Evaluating hepatitis B care outcomes in Rwanda : insights from national program data

Chronic hepatitis B virus (HBV) remains a significant global health challenge, requiring strong monitoring of HBV treatment and outcomes to inform elimination strategies. In Sub-Saharan Africa, data on HBV care and outcomes, including complications, mortality, and the impact of human immune-deficiency virus (HIV) co-infection, remain scarce. Rwanda has made progress in reducing HBV burden through systematic screening, national campaigns, and integrated vaccination programs, but gaps remain, especially in data on HBV epidemiology and HIV co-infection. This dissertation examined the HBV care cascade and treatment outcomes, including mortality and treatment success, in Rwanda from 2016 to 2023, with a focus on HIV co-infection impact. A retrospective cohort study analyzed six stages of the HBV care cascade, from diagnosis to treatment retention. Multilevel logistic regression identified factors affecting cascade progression. Among treated individuals, treatment success (defined as undetectable HBV DNA or normal alanine amino transaminase at 12 months) rates were calculated, and hospital clustering was addressed using multilevel regression. Crude mortality rates were estimated, and Cox regression assessed the impact of HBV/HIV co-infection on all-cause mortality, adjusting for socio-demographic and clinical factors. Among screened individuals, 138,512 were diagnosed with HBV. Of 57,520 individuals who tested positive with data available, 37.0% enrolled in care; 30.3% of them were eligible for treatment, 76.1% of the eligible initiated treatment, and 98.9% remained on treatment for ≥1-year. Individuals aged 35–54 were more likely to engage in care, initiate treatment, and remain on treatment than those under 35. People living 30–60 minutes from facilities were less likely to engage or remain in care than those closer. Treatment success was high, with comparable outcomes between HBV mono-infected and HBV/HIV co-infected individuals. Overall mortality was low; however, people with HBV/HIV co-infection had a threefold higher mortality rate than those with HBV mono-infection. The high treatment uptake and treatment success rates for Rwanda's national HBV program emphasize the importance of early treatment initiation, consistent follow-up, and affordable care, in improving outcomes in resource-limited settings. Given the disproportionate risk of mortality among people with HBV/HIV co-infection, strengthening early detection and timely treatment are crucial for reducing mortality and optimizing the HBV care continuum.