes a declining portion of deaths among HIV-infected individuals in Rwanda, but the portion of deaths among those LTFU is expected to increase the most over the next decade. Combined improvements to the HIV care continuum might be needed to reduce the number of deaths among those with HIV.
authors.affiliation: Division of General Medical Disciplines, Stanford University, Stanford, CA, USA. ebd@stanford.edu.|Center for Health Policy and the Center for Primary Care and Outcomes Research, Stanford University, Stanford, CA, USA. ebd@stanford.edu.
authors.forename: Eran
authors.identifier: 0000-0002-8364-4711
authors.initials: E
authors.lastname: Bendavid
authors.affiliation: Center for Health Policy and the Center for Primary Care and Outcomes Research, Stanford University, Stanford, CA, USA.
authors.forename: David
authors.initials: D
authors.lastname: Stauffer
authors.affiliation: Institute of HIV Disease Prevention and Control, Rwanda Bio-Medical Center, Kigali, Rwanda.
authors.forename: Eric
authors.initials: E
authors.lastname: Remera
authors.affiliation: Institute of HIV Disease Prevention and Control, Rwanda Bio-Medical Center, Kigali, Rwanda.|Basel Institute for Clinical Epidemiology & Biostatistics and Swiss Tropical and Public Health Institute, University of Basel, Basel, Switzerland.
authors.forename: Sabin
authors.initials: S
authors.lastname: Nsanzimana
authors.affiliation: Precision Global Health, Vancouver, Canada.
authors.forename: Steve
authors.initials: S
authors.lastname: Kanters
authors.affiliation: Precision Global Health, Vancouver, Canada.
authors.forename: Edward J
authors.initials: EJ
authors.lastname: Mills
mesh_terms: D000293:Adolescent; D000328:Adult; D017954:Africa South of the Sahara / Q000453:epidemiology; D019380:Anti-HIV Agents / Q000627:therapeutic use; D023241:Antiretroviral Therapy, Highly Active; D003266:Continuity of Patient Care / Q000592:standards*; D005260:Female; D015658:HIV Infections / Q000188:drug therapy / Q000401:mortality*; D006801:Humans; D008297:Male; D008875:Middle Aged; D008962:Models, Theoretical; D012432:Rwanda / Q000453:epidemiology; D055815:Young Adult
chemical_list: D019380:Anti-HIV Agents
keywords: Antiretroviral coverage; Care cascade; Care continuum; HIV; Loss from care; Mortality; Rwanda; Universal test and treat