Factors Associated With Viral Load Suppression Among Adolescents and Young Adults Living With HIV on ART in Rwanda: Data From Rwanda HIV Case-Based Surveillance, 2019-2025.

BACKGROUND: Adolescents and young adults living with HIV (AYALHIV) in sub-Saharan Africa have lower viral load (VL) suppression (VLS) rates than older adults. Rwanda lacks national-level evidence on predictors of VLS in this age group. This study assessed demographic and clinical determinants of VLS among AYALHIV aged 15-24 years on antiretroviral therapy (ART), using national case-based surveillance (CBS) data. METHODS: We conducted a retrospective cohort analysis of AYALHIV enrolled in Rwanda's CBS system who initiated ART between January 2019 and December 2025 and had a documented VL at least six months after ART initiation. The primary outcome, VLS, was defined as VL ≤ 1000 copies/mL. Modified Poisson regression with robust, facility-clustered standard errors was used to estimate prevalence ratios (PRs); missing covariate data were addressed using multiple imputation (m = 20), pooled using Rubin's rules. RESULTS: A total of 4140 participants across 458 health facilities were included. Most were female (88%) and aged 20-24 years (90.7%); 91.6% were initiated on a dolutegravir-based regimen, 98.7% demonstrated good adherence, and overall, 96.1% achieved VLS. In multivariable analysis, good adherence was the only factor independently associated with VLS, corresponding to a 70% higher prevalence of suppression relative to bad/moderate adherence (adjusted PR = 1.70; 95% CI: 1.33-2.19; p < 0.001). CONCLUSION: VLS among AYALHIV aged 15-24 years engaged in Rwanda's HIV care program is high, exceeding the UNAIDS 95% target. Country HIV programs should prioritize adherence-focused interventions and proactively address underlying barriers to adherence in order to sustain optimal treatment outcomes in this population.