{"paper_id":"0d86d54d-07f8-4c95-b016-e0bef9955704","body_text":"Factors Associated With Risky Sexual Behaviors Among People on Antiretroviral Therapy at Selected Health Centers in Rulindo District, Rwanda | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Factors Associated With Risky Sexual Behaviors Among People on Antiretroviral Therapy at Selected Health Centers in Rulindo District, Rwanda NGONGO UZILO, Mojeed Akorede Gbadamosi, Monica Mochama, Amos HABIMANA This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8682260/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 5 You are reading this latest preprint version Abstract Background As access to antiretroviral therapy (ART) expands, the health and longevity of people living with HIV (PLHIV) have improved. This may contribute to reduced risk perception and increased engagement in behaviours that facilitate HIV transmission. Risky sexual behaviours in this study include inconsistent condom use, multiple sexual partners, oral or anal sex, sex under the influence of alcohol, and transactional sex. This study assessed the prevalence of such behaviours and identified associated factors among PLHIV receiving ART at selected health centres in Rulindo District, Rwanda. Methods A cross-sectional quantitative study was conducted among 400 consenting PLHIV receiving ART at selected health centres. Probability proportional to size sampling ensured representative recruitment across centres. Data were collected via structured questionnaires. Modified Poisson regression with robust variance was performed using SPSS version 27 to estimate prevalence ratios with 95% confidence intervals. Ethical approval was obtained from Mount Kenya University, and Rutongo District Hospital granted permission. Results Of 400 PLHIV, 381 were sexually active, with complete data for risk assessment. Risky sexual behaviour was prevalent in 95.2% (362/381), with 71.6% classified as high risk. In adjusted models, female sex (aPR = 1.15; 95% CI: 1.03–1.29), age ≥ 46 years (aPR = 1.15; 95% CI: 1.03–1.28), and longer ART duration 10–15 years (aPR = 1.36; 95% CI: 1.18–1.58) or ≥ 16 years (aPR = 1.36; 95% CI: 1.17–1.57) were significantly associated with increased risk. Participants who missed ART doses showed lower risk (aPR = 0.88; 95% CI: 0.80–0.97). Sensitivity analyses confirmed the robustness of these associations. Conclusions Risky sexual behaviour was highly prevalent among PLHIV attending ART clinics in the Rulindo District. Several individual and treatment-related characteristics were associated with increased risk. These findings highlight the need to consider behavioural risk alongside clinical care in long-term ART settings. Antiretroviral therapy (ART) People living with HIV (PLHIV) Prevalence ratios Risky sexual behavior Rwanda Figures Figure 1 Background HIV remains a critical public health challenge in sub-Saharan Africa (SSA), which accounts for 67% of global infections, and the WHO African Region bears the world’s highest burden. In Rwanda, adult HIV prevalence is 3.0%, significantly lower than the SSA average (4.3%) and the WHO African Region average (3.4%), yet incidence persists at 0.08% (~ 5,400 new cases annually) [ 1 ]. Rwanda’s HIV epidemic is primarily driven by stable serodiscordant partnerships (65% of new infections), with additional contributions from key populations [ 2 ]. Risky sexual behaviours (RSB), such as condomless sex and multiple partners, among people living with HIV (PLHIV) on antiretroviral therapy (ART) exacerbate transmission risks and threaten progress [ 3 , 4 ]. Factors like alcohol use and non-disclosure of HIV status further amplify RSB, as evidenced in SSA-wide studies [ 5 ]. Though a prior Rwandan study at Kigeme Hospital identified RSB in 38% of sexually active PLHIV on ART [ 6 ], data from other districts (including Rutongo, where this study occurred) remain scarce. An observed surge in new HIV cases at Rutongo District Hospital’s catchment underscores the urgency to address RSB locally. This study assessed prevalence and predictors of RSB among PLHIV on ART at selected health centres in Rutongo District to inform targeted interventions. Method Study setting This study was conducted between 15 August, 2024 and 24 September, 2024 at three public health centers (Rulindo, Murambi, and Remera Mbogo) in the Rutongo District Hospital catchment area, Rulindo District, Rwanda. These centers collectively provided ART to 842 adult (≥ 18 years) people living with HIV (PLHIV) at the time of the study, constituting our target population. Study Population We enrolled PLHIV in ART clinics at the selected health centers. Inclusion Criteria : To be eligible, participants needed to be: (1) Diagnosed with HIV, (2) On ART for at least one year at one of the three study health centers, (3) Aged 18 years or older, and (4) Willing to participate and provide written informed consent. Exclusion Criteria : We excluded individuals under 18 years old and any adult meeting the inclusion criteria who declined to participate. Study Design We used a cross-sectional design. This means we collected data from our study population at a single point in time. This design was chosen because it efficiently allows us to estimate the prevalence of risky sexual behavior (RSB) among people living with HIV (PLHIV) on antiretroviral therapy (ART) in this setting and to examine potential associations between RSB and other factors (like substance use or clinical characteristics) at that specific time. It was practical for collecting potentially sensitive behavioral data using a questionnaire within the clinic setting. Variables: Primary Outcome (Risky Sexual Behavior - RSB) : Risky sexual behavior (RSB) was assessed using six behavioral indicators: number of sexual partners, condom use, engagement in transactional sex, sex under the influence of alcohol or drugs, and engagement in oral or anal sex. Each risky behavior contributed to a cumulative risk score ranging from 0 to 6. the outcome variable was reclassified into a binary measure for regression analysis: Low Risk (score = 0) – Reference group Moderate/High Risk (score ≥ 1) – Indicates engagement in at least one risky sexual behavior This binary classification is consistent with prior studies using similar composite indices for behavioral risk. Key Independent Variables : These included socio-demographics (age, gender, education, occupation, marital status, religion), individual factors (alcohol consumption frequency/patterns, use of other substances), and clinical factors (self-reported WHO clinical stage, most recent viral load result [undetectable/detectable], current ART regimen). All variables were assessed using a structured questionnaire. Sampling: We needed a sample large enough to provide precise prevalence estimates. Using the Yamane formula (n = N / [1 + N(e²)]) [ 7 ], with a total population (N) of 842 and a desired margin of error (e) of 5%, we calculated a minimum sample size of 400 participants. To ensure proportional representation across the three health centers, we used Probability Proportional to Size (PPS) sampling to allocate the 400 participants (Table 1 ). Within each health center's ART patient list, we used systematic random sampling to select participants. We calculated a sampling interval (k = N_site / n_site) for each site. Starting from a randomly chosen number between 1 and k, we selected every k-th eligible patient on the list until the site's sample size was reached. Table 1 Sample Allocation by Health Center Selected Health Center Target Population Sample Size Rulindo Health Center 427 203 Remera Mbogo Health Center 205 97 Murambi Health Center 210 100 Total 842 400 Data Collection: Instrument : We used a structured, self-administered questionnaire adopted from a previously published WHO instrument on sexual health assessment(15). Minor modifications were made to align it with study objectives and the local context. It covered: participant information/consent, socio-demographics, substance use, RSB (using our operational definition above), and clinical information. Questions were primarily closed-ended (tick boxes, multiple choice). Data Collectors and Training : Data collection was managed by trained ART nurses from each health center who were not involved in the direct clinical care of the participants they surveyed. These nurses participated in a standardized two-day training workshop. The training covered the study objectives, questionnaire administration, ethical procedures (emphasizing confidentiality, voluntary participation, and obtaining informed consent), how to assist participants with low literacy, and standardized methods for answering questions without influencing responses. Procedure : Potential participants were approached by the trained ART nurse data collectors during their routine clinic visits. The study's purpose, procedures, risks, and benefits were explained verbally. Written informed consent was obtained before questionnaire distribution. Participants completed the questionnaire privately in the ART clinic room. For participants with limited literacy, the data collector read the questions aloud verbatim and recorded the participant's responses anonymously. Completed questionnaires were collected immediately by the data collector and stored securely. The principal investigator maintained close communication with data collectors to resolve any queries promptly. Instrument Validity and Reliability: Validity : To ensure the questionnaire measured what it intended (validity), its content was reviewed by an expert from the Care and Treatment Unit within the HIV Division at the Rwanda Biomedical Centre. We discussed the relevance, clarity, and comprehensiveness of the items, particularly the RSB section adapted for our context, and incorporated their feedback. Reliability and Feasibility : We pre-tested the final questionnaire with 20 PLHIV meeting the inclusion criteria at Kiyanza Health Center (a similar health center in the same catchment area, excluded from the main study). The pre-test assessed clarity of questions, time to completion, and overall feasibility. Minor adjustments were made to wording and flow based on participant feedback. While the primary goal was feasibility and comprehension, the pre-test also provided an initial check on internal consistency for key scales (like RSB items). Statistical Analysis: We used SPSS version 27 for all analyses. Descriptive statistics summarized participant characteristics and RSB categories. To estimate the association between independent variables and risky sexual behavior, we used modified Poisson regression with robust standard errors, implemented via the Generalized Linear Models (GENLIN) procedure in SPSS. This approach is preferred when the outcome is common, as it directly estimates prevalence ratios (PRs) and avoids the overestimation associated with odds ratios from logistic regression [ 8 ]. We complied with the STROBE Guidelines in the reporting, presentation and interpretation of findings. The model specification included: Distribution : Poisson Link function : Log Robust estimator : Applied to correct standard errors Reference group : Low risk (RSB score = 0) Bivariate and multivariable models were fitted. In the multivariable model, all covariates were included simultaneously. Adjusted prevalence ratios (aPRs) with 95% confidence intervals were reported. A p-value less than 0.05 was considered statistically significant in all analyses. Results Participant Characteristics Table 2 shows the socio-demographic characteristics of the 400 PLHIV enrolled. Females accounted for 66.5% of participants, and 54.3% were aged ≥ 46 years. Primary education was reported by 85.0% of participants, and 93.3% reported farming as their primary occupation. Marital status was reported as married by 57.3% of participants, and 85.3% identified as Catholic. Care was received at Rulindo Health Centre by 50.9% of participants. Table 2 Socio-demographic characteristics of PLHIV attending ART at selected Health centres in Rulindo District, Northern Rwanda, 2024 (n = 400) Characteristic Category Frequency (n) Percentage (%) Sex Male 134 33.5 Female 266 66.5 Age (years) 18–25 19 4.8 25–35 69 17.3 35–45 95 23.6 ≥46 217 54.3 Education No formal education 27 6.6 Primary 340 85.0 Secondary 28 7.0 University 5 1.3 Occupation Employee 17 4.3 Entrepreneur 10 2.4 Farming 373 93.3 Marital status Single 84 21.0 Divorced 19 4.7 Widowed 68 17.0 Married 229 57.3 Religion Catholic 341 85.3 Protestant 48 12.0 Islam 2 0.5 Other 9 2.3 Health center Rulindo 203 50.9 Remera Mbogo 97 24.2 Murambi Health 100 24.9 Table 3 details clinical profiles. WHO HIV Stage 1 was reported in 68.0% of participants, and 97.5% were on a first-line ART regimen. The median duration of ART was 13 years (IQR: 9; range: 1–24 years). Missing at least one ART dose was reported by 21.0% of participants. Viral load suppression was observed in 92.8% of participants. Alcohol use and substance use were reported by 82.3% and 95.0% of participants, respectively. Table 3 Clinical characteristics of PLHIV attending ART at selected Health Centres in Rulindo District, Northern Rwanda, 2024 (n = 400) Characteristic Category Frquency (n) Percentage (%) Clinical stage of HIV Stage 1 272 68.0 Stage 2 60 15.0 Stage 3 62 15.5 Stage 4 6 1.5 ART regimen First line 390 97.5 Second line 10 2.5 Duration after ART (years) Medium (IQR) ᵃ 13 (9) Min, Max 1, 24 < 9 110 27.5 10–15 129 32.3 ≥ 16 142 35.5 Missed ART doses No 316 79.0 Yes 84 21.0 Latest viral load suppression status Suppressed 371 92.8 Unsuppressed 29 7.2 Drink alcohol No 71 17.7 Yes 329 82.3 Substance use No 20 5.0 Yes 380 95.0 Abbreviation : ART, Antiretroviral Therapy; IQR, Inter-quartile range; Min, Max, Minimum, Maximum ᵃVariable not normally distributed, Shapiro-Wilk p-value less than 0.05 Discussion In this study of 400 adults living with HIV on long-term ART in rural Rwanda, we found that risky sexual behavior (RSB) was alarmingly common: nearly 80% of participants engaged in moderate-to-high-risk practices. Key predictors of RSB included older age (≥ 46 years), female gender, and longer duration on ART (10 + years). Surprisingly, missing ART doses was associated with lower RSB. Viral load suppression, while high overall (93%), did not significantly influence risk behaviors. The high prevalence of RSB aligns with previous studies in sub-Saharan Africa showing persistent sexual risk among PLHIV despite expanded ART coverage. A comparable Rwandan study by Kagimbangabo et al. (2012) [ 9 ] reported high rates of inconsistent condom use and multiple partnerships among youth living with HIV, echoing our findings. However, our older adult population showed even higher rates of cumulative risk, suggesting age may not be as protective as often assumed. The link between long-term ART use and higher RSB is not new but often underexplored. Some literature suggests that perceived invulnerability after years of viral suppression can lead to behavioural disinhibition [ 10 ]. WHO’s 2021 guidelines for differentiated HIV care in Africa also flag behavioural complacency as a concern in long-term ART management, especially in resource-limited settings [ 11 ]. Our data support that warning. On the other hand, our finding that ART non-adherence was associated with lower RSB is surprising. One possible explanation is that people missing doses may also have poorer health or higher psychosocial stress, reducing sexual activity or opportunity. Alternatively, they might be more cautious due to perceived health risks. This finding differs from earlier work in Uganda [ 12 ] and Ethiopia [ 13 ], where non-adherence was typically associated with higher RSB, so it warrants further investigation. Finally, the lack of association between viral load suppression and sexual behaviour contrasts with studies in Uganda [ 12 ] and a systematic review [ 14 ], where viral suppression often correlated with reduced risk-taking. This difference might reflect our study’s context; nearly all participants were virally suppressed, leaving slight variation to detect. Limitations This study has several limitations. First, the cross-sectional design means we can't infer causality, only associations. For instance, we cannot say whether long-term ART use leads to RSB or if people with risky behaviour survive longer on ART. Second, self-reported sexual behaviour data are subject to social desirability and recall bias. Although interviewers were trained to reduce bias, underreporting of sensitive behaviours (like transactional sex or anal sex) is still possible. Third, our sample came from only two health centres in one district, limiting generalizability. In addition, our outcome variable, a cumulative RSB score, is not yet standardized across studies, though we based it on common WHO indicators. Lastly, we excluded some variables from multivariable models due to collinearity, which could have masked potential associations. Public health implications These findings suggest that Rwanda’s HIV programs need to move beyond biomedical targets and pay closer attention to behavioural risk, especially among older adults and long-term ART users. First, existing prevention messages should be tailored for PLHIV who have been on ART for a decade or more. Many individuals may feel \"safe\" due to viral suppression and no longer view themselves as infectious. Clear, age-appropriate messaging on continued sexual risk and transmission is essential. Second, counselling and adherence support services should incorporate sexual health discussions routinely, not just during ART initiation. The counterintuitive association between missed doses and lower RSB also highlights the need for more nuanced, individualized support; risk reduction counselling should not assume that good adherence always equals safer sex. Lastly, national HIV surveillance tools should include behavioural risk metrics to capture trends among older PLHIV. RSB data are often absent in routine care settings, leading to missed prevention opportunities. Conclusion We set out to assess how common risky sexual behaviour is among people living with HIV on ART in Rutongo District and what factors predict it. We found that 79% of participants engaged in moderate to high levels of risky behaviour, with higher rates among women, those aged 46 and older, and those on ART for more than 10 years. These findings suggest that behavioural risk remains high despite treatment and viral suppression. HIV programs in Rwanda should integrate targeted sexual health counselling into long-term ART care. Future research should explore why long-term ART users continue high-risk behaviours despite clinical stability. Abbreviations aPR Adjusted Prevalence Ratio ART Antiretroviral Therapy CI Confidence Interval FSW Female Sexual Workers HIV Human Immunodeficiency Virus n Number PLHIV People Living with HIV RBC Rwanda Biomedical Center SPSS Statistical Package for Social Sciences STIs Sexually Transmitted Infection UNAIDS Joint United Nations Programme on HIV/AIDS Declarations Ethics approval and consent to participate This study was conducted in selected health centers located in the catchment area of Rutongo District Hospital in Rulindo District, Rwanda, and was carried out in accordance with the principles of the declaration of Helsinki. Ethical approval was obtained from the Ethical Review Board of Mount Kenya University, Rwanda, under REF: MKU/ETHICS/23/01/2024(1). The study received also authorization from the administration of Rutongo District Hospital. After the clear explanation by the researcher of the study’s objectives, benefits, and process, all study participants voluntarily signed an informed consent before enrollment in the study. Confidentiality was strictly maintained; no personal identifiers were collected on the questionnaires, and data were stored securely on password-protected devices accessible only to the research team. Consent for publication Not applicable Clinical trial number Not applicable. Competing interest The authors declare that they have no competing interests Funding This study did not receive any financial support. Author Contribution NU was designed the study, and collected the data as part of his master of public health study. He also drafted the manuscript. MAG analyzed and interpreted the data and contributed to the manuscript revision. MM and AH supervised the study and contributed to reviewing and editing the manuscript. All authors reviewed and approved the final version of the manuscript before submission. Acknowledgement The author acknowledges the support of the School of Public Health Department, Mount Kenya University, and appreciates the lecturers for their academic guidance. Special thanks to the UZILO family and my lovely wife Natacha for their support, as well as the Ngongo family and fellow doctors in Cancre City for their encouragement and inspiration. Data Availability All data generated or analysed during this study are included in this published article [and its supplementary information files] References Rwanda Population-Based HIV Impact Assessment (RPHIA). Rwanda Population-Based HIV Impact Assessment. RPHIA Summary Sheet. 2019 Oct. pp. 2–7. Available from: https://phia.icap.columbia.edu/wp-content/uploads/2019/10/RPHIA-Summary-Sheet_Oct-2019.pdf Ministry of Health Rwanda. Republic of Rwanda Ministry of Health national HIV/AIDS targets. Natl HIV/AIDS Targets [Internet]. 2020;1(Towards Ending AIDS Epidemics in Rwanda):18. Available from: https://rbc.gov.rw/IMG/pdf/rwanda_hiv_aids_2020_and_2030_targets.pdf Bekele Z, Mussa I, Assefa Y, Abera N, Amerga EW, Girma A et al. Risky sexual practice and associated factors among adult people living with HIV/AIDS in public hospitals of Kembata Tambaro Zone, Southern Ethiopia: A cross-sectional study. BMJ Open. 2023;13(7). Available from: https://doi.org/10.1136/bmjopen-2023-072505 Mosisa G, Woldemichael K, Ayalew F. Risky sexual behavior and associated factors among antiretroviral therapy attendees in Nekemte Referral Hospital, Western Ethiopia: A cross-sectional study. HIV AIDS (Auckl). 2018;10:125–31. Available from: https://doi.org/10.2147/HIV.S159670 Wondmeneh TG. Risky sexual behaviour among HIV-infected adults in Sub-Saharan Africa: A systematic review and meta-analysis. 2023;2023. Kagimbangabo JMV, Njau Ngomi N, Marete O. Factors influencing risky sexual behaviours of HIV-infected people on first-line antiretroviral therapy in Kigeme District Hospital, Rwanda: A cross-sectional study. Rwanda Med J. 2020;77(1):1–6. Yamane T, Statistics. An introductory analysis. 2nd ed. New York: Harper & Row; 1967. p. 886. Zou G. A modified Poisson regression approach to prospective studies with binary data. Am J Epidemiol. 2004;159(7):702–6. Kagimbangabo T, Medley A, Nyombayire J, Murenzi G, Small L, Mugwaneza P et al. Gender inequities in sexual risks among youth with HIV in Kigali, Rwanda. Int J STD AIDS. 2012;23(10):715–9. 10.1258/ijsa.2011.011339 . PMID: 22807531. Kembabazi A, Bajunirwe F, Hunt PW, Martin JN, Muzoora C, Haberer JE, et al. Disinhibition in risky sexual behavior in men, but not women, during four years of antiretroviral therapy in rural, southwestern Uganda. PLoS ONE. 2013;8(7):e69634. World Health Organization. Consolidated guidelines on HIV prevention, testing, treatment, service delivery and monitoring: recommendations for a public health approach. Geneva: World Health Organization; 2021 Jul. p. 16. Nakiganda LJ, Nakigozi G, Kagaayi J, Nalugoda F, Serwadda D, Sewankambo N, et al. Cross-sectional comparative study of risky sexual behaviours among HIV-infected persons initiated and waiting to start antiretroviral therapy in rural Rakai, Uganda. BMJ Open. 2017;7(9):e016954. Tadesse WB, Gelagay AA. Risky sexual practice and associated factors among HIV positive adults visiting ART clinics in public hospitals in Addis Ababa city, Ethiopia: a cross-sectional study. BMC Public Health. 2019;19:1–8. LeMessurier J, Traversy G, Varsaneux O, Weekes M, Avey MT, Niragira O, et al. Risk of sexual transmission of human immunodeficiency virus with antiretroviral therapy, suppressed viral load and condom use: a systematic review. CMAJ. 2018;190(46):E1350–60. World Heatlh Organization. Sexual Health Assessment of Practices and Experiences (SHAPE). 2023. Additional Declarations No competing interests reported. Supplementary Files SupplementaryTables2.pdf Cite Share Download PDF Status: Under Review Version 1 posted Reviewers invited by journal 26 Feb, 2026 Editor assigned by journal 26 Feb, 2026 Editor invited by journal 06 Feb, 2026 Submission checks completed at journal 05 Feb, 2026 First submitted to journal 05 Feb, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {\"props\":{\"pageProps\":{\"initialData\":{\"identity\":\"rs-8682260\",\"acceptedTermsAndConditions\":true,\"allowDirectSubmit\":false,\"archivedVersions\":[],\"articleType\":\"Research Article\",\"associatedPublications\":[],\"authors\":[{\"id\":598632142,\"identity\":\"3dc0ea98-6f01-4aaa-b9f4-71b4a5a2939b\",\"order_by\":0,\"name\":\"NGONGO UZILO\",\"email\":\"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA7klEQVRIiWNgGAWjYDADNnYGxgcfIAxitTAzMBvOgDCIBcwMbNI8EAZ+YM6/+NjDLxWH7fmYmQ9I2/zaJs/HzMD44WMObi2WM56lG8ucOczMxsyWYJzbd9uwDehCyZnbcGsxuHHGTFqy7TAbGzOPQXJuz21GoBY2Zl4itPCAtBy27LltT1jL+R4zyY9thyWAWgybGX7cTiTCFrY0aYYz6QZAvyQz9jbcTm5jZmzG75fzh49J/qiwtpdvbz7+48ef27bz25sPfviIRwuDRAIDMw+Mw9gGJhvwqAcC/gMMjD/gvD/4FY+CUTAKRsHIBADMC0mU3L7IkQAAAABJRU5ErkJggg==\",\"orcid\":\"\",\"institution\":\"Mount Kenya University\",\"correspondingAuthor\":true,\"prefix\":\"\",\"firstName\":\"NGONGO\",\"middleName\":\"\",\"lastName\":\"UZILO\",\"suffix\":\"\"},{\"id\":598632143,\"identity\":\"bb842580-ab22-4d0f-91e0-64e6bbd9636a\",\"order_by\":1,\"name\":\"Mojeed Akorede Gbadamosi\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"Mount Kenya University\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Mojeed\",\"middleName\":\"Akorede\",\"lastName\":\"Gbadamosi\",\"suffix\":\"\"},{\"id\":598632144,\"identity\":\"d8a43a0f-0a51-468c-9bba-97c2d3e39028\",\"order_by\":2,\"name\":\"Monica Mochama\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"Mount Kenya University\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Monica\",\"middleName\":\"\",\"lastName\":\"Mochama\",\"suffix\":\"\"},{\"id\":598632145,\"identity\":\"6f226d68-5411-48cd-acc3-336c62445d02\",\"order_by\":3,\"name\":\"Amos HABIMANA\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"Mount Kenya University\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Amos\",\"middleName\":\"\",\"lastName\":\"HABIMANA\",\"suffix\":\"\"}],\"badges\":[],\"createdAt\":\"2026-01-23 20:08:18\",\"currentVersionCode\":1,\"declarations\":\"\",\"doi\":\"10.21203/rs.3.rs-8682260/v1\",\"doiUrl\":\"https://doi.org/10.21203/rs.3.rs-8682260/v1\",\"draftVersion\":[],\"editorialEvents\":[],\"editorialNote\":\"\",\"failedWorkflow\":false,\"files\":[{\"id\":104170125,\"identity\":\"052439a6-2a5e-4645-9099-a3ceef973d26\",\"added_by\":\"auto\",\"created_at\":\"2026-03-08 14:44:16\",\"extension\":\"jpg\",\"order_by\":1,\"title\":\"Figure 1\",\"display\":\"\",\"copyAsset\":false,\"role\":\"figure\",\"size\":128656,\"visible\":true,\"origin\":\"\",\"legend\":\"\\u003cp\\u003e\\u003cem\\u003ePrevalence of risky sexual behaviour among PLHIV attending ART clinics in Rulindo District, Northern Rwanda (n = 381).\\u003c/em\\u003e\\u003c/p\\u003e\",\"description\":\"\",\"filename\":\"Picture1.jpg\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-8682260/v1/7fbcdb9d7e3b4150e3feb17f.jpg\"},{\"id\":104403794,\"identity\":\"c584632e-d909-4b91-95eb-794c68023270\",\"added_by\":\"auto\",\"created_at\":\"2026-03-11 12:19:04\",\"extension\":\"pdf\",\"order_by\":0,\"title\":\"\",\"display\":\"\",\"copyAsset\":false,\"role\":\"manuscript-pdf\",\"size\":1066916,\"visible\":true,\"origin\":\"\",\"legend\":\"\",\"description\":\"\",\"filename\":\"manuscript.pdf\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-8682260/v1/6a77e468-08ff-4e44-89a1-c87efed673f4.pdf\"},{\"id\":104170123,\"identity\":\"44ece739-7d24-49a5-822e-7a9d496fc68f\",\"added_by\":\"auto\",\"created_at\":\"2026-03-08 14:44:14\",\"extension\":\"pdf\",\"order_by\":0,\"title\":\"\",\"display\":\"\",\"copyAsset\":false,\"role\":\"supplement\",\"size\":208499,\"visible\":true,\"origin\":\"\",\"legend\":\"\",\"description\":\"\",\"filename\":\"SupplementaryTables2.pdf\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-8682260/v1/dfacebb13b63ea5145e6ddee.pdf\"}],\"financialInterests\":\"No competing interests reported.\",\"formattedTitle\":\"\\u003cp\\u003eFactors Associated With Risky Sexual Behaviors Among People on Antiretroviral Therapy at Selected Health Centers in Rulindo District, Rwanda\\u003c/p\\u003e\",\"fulltext\":[{\"header\":\"Background\",\"content\":\"\\u003cp\\u003eHIV remains a critical public health challenge in sub-Saharan Africa (SSA), which accounts for 67% of global infections, and the WHO African Region bears the world\\u0026rsquo;s highest burden. In Rwanda, adult HIV prevalence is 3.0%, significantly lower than the SSA average (4.3%) and the WHO African Region average (3.4%), yet incidence persists at 0.08% (~\\u0026thinsp;5,400 new cases annually) [\\u003cspan citationid=\\\"CR1\\\" class=\\\"CitationRef\\\"\\u003e1\\u003c/span\\u003e].\\u003c/p\\u003e \\u003cp\\u003eRwanda\\u0026rsquo;s HIV epidemic is primarily driven by stable serodiscordant partnerships (65% of new infections), with additional contributions from key populations [\\u003cspan citationid=\\\"CR2\\\" class=\\\"CitationRef\\\"\\u003e2\\u003c/span\\u003e]. Risky sexual behaviours (RSB), such as condomless sex and multiple partners, among people living with HIV (PLHIV) on antiretroviral therapy (ART) exacerbate transmission risks and threaten progress [\\u003cspan citationid=\\\"CR3\\\" class=\\\"CitationRef\\\"\\u003e3\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR4\\\" class=\\\"CitationRef\\\"\\u003e4\\u003c/span\\u003e]. Factors like alcohol use and non-disclosure of HIV status further amplify RSB, as evidenced in SSA-wide studies [\\u003cspan citationid=\\\"CR5\\\" class=\\\"CitationRef\\\"\\u003e5\\u003c/span\\u003e].\\u003c/p\\u003e \\u003cp\\u003eThough a prior Rwandan study at Kigeme Hospital identified RSB in 38% of sexually active PLHIV on ART [\\u003cspan citationid=\\\"CR6\\\" class=\\\"CitationRef\\\"\\u003e6\\u003c/span\\u003e], data from other districts (including Rutongo, where this study occurred) remain scarce. An observed surge in new HIV cases at Rutongo District Hospital\\u0026rsquo;s catchment underscores the urgency to address RSB locally. This study assessed prevalence and predictors of RSB among PLHIV on ART at selected health centres in Rutongo District to inform targeted interventions.\\u003c/p\\u003e\"},{\"header\":\"Method\",\"content\":\"\\u003cp\\u003e \\u003cstrong\\u003eStudy setting\\u003c/strong\\u003e \\u003cp\\u003eThis study was conducted between 15 August, 2024 and 24 September, 2024 at three public health centers (Rulindo, Murambi, and Remera Mbogo) in the Rutongo District Hospital catchment area, Rulindo District, Rwanda. These centers collectively provided ART to 842 adult (\\u0026ge;\\u0026thinsp;18 years) people living with HIV (PLHIV) at the time of the study, constituting our target population.\\u003c/p\\u003e \\u003c/p\\u003e \\u003cp\\u003e \\u003cstrong\\u003eStudy Population\\u003c/strong\\u003e \\u003cp\\u003eWe enrolled PLHIV in ART clinics at the selected health centers.\\u003c/p\\u003e \\u003c/p\\u003e \\u003cp\\u003e\\u003cul\\u003e\\u003cli\\u003e\\u003cp\\u003e\\u003cb\\u003eInclusion Criteria\\u003c/b\\u003e: To be eligible, participants needed to be: (1) Diagnosed with HIV, (2) On ART for at least one year at one of the three study health centers, (3) Aged 18 years or older, and (4) Willing to participate and provide written informed consent.\\u003c/p\\u003e\\u003c/li\\u003e\\u003cli\\u003e\\u003cp\\u003e\\u003cb\\u003eExclusion Criteria\\u003c/b\\u003e: We excluded individuals under 18 years old and any adult meeting the inclusion criteria who declined to participate.\\u003c/p\\u003e\\u003c/li\\u003e\\u003c/ul\\u003e\\u003c/p\\u003e \\u003cp\\u003e \\u003cstrong\\u003eStudy Design\\u003c/strong\\u003e \\u003cp\\u003eWe used a cross-sectional design. This means we collected data from our study population at a single point in time. This design was chosen because it efficiently allows us to estimate the prevalence of risky sexual behavior (RSB) among people living with HIV (PLHIV) on antiretroviral therapy (ART) in this setting and to examine potential associations between RSB and other factors (like substance use or clinical characteristics) at that specific time. It was practical for collecting potentially sensitive behavioral data using a questionnaire within the clinic setting.\\u003c/p\\u003e \\u003c/p\\u003e \\u003cdiv id=\\\"Sec3\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003eVariables:\\u003c/h2\\u003e \\u003cp\\u003e \\u003cul\\u003e \\u003cli\\u003e \\u003cp\\u003e \\u003cb\\u003ePrimary Outcome (Risky Sexual Behavior - RSB)\\u003c/b\\u003e: Risky sexual behavior (RSB) was assessed using six behavioral indicators: number of sexual partners, condom use, engagement in transactional sex, sex under the influence of alcohol or drugs, and engagement in oral or anal sex. Each risky behavior contributed to a cumulative risk score ranging from 0 to 6. the outcome variable was reclassified into a binary measure for regression analysis:\\u003c/p\\u003e \\u003cp\\u003e \\u003cul\\u003e \\u003cli\\u003e \\u003cp\\u003eLow Risk (score\\u0026thinsp;=\\u0026thinsp;0) \\u0026ndash; Reference group\\u003c/p\\u003e \\u003c/li\\u003e \\u003cli\\u003e \\u003cp\\u003eModerate/High Risk (score\\u0026thinsp;\\u0026ge;\\u0026thinsp;1) \\u0026ndash; Indicates engagement in at least one risky sexual behavior\\u003c/p\\u003e \\u003c/li\\u003e \\u003c/ul\\u003e \\u003c/p\\u003e \\u003c/li\\u003e \\u003cli\\u003e \\u003cp\\u003eThis binary classification is consistent with prior studies using similar composite indices for behavioral risk.\\u003c/p\\u003e \\u003c/li\\u003e \\u003cli\\u003e \\u003cp\\u003e \\u003cb\\u003eKey Independent Variables\\u003c/b\\u003e: These included socio-demographics (age, gender, education, occupation, marital status, religion), individual factors (alcohol consumption frequency/patterns, use of other substances), and clinical factors (self-reported WHO clinical stage, most recent viral load result [undetectable/detectable], current ART regimen).\\u003c/p\\u003e \\u003c/li\\u003e \\u003cli\\u003e \\u003cp\\u003eAll variables were assessed using a structured questionnaire.\\u003c/p\\u003e \\u003c/li\\u003e \\u003c/ul\\u003e \\u003c/p\\u003e \\u003c/div\\u003e\\n\\u003ch3\\u003eSampling:\\u003c/h3\\u003e\\n\\u003cp\\u003eWe needed a sample large enough to provide precise prevalence estimates. Using the Yamane formula (n\\u0026thinsp;=\\u0026thinsp;N / [1\\u0026thinsp;+\\u0026thinsp;N(e\\u0026sup2;)]) [\\u003cspan citationid=\\\"CR7\\\" class=\\\"CitationRef\\\"\\u003e7\\u003c/span\\u003e], with a total population (N) of 842 and a desired margin of error (e) of 5%, we calculated a minimum sample size of 400 participants.\\u003c/p\\u003e \\u003cp\\u003eTo ensure proportional representation across the three health centers, we used Probability Proportional to Size (PPS) sampling to allocate the 400 participants (Table\\u0026nbsp;\\u003cspan refid=\\\"Tab1\\\" class=\\\"InternalRef\\\"\\u003e1\\u003c/span\\u003e). Within each health center's ART patient list, we used systematic random sampling to select participants. We calculated a sampling interval (k\\u0026thinsp;=\\u0026thinsp;N_site / n_site) for each site. Starting from a randomly chosen number between 1 and k, we selected every k-th eligible patient on the list until the site's sample size was reached.\\u003c/p\\u003e \\u003cp\\u003e \\u003cdiv class=\\\"gridtable\\\"\\u003e\\u003ctable float=\\\"Yes\\\" id=\\\"Tab1\\\" border=\\\"1\\\"\\u003e \\u003ccaption language=\\\"En\\\"\\u003e \\u003cdiv class=\\\"CaptionNumber\\\"\\u003eTable 1\\u003c/div\\u003e \\u003cdiv class=\\\"CaptionContent\\\"\\u003e \\u003cp\\u003eSample Allocation by Health Center\\u003c/p\\u003e \\u003c/div\\u003e \\u003c/caption\\u003e \\u003ccolgroup cols=\\\"3\\\"\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c1\\\" colnum=\\\"1\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"char\\\" char=\\\".\\\" class=\\\"colspec\\\" colname=\\\"c2\\\" colnum=\\\"2\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"char\\\" char=\\\".\\\" class=\\\"colspec\\\" colname=\\\"c3\\\" colnum=\\\"3\\\"\\u003e\\u003c/div\\u003e \\u003cthead\\u003e \\u003ctr\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eSelected Health Center\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eTarget Population\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003eSample Size\\u003c/p\\u003e \\u003c/th\\u003e \\u003c/tr\\u003e \\u003c/thead\\u003e \\u003ctbody\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eRulindo Health Center\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e427\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e203\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eRemera Mbogo Health Center\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e205\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e97\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eMurambi Health Center\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e210\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e100\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003e\\u003cb\\u003eTotal\\u003c/b\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e\\u003cb\\u003e842\\u003c/b\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e\\u003cb\\u003e400\\u003c/b\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003c/tbody\\u003e \\u003c/colgroup\\u003e \\u003c/table\\u003e\\u003c/div\\u003e \\u003c/p\\u003e\\n\\u003ch3\\u003eData Collection:\\u003c/h3\\u003e\\n\\u003cp\\u003e\\u003cul\\u003e\\u003cli\\u003e\\u003cp\\u003e\\u003cb\\u003eInstrument\\u003c/b\\u003e: We used a structured, self-administered questionnaire adopted from a previously published WHO instrument on sexual health assessment(15). Minor modifications were made to align it with study objectives and the local context. It covered: participant information/consent, socio-demographics, substance use, RSB (using our operational definition above), and clinical information. Questions were primarily closed-ended (tick boxes, multiple choice).\\u003c/p\\u003e\\u003c/li\\u003e\\u003cli\\u003e\\u003cp\\u003e\\u003cb\\u003eData Collectors and Training\\u003c/b\\u003e: Data collection was managed by trained ART nurses from each health center who were \\u003cb\\u003enot\\u003c/b\\u003e involved in the direct clinical care of the participants they surveyed. These nurses participated in a standardized two-day training workshop. The training covered the study objectives, questionnaire administration, ethical procedures (emphasizing confidentiality, voluntary participation, and obtaining informed consent), how to assist participants with low literacy, and standardized methods for answering questions without influencing responses.\\u003c/p\\u003e\\u003c/li\\u003e\\u003cli\\u003e\\u003cp\\u003e\\u003cb\\u003eProcedure\\u003c/b\\u003e: Potential participants were approached by the trained ART nurse data collectors during their routine clinic visits. The study's purpose, procedures, risks, and benefits were explained verbally. Written informed consent was obtained before questionnaire distribution. Participants completed the questionnaire privately in the ART clinic room. For participants with limited literacy, the data collector read the questions aloud verbatim and recorded the participant's responses anonymously. Completed questionnaires were collected immediately by the data collector and stored securely. The principal investigator maintained close communication with data collectors to resolve any queries promptly.\\u003c/p\\u003e\\u003c/li\\u003e\\u003c/ul\\u003e\\u003c/p\\u003e\\n\\u003ch3\\u003eInstrument Validity and Reliability:\\u003c/h3\\u003e\\n\\u003cp\\u003e \\u003cul\\u003e \\u003cli\\u003e \\u003cp\\u003e \\u003cb\\u003eValidity\\u003c/b\\u003e: To ensure the questionnaire measured what it intended (validity), its content was reviewed by an expert from the Care and Treatment Unit within the HIV Division at the Rwanda Biomedical Centre. We discussed the relevance, clarity, and comprehensiveness of the items, particularly the RSB section adapted for our context, and incorporated their feedback.\\u003c/p\\u003e \\u003c/li\\u003e \\u003cli\\u003e \\u003cp\\u003e \\u003cb\\u003eReliability and Feasibility\\u003c/b\\u003e: We pre-tested the final questionnaire with 20 PLHIV meeting the inclusion criteria at Kiyanza Health Center (a similar health center in the same catchment area, excluded from the main study). The pre-test assessed clarity of questions, time to completion, and overall feasibility. Minor adjustments were made to wording and flow based on participant feedback. While the primary goal was feasibility and comprehension, the pre-test also provided an initial check on internal consistency for key scales (like RSB items).\\u003c/p\\u003e \\u003c/li\\u003e \\u003c/ul\\u003e \\u003c/p\\u003e \\u003cdiv id=\\\"Sec7\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003eStatistical Analysis:\\u003c/h2\\u003e \\u003cp\\u003eWe used SPSS version 27 for all analyses. Descriptive statistics summarized participant characteristics and RSB categories. To estimate the association between independent variables and risky sexual behavior, we used modified Poisson regression with robust standard errors, implemented via the Generalized Linear Models (GENLIN) procedure in SPSS. This approach is preferred when the outcome is common, as it directly estimates prevalence ratios (PRs) and avoids the overestimation associated with odds ratios from logistic regression [\\u003cspan citationid=\\\"CR8\\\" class=\\\"CitationRef\\\"\\u003e8\\u003c/span\\u003e]. We complied with the STROBE Guidelines in the reporting, presentation and interpretation of findings.\\u003c/p\\u003e \\u003cp\\u003eThe model specification included:\\u003c/p\\u003e \\u003cp\\u003e \\u003cul\\u003e \\u003cli\\u003e \\u003cp\\u003e \\u003cb\\u003eDistribution\\u003c/b\\u003e: Poisson\\u003c/p\\u003e \\u003c/li\\u003e \\u003cli\\u003e \\u003cp\\u003e \\u003cb\\u003eLink function\\u003c/b\\u003e: Log\\u003c/p\\u003e \\u003c/li\\u003e \\u003cli\\u003e \\u003cp\\u003e \\u003cb\\u003eRobust estimator\\u003c/b\\u003e: Applied to correct standard errors\\u003c/p\\u003e \\u003c/li\\u003e \\u003cli\\u003e \\u003cp\\u003e \\u003cb\\u003eReference group\\u003c/b\\u003e: Low risk (RSB score\\u0026thinsp;=\\u0026thinsp;0)\\u003c/p\\u003e \\u003c/li\\u003e \\u003c/ul\\u003e \\u003c/p\\u003e \\u003cp\\u003eBivariate and multivariable models were fitted. In the multivariable model, all covariates were included simultaneously. Adjusted prevalence ratios (aPRs) with 95% confidence intervals were reported. A p-value less than 0.05 was considered statistically significant in all analyses.\\u003c/p\\u003e \\u003c/div\\u003e\"},{\"header\":\"Results\",\"content\":\"\\u003cdiv id=\\\"Sec9\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003eParticipant Characteristics\\u003c/h2\\u003e \\u003cp\\u003eTable\\u0026nbsp;\\u003cspan refid=\\\"Tab2\\\" class=\\\"InternalRef\\\"\\u003e2\\u003c/span\\u003e shows the socio-demographic characteristics of the 400 PLHIV enrolled. Females accounted for 66.5% of participants, and 54.3% were aged\\u0026thinsp;\\u0026ge;\\u0026thinsp;46 years. Primary education was reported by 85.0% of participants, and 93.3% reported farming as their primary occupation. Marital status was reported as married by 57.3% of participants, and 85.3% identified as Catholic. Care was received at Rulindo Health Centre by 50.9% of participants.\\u003c/p\\u003e \\u003cp\\u003e \\u003cdiv class=\\\"gridtable\\\"\\u003e\\u003ctable float=\\\"Yes\\\" id=\\\"Tab2\\\" border=\\\"1\\\"\\u003e \\u003ccaption language=\\\"En\\\"\\u003e \\u003cdiv class=\\\"CaptionNumber\\\"\\u003eTable 2\\u003c/div\\u003e \\u003cdiv class=\\\"CaptionContent\\\"\\u003e \\u003cp\\u003eSocio-demographic characteristics of PLHIV attending ART at selected Health centres in Rulindo District, Northern Rwanda, 2024 (n\\u0026thinsp;=\\u0026thinsp;400)\\u003c/p\\u003e \\u003c/div\\u003e \\u003c/caption\\u003e \\u003ccolgroup cols=\\\"4\\\"\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c1\\\" colnum=\\\"1\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c2\\\" colnum=\\\"2\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"char\\\" char=\\\".\\\" class=\\\"colspec\\\" colname=\\\"c3\\\" colnum=\\\"3\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"char\\\" char=\\\".\\\" class=\\\"colspec\\\" colname=\\\"c4\\\" colnum=\\\"4\\\"\\u003e\\u003c/div\\u003e \\u003cthead\\u003e \\u003ctr\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eCharacteristic\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eCategory\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003eFrequency (n)\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003ePercentage (%)\\u003c/p\\u003e \\u003c/th\\u003e \\u003c/tr\\u003e \\u003c/thead\\u003e \\u003ctbody\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003e\\u003cb\\u003eSex\\u003c/b\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eMale\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e134\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e33.5\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eFemale\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e266\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e66.5\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003e\\u003cb\\u003eAge (years)\\u003c/b\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e18\\u0026ndash;25\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e19\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e4.8\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e25\\u0026ndash;35\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e69\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e17.3\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e35\\u0026ndash;45\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e95\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e23.6\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e\\u0026ge;46\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e217\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e54.3\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003e\\u003cb\\u003eEducation\\u003c/b\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eNo formal education\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e27\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e6.6\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003ePrimary\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e340\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e85.0\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eSecondary\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e28\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e7.0\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eUniversity\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e5\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e1.3\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003e\\u003cb\\u003eOccupation\\u003c/b\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eEmployee\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e17\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e4.3\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eEntrepreneur\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e10\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e2.4\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eFarming\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e373\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e93.3\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003e\\u003cb\\u003eMarital status\\u003c/b\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eSingle\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e84\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e21.0\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eDivorced\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e19\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e4.7\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eWidowed\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e68\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e17.0\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eMarried\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e229\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e57.3\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003e\\u003cb\\u003eReligion\\u003c/b\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eCatholic\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e341\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e85.3\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eProtestant\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e48\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e12.0\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eIslam\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e2\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e0.5\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eOther\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e9\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e2.3\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003e\\u003cb\\u003eHealth center\\u003c/b\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eRulindo\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e203\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e50.9\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eRemera Mbogo\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e97\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e24.2\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eMurambi Health\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e100\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e24.9\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003c/tbody\\u003e \\u003c/colgroup\\u003e \\u003c/table\\u003e\\u003c/div\\u003e \\u003c/p\\u003e \\u003cp\\u003eTable\\u0026nbsp;\\u003cspan refid=\\\"Tab3\\\" class=\\\"InternalRef\\\"\\u003e3\\u003c/span\\u003e details clinical profiles. WHO HIV Stage 1 was reported in 68.0% of participants, and 97.5% were on a first-line ART regimen. The median duration of ART was 13 years (IQR: 9; range: 1\\u0026ndash;24 years). Missing at least one ART dose was reported by 21.0% of participants. Viral load suppression was observed in 92.8% of participants. Alcohol use and substance use were reported by 82.3% and 95.0% of participants, respectively.\\u003c/p\\u003e \\u003cp\\u003e \\u003cdiv class=\\\"gridtable\\\"\\u003e\\u003ctable float=\\\"Yes\\\" id=\\\"Tab3\\\" border=\\\"1\\\"\\u003e \\u003ccaption language=\\\"En\\\"\\u003e \\u003cdiv class=\\\"CaptionNumber\\\"\\u003eTable 3\\u003c/div\\u003e \\u003cdiv class=\\\"CaptionContent\\\"\\u003e \\u003cp\\u003eClinical characteristics of PLHIV attending ART at selected Health Centres in Rulindo District, Northern Rwanda, 2024 (n\\u0026thinsp;=\\u0026thinsp;400)\\u003c/p\\u003e \\u003c/div\\u003e \\u003c/caption\\u003e \\u003ccolgroup cols=\\\"4\\\"\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c1\\\" colnum=\\\"1\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c2\\\" colnum=\\\"2\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c3\\\" colnum=\\\"3\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c4\\\" colnum=\\\"4\\\"\\u003e\\u003c/div\\u003e \\u003cthead\\u003e \\u003ctr\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eCharacteristic\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eCategory\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003eFrquency (n)\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003ePercentage (%)\\u003c/p\\u003e \\u003c/th\\u003e \\u003c/tr\\u003e \\u003c/thead\\u003e \\u003ctbody\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003e\\u003cb\\u003eClinical stage of HIV\\u003c/b\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eStage 1\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e272\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e68.0\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eStage 2\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e60\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e15.0\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eStage 3\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e62\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e15.5\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eStage 4\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e6\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e1.5\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003e\\u003cb\\u003eART regimen\\u003c/b\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eFirst line\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e390\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e97.5\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eSecond line\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e10\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e2.5\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003e\\u003cb\\u003eDuration after ART\\u003c/b\\u003e (years)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e\\u003cb\\u003eMedium (IQR)\\u003c/b\\u003eᵃ\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e13 (9)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e\\u003cb\\u003eMin, Max\\u003c/b\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e1, 24\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e\\u0026lt; 9\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e110\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e27.5\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e10\\u0026ndash;15\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e129\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e32.3\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e\\u0026ge; 16\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e142\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e35.5\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003e\\u003cb\\u003eMissed ART doses\\u003c/b\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eNo\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e316\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e79.0\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eYes\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e84\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e21.0\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003e\\u003cb\\u003eLatest viral load suppression status\\u003c/b\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eSuppressed\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e371\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e92.8\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eUnsuppressed\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e29\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e7.2\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003e\\u003cb\\u003eDrink alcohol\\u003c/b\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eNo\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e71\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e17.7\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eYes\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e329\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e82.3\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003e\\u003cb\\u003eSubstance use\\u003c/b\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eNo\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e20\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e5.0\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eYes\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e380\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e95.0\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colspan=\\\"4\\\" nameend=\\\"c4\\\" namest=\\\"c1\\\"\\u003e \\u003cp\\u003e\\u003cb\\u003eAbbreviation\\u003c/b\\u003e: ART, Antiretroviral Therapy; IQR, Inter-quartile range; Min, Max, Minimum, Maximum\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colspan=\\\"4\\\" nameend=\\\"c4\\\" namest=\\\"c1\\\"\\u003e \\u003cp\\u003eᵃVariable not normally distributed, Shapiro-Wilk p-value less than 0.05\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003c/tbody\\u003e \\u003c/colgroup\\u003e \\u003c/table\\u003e\\u003c/div\\u003e \\u003c/p\\u003e \\u003c/div\\u003e\"},{\"header\":\"Discussion\",\"content\":\"\\u003cp\\u003eIn this study of 400 adults living with HIV on long-term ART in rural Rwanda, we found that risky sexual behavior (RSB) was alarmingly common: nearly 80% of participants engaged in moderate-to-high-risk practices. Key predictors of RSB included older age (\\u0026ge;\\u0026thinsp;46 years), female gender, and longer duration on ART (10\\u0026thinsp;+\\u0026thinsp;years). Surprisingly, missing ART doses was associated with lower RSB. Viral load suppression, while high overall (93%), did not significantly influence risk behaviors.\\u003c/p\\u003e \\u003cp\\u003eThe high prevalence of RSB aligns with previous studies in sub-Saharan Africa showing persistent sexual risk among PLHIV despite expanded ART coverage. A comparable Rwandan study by Kagimbangabo et al. (2012) [\\u003cspan citationid=\\\"CR9\\\" class=\\\"CitationRef\\\"\\u003e9\\u003c/span\\u003e] reported high rates of inconsistent condom use and multiple partnerships among youth living with HIV, echoing our findings. However, our older adult population showed even higher rates of cumulative risk, suggesting age may not be as protective as often assumed.\\u003c/p\\u003e \\u003cp\\u003eThe link between long-term ART use and higher RSB is not new but often underexplored. Some literature suggests that perceived invulnerability after years of viral suppression can lead to behavioural disinhibition [\\u003cspan citationid=\\\"CR10\\\" class=\\\"CitationRef\\\"\\u003e10\\u003c/span\\u003e]. WHO\\u0026rsquo;s 2021 guidelines for differentiated HIV care in Africa also flag behavioural complacency as a concern in long-term ART management, especially in resource-limited settings [\\u003cspan citationid=\\\"CR11\\\" class=\\\"CitationRef\\\"\\u003e11\\u003c/span\\u003e]. Our data support that warning. On the other hand, our finding that ART non-adherence was associated with lower RSB is surprising. One possible explanation is that people missing doses may also have poorer health or higher psychosocial stress, reducing sexual activity or opportunity. Alternatively, they might be more cautious due to perceived health risks. This finding differs from earlier work in Uganda [\\u003cspan citationid=\\\"CR12\\\" class=\\\"CitationRef\\\"\\u003e12\\u003c/span\\u003e] and Ethiopia [\\u003cspan citationid=\\\"CR13\\\" class=\\\"CitationRef\\\"\\u003e13\\u003c/span\\u003e], where non-adherence was typically associated with higher RSB, so it warrants further investigation.\\u003c/p\\u003e \\u003cp\\u003eFinally, the lack of association between viral load suppression and sexual behaviour contrasts with studies in Uganda [\\u003cspan citationid=\\\"CR12\\\" class=\\\"CitationRef\\\"\\u003e12\\u003c/span\\u003e] and a systematic review [\\u003cspan citationid=\\\"CR14\\\" class=\\\"CitationRef\\\"\\u003e14\\u003c/span\\u003e], where viral suppression often correlated with reduced risk-taking. This difference might reflect our study\\u0026rsquo;s context; nearly all participants were virally suppressed, leaving slight variation to detect.\\u003c/p\\u003e \\u003cdiv id=\\\"Sec13\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003eLimitations\\u003c/h2\\u003e \\u003cp\\u003eThis study has several limitations. First, the cross-sectional design means we can't infer causality, only associations. For instance, we cannot say whether long-term ART use leads to RSB or if people with risky behaviour survive longer on ART. Second, self-reported sexual behaviour data are subject to social desirability and recall bias. Although interviewers were trained to reduce bias, underreporting of sensitive behaviours (like transactional sex or anal sex) is still possible. Third, our sample came from only two health centres in one district, limiting generalizability. In addition, our outcome variable, a cumulative RSB score, is not yet standardized across studies, though we based it on common WHO indicators. Lastly, we excluded some variables from multivariable models due to collinearity, which could have masked potential associations.\\u003c/p\\u003e \\u003c/div\\u003e \\u003cdiv id=\\\"Sec14\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003ePublic health implications\\u003c/h2\\u003e \\u003cp\\u003eThese findings suggest that Rwanda\\u0026rsquo;s HIV programs need to move beyond biomedical targets and pay closer attention to behavioural risk, especially among older adults and long-term ART users. First, existing prevention messages should be tailored for PLHIV who have been on ART for a decade or more. Many individuals may feel \\\"safe\\\" due to viral suppression and no longer view themselves as infectious. Clear, age-appropriate messaging on continued sexual risk and transmission is essential.\\u003c/p\\u003e \\u003cp\\u003eSecond, counselling and adherence support services should incorporate sexual health discussions routinely, not just during ART initiation. The counterintuitive association between missed doses and lower RSB also highlights the need for more nuanced, individualized support; risk reduction counselling should not assume that good adherence always equals safer sex.\\u003c/p\\u003e \\u003cp\\u003eLastly, national HIV surveillance tools should include behavioural risk metrics to capture trends among older PLHIV. RSB data are often absent in routine care settings, leading to missed prevention opportunities.\\u003c/p\\u003e \\u003c/div\\u003e\"},{\"header\":\"Conclusion\",\"content\":\"\\u003cp\\u003eWe set out to assess how common risky sexual behaviour is among people living with HIV on ART in Rutongo District and what factors predict it. We found that 79% of participants engaged in moderate to high levels of risky behaviour, with higher rates among women, those aged 46 and older, and those on ART for more than 10 years. These findings suggest that behavioural risk remains high despite treatment and viral suppression. HIV programs in Rwanda should integrate targeted sexual health counselling into long-term ART care. Future research should explore why long-term ART users continue high-risk behaviours despite clinical stability.\\u003c/p\\u003e\"},{\"header\":\"Abbreviations\",\"content\":\"\\u003cdiv class=\\\"DefinitionList\\\"\\u003e \\u003cdiv class=\\\"DefinitionListEntry\\\"\\u003e \\u003cdiv class=\\\"Term\\\"\\u003e\\u003cb\\u003eaPR\\u003c/b\\u003e\\u003c/div\\u003e \\u003cdiv class=\\\"Description\\\"\\u003e \\u003cp\\u003eAdjusted Prevalence Ratio\\u003c/p\\u003e \\u003c/div\\u003e \\u003c/div\\u003e \\u003cdiv class=\\\"DefinitionListEntry\\\"\\u003e \\u003cdiv class=\\\"Term\\\"\\u003e\\u003cb\\u003eART\\u003c/b\\u003e\\u003c/div\\u003e \\u003cdiv class=\\\"Description\\\"\\u003e \\u003cp\\u003eAntiretroviral Therapy\\u003c/p\\u003e \\u003c/div\\u003e \\u003c/div\\u003e \\u003cdiv class=\\\"DefinitionListEntry\\\"\\u003e \\u003cdiv class=\\\"Term\\\"\\u003e\\u003cb\\u003eCI\\u003c/b\\u003e\\u003c/div\\u003e \\u003cdiv class=\\\"Description\\\"\\u003e \\u003cp\\u003eConfidence Interval\\u003c/p\\u003e \\u003c/div\\u003e \\u003c/div\\u003e \\u003cdiv class=\\\"DefinitionListEntry\\\"\\u003e \\u003cdiv class=\\\"Term\\\"\\u003e\\u003cb\\u003eFSW\\u003c/b\\u003e\\u003c/div\\u003e \\u003cdiv class=\\\"Description\\\"\\u003e \\u003cp\\u003eFemale Sexual Workers\\u003c/p\\u003e \\u003c/div\\u003e \\u003c/div\\u003e \\u003cdiv class=\\\"DefinitionListEntry\\\"\\u003e \\u003cdiv class=\\\"Term\\\"\\u003e\\u003cb\\u003eHIV\\u003c/b\\u003e\\u003c/div\\u003e \\u003cdiv class=\\\"Description\\\"\\u003e \\u003cp\\u003eHuman Immunodeficiency Virus\\u003c/p\\u003e \\u003c/div\\u003e \\u003c/div\\u003e \\u003cdiv class=\\\"DefinitionListEntry\\\"\\u003e \\u003cdiv class=\\\"Term\\\"\\u003e\\u003cb\\u003en\\u003c/b\\u003e\\u003c/div\\u003e \\u003cdiv class=\\\"Description\\\"\\u003e \\u003cp\\u003eNumber\\u003c/p\\u003e \\u003c/div\\u003e \\u003c/div\\u003e \\u003cdiv class=\\\"DefinitionListEntry\\\"\\u003e \\u003cdiv class=\\\"Term\\\"\\u003e\\u003cb\\u003ePLHIV\\u003c/b\\u003e\\u003c/div\\u003e \\u003cdiv class=\\\"Description\\\"\\u003e \\u003cp\\u003ePeople Living with HIV\\u003c/p\\u003e \\u003c/div\\u003e \\u003c/div\\u003e \\u003cdiv class=\\\"DefinitionListEntry\\\"\\u003e \\u003cdiv class=\\\"Term\\\"\\u003e\\u003cb\\u003eRBC\\u003c/b\\u003e\\u003c/div\\u003e \\u003cdiv class=\\\"Description\\\"\\u003e \\u003cp\\u003eRwanda Biomedical Center\\u003c/p\\u003e \\u003c/div\\u003e \\u003c/div\\u003e \\u003cdiv class=\\\"DefinitionListEntry\\\"\\u003e \\u003cdiv class=\\\"Term\\\"\\u003e\\u003cb\\u003eSPSS\\u003c/b\\u003e\\u003c/div\\u003e \\u003cdiv class=\\\"Description\\\"\\u003e \\u003cp\\u003eStatistical Package for Social Sciences\\u003c/p\\u003e \\u003c/div\\u003e \\u003c/div\\u003e \\u003cdiv class=\\\"DefinitionListEntry\\\"\\u003e \\u003cdiv class=\\\"Term\\\"\\u003e\\u003cb\\u003eSTIs\\u003c/b\\u003e\\u003c/div\\u003e \\u003cdiv class=\\\"Description\\\"\\u003e \\u003cp\\u003eSexually Transmitted Infection\\u003c/p\\u003e \\u003c/div\\u003e \\u003c/div\\u003e \\u003cdiv class=\\\"DefinitionListEntry\\\"\\u003e \\u003cdiv class=\\\"Term\\\"\\u003e\\u003cb\\u003eUNAIDS\\u003c/b\\u003e\\u003c/div\\u003e \\u003cdiv class=\\\"Description\\\"\\u003e \\u003cp\\u003eJoint United Nations Programme on HIV/AIDS\\u003c/p\\u003e \\u003c/div\\u003e \\u003c/div\\u003e \\u003c/div\\u003e\"},{\"header\":\"Declarations\",\"content\":\" \\u003cp\\u003e \\u003cstrong\\u003eEthics approval and consent to participate\\u003c/strong\\u003e \\u003cp\\u003e This study was conducted in selected health centers located in the catchment area of Rutongo District Hospital in Rulindo District, Rwanda, and was carried out in accordance with the principles of the declaration of Helsinki. Ethical approval was obtained from the Ethical Review Board of Mount Kenya University, Rwanda, under REF: MKU/ETHICS/23/01/2024(1). The study received also authorization from the administration of Rutongo District Hospital. After the clear explanation by the researcher of the study\\u0026rsquo;s objectives, benefits, and process, all study participants voluntarily signed an informed consent before enrollment in the study. Confidentiality was strictly maintained; no personal identifiers were collected on the questionnaires, and data were stored securely on password-protected devices accessible only to the research team.\\u003c/p\\u003e \\u003c/p\\u003e \\u003cp\\u003e \\u003cstrong\\u003eConsent for publication\\u003c/strong\\u003e \\u003cp\\u003eNot applicable\\u003c/p\\u003e \\u003c/p\\u003e \\u003cp\\u003e \\u003cstrong\\u003eClinical trial number\\u003c/strong\\u003e \\u003cp\\u003eNot applicable.\\u003c/p\\u003e \\u003c/p\\u003e\\u003cp\\u003e \\u003ch2\\u003eCompeting interest\\u003c/h2\\u003e \\u003cp\\u003eThe authors declare that they have no competing interests\\u003c/p\\u003e \\u003c/p\\u003e\\u003ch2\\u003eFunding\\u003c/h2\\u003e \\u003cp\\u003eThis study did not receive any financial support.\\u003c/p\\u003e\\u003ch2\\u003eAuthor Contribution\\u003c/h2\\u003e\\u003cp\\u003eNU was designed the study, and collected the data as part of his master of public health study. He also drafted the manuscript. MAG analyzed and interpreted the data and contributed to the manuscript revision. MM and AH supervised the study and contributed to reviewing and editing the manuscript. All authors reviewed and approved the final version of the manuscript before submission.\\u003c/p\\u003e\\u003ch2\\u003eAcknowledgement\\u003c/h2\\u003e\\u003cp\\u003eThe author acknowledges the support of the School of Public Health Department, Mount Kenya University, and appreciates the lecturers for their academic guidance. Special thanks to the UZILO family and my lovely wife Natacha for their support, as well as the Ngongo family and fellow doctors in Cancre City for their encouragement and inspiration.\\u003c/p\\u003e\\u003ch2\\u003eData Availability\\u003c/h2\\u003e\\u003cp\\u003eAll data generated or analysed during this study are included in this published article [and its supplementary information files]\\u003c/p\\u003e\"},{\"header\":\"References\",\"content\":\"\\u003col\\u003e\\u003cli\\u003e\\u003cspan\\u003eRwanda Population-Based HIV Impact Assessment (RPHIA). Rwanda Population-Based HIV Impact Assessment. RPHIA Summary Sheet. 2019 Oct. pp. 2\\u0026ndash;7. Available from: \\u003cspan class=\\\"ExternalRef\\\"\\u003e\\u003cspan class=\\\"RefSource\\\"\\u003ehttps://phia.icap.columbia.edu/wp-content/uploads/2019/10/RPHIA-Summary-Sheet_Oct-2019.pdf\\u003c/span\\u003e\\u003cspan address=\\\"https://phia.icap.columbia.edu/wp-content/uploads/2019/10/RPHIA-Summary-Sheet_Oct-2019.pdf\\\" targettype=\\\"URL\\\" class=\\\"RefTarget\\\"\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eMinistry of Health Rwanda. Republic of Rwanda Ministry of Health national HIV/AIDS targets. Natl HIV/AIDS Targets [Internet]. 2020;1(Towards Ending AIDS Epidemics in Rwanda):18. Available from: \\u003cspan class=\\\"ExternalRef\\\"\\u003e\\u003cspan class=\\\"RefSource\\\"\\u003ehttps://rbc.gov.rw/IMG/pdf/rwanda_hiv_aids_2020_and_2030_targets.pdf\\u003c/span\\u003e\\u003cspan address=\\\"https://rbc.gov.rw/IMG/pdf/rwanda_hiv_aids_2020_and_2030_targets.pdf\\\" targettype=\\\"URL\\\" class=\\\"RefTarget\\\"\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eBekele Z, Mussa I, Assefa Y, Abera N, Amerga EW, Girma A et al. Risky sexual practice and associated factors among adult people living with HIV/AIDS in public hospitals of Kembata Tambaro Zone, Southern Ethiopia: A cross-sectional study. BMJ Open. 2023;13(7). Available from: \\u003cspan class=\\\"ExternalRef\\\"\\u003e\\u003cspan class=\\\"RefSource\\\"\\u003ehttps://doi.org/10.1136/bmjopen-2023-072505\\u003c/span\\u003e\\u003cspan address=\\\"10.1136/bmjopen-2023-072505\\\" targettype=\\\"DOI\\\" class=\\\"RefTarget\\\"\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eMosisa G, Woldemichael K, Ayalew F. Risky sexual behavior and associated factors among antiretroviral therapy attendees in Nekemte Referral Hospital, Western Ethiopia: A cross-sectional study. HIV AIDS (Auckl). 2018;10:125\\u0026ndash;31. Available from: \\u003cspan class=\\\"ExternalRef\\\"\\u003e\\u003cspan class=\\\"RefSource\\\"\\u003ehttps://doi.org/10.2147/HIV.S159670\\u003c/span\\u003e\\u003cspan address=\\\"10.2147/HIV.S159670\\\" targettype=\\\"DOI\\\" class=\\\"RefTarget\\\"\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eWondmeneh TG. Risky sexual behaviour among HIV-infected adults in Sub-Saharan Africa: A systematic review and meta-analysis. 2023;2023.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eKagimbangabo JMV, Njau Ngomi N, Marete O. Factors influencing risky sexual behaviours of HIV-infected people on first-line antiretroviral therapy in Kigeme District Hospital, Rwanda: A cross-sectional study. Rwanda Med J. 2020;77(1):1\\u0026ndash;6.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eYamane T, Statistics. An introductory analysis. 2nd ed. New York: Harper \\u0026amp; Row; 1967. p. 886.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eZou G. A modified Poisson regression approach to prospective studies with binary data. Am J Epidemiol. 2004;159(7):702\\u0026ndash;6.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eKagimbangabo T, Medley A, Nyombayire J, Murenzi G, Small L, Mugwaneza P et al. Gender inequities in sexual risks among youth with HIV in Kigali, Rwanda. Int J STD AIDS. 2012;23(10):715\\u0026ndash;9. \\u003cspan class=\\\"ExternalRef\\\"\\u003e\\u003cspan class=\\\"RefSource\\\"\\u003e10.1258/ijsa.2011.011339\\u003c/span\\u003e\\u003cspan address=\\\"10.1258/ijsa.2011.011339\\\" targettype=\\\"DOI\\\" class=\\\"RefTarget\\\"\\u003e\\u003c/span\\u003e\\u003c/span\\u003e. PMID: 22807531.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eKembabazi A, Bajunirwe F, Hunt PW, Martin JN, Muzoora C, Haberer JE, et al. Disinhibition in risky sexual behavior in men, but not women, during four years of antiretroviral therapy in rural, southwestern Uganda. PLoS ONE. 2013;8(7):e69634.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eWorld Health Organization. Consolidated guidelines on HIV prevention, testing, treatment, service delivery and monitoring: recommendations for a public health approach. Geneva: World Health Organization; 2021 Jul. p. 16.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eNakiganda LJ, Nakigozi G, Kagaayi J, Nalugoda F, Serwadda D, Sewankambo N, et al. Cross-sectional comparative study of risky sexual behaviours among HIV-infected persons initiated and waiting to start antiretroviral therapy in rural Rakai, Uganda. BMJ Open. 2017;7(9):e016954.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eTadesse WB, Gelagay AA. Risky sexual practice and associated factors among HIV positive adults visiting ART clinics in public hospitals in Addis Ababa city, Ethiopia: a cross-sectional study. BMC Public Health. 2019;19:1\\u0026ndash;8.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eLeMessurier J, Traversy G, Varsaneux O, Weekes M, Avey MT, Niragira O, et al. Risk of sexual transmission of human immunodeficiency virus with antiretroviral therapy, suppressed viral load and condom use: a systematic review. CMAJ. 2018;190(46):E1350\\u0026ndash;60.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eWorld Heatlh Organization. Sexual Health Assessment of Practices and Experiences (SHAPE). 2023.\\u003c/span\\u003e\\u003c/li\\u003e\\u003c/ol\\u003e\"}],\"fulltextSource\":\"\",\"fullText\":\"\",\"funders\":[],\"hasAdminPriorityOnWorkflow\":false,\"hasManuscriptDocX\":true,\"hasOptedInToPreprint\":true,\"hasPassedJournalQc\":\"\",\"hasAnyPriority\":false,\"hideJournal\":false,\"highlight\":\"\",\"institution\":\"\",\"isAcceptedByJournal\":false,\"isAuthorSuppliedPdf\":false,\"isDeskRejected\":\"\",\"isHiddenFromSearch\":false,\"isInQc\":false,\"isInWorkflow\":false,\"isPdf\":false,\"isPdfUpToDate\":true,\"isWithdrawnOrRetracted\":false,\"journal\":{\"display\":true,\"email\":\"info@researchsquare.com\",\"identity\":\"bmc-infectious-diseases\",\"isNatureJournal\":false,\"hasQc\":true,\"allowDirectSubmit\":false,\"externalIdentity\":\"infd\",\"sideBox\":\"Learn more about [BMC Infectious Diseases](http://bmcinfectdis.biomedcentral.com/)\",\"snPcode\":\"\",\"submissionUrl\":\"https://www.editorialmanager.com/infd\",\"title\":\"BMC Infectious Diseases\",\"twitterHandle\":\"#bmcinfectdis\",\"acdcEnabled\":true,\"dfaEnabled\":false,\"editorialSystem\":\"em\",\"reportingPortfolio\":\"BMC Series\",\"inReviewEnabled\":true,\"inReviewRevisionsEnabled\":true},\"keywords\":\"Antiretroviral therapy (ART), People living with HIV (PLHIV), Prevalence ratios, Risky sexual behavior, Rwanda\",\"lastPublishedDoi\":\"10.21203/rs.3.rs-8682260/v1\",\"lastPublishedDoiUrl\":\"https://doi.org/10.21203/rs.3.rs-8682260/v1\",\"license\":{\"name\":\"CC BY 4.0\",\"url\":\"https://creativecommons.org/licenses/by/4.0/\"},\"manuscriptAbstract\":\"\\u003ch2\\u003eBackground\\u003c/h2\\u003e \\u003cp\\u003eAs access to antiretroviral therapy (ART) expands, the health and longevity of people living with HIV (PLHIV) have improved. This may contribute to reduced risk perception and increased engagement in behaviours that facilitate HIV transmission. Risky sexual behaviours in this study include inconsistent condom use, multiple sexual partners, oral or anal sex, sex under the influence of alcohol, and transactional sex. This study assessed the prevalence of such behaviours and identified associated factors among PLHIV receiving ART at selected health centres in Rulindo District, Rwanda.\\u003c/p\\u003e\\u003ch2\\u003eMethods\\u003c/h2\\u003e \\u003cp\\u003eA cross-sectional quantitative study was conducted among 400 consenting PLHIV receiving ART at selected health centres. Probability proportional to size sampling ensured representative recruitment across centres. Data were collected via structured questionnaires. Modified Poisson regression with robust variance was performed using SPSS version 27 to estimate prevalence ratios with 95% confidence intervals. Ethical approval was obtained from Mount Kenya University, and Rutongo District Hospital granted permission.\\u003c/p\\u003e\\u003ch2\\u003eResults\\u003c/h2\\u003e \\u003cp\\u003eOf 400 PLHIV, 381 were sexually active, with complete data for risk assessment. Risky sexual behaviour was prevalent in 95.2% (362/381), with 71.6% classified as high risk. In adjusted models, female sex (aPR\\u0026thinsp;=\\u0026thinsp;1.15; 95% CI: 1.03\\u0026ndash;1.29), age\\u0026thinsp;\\u0026ge;\\u0026thinsp;46 years (aPR\\u0026thinsp;=\\u0026thinsp;1.15; 95% CI: 1.03\\u0026ndash;1.28), and longer ART duration 10\\u0026ndash;15 years (aPR\\u0026thinsp;=\\u0026thinsp;1.36; 95% CI: 1.18\\u0026ndash;1.58) or \\u0026ge;\\u0026thinsp;16 years (aPR\\u0026thinsp;=\\u0026thinsp;1.36; 95% CI: 1.17\\u0026ndash;1.57) were significantly associated with increased risk. Participants who missed ART doses showed lower risk (aPR\\u0026thinsp;=\\u0026thinsp;0.88; 95% CI: 0.80\\u0026ndash;0.97). Sensitivity analyses confirmed the robustness of these associations.\\u003c/p\\u003e\\u003ch2\\u003eConclusions\\u003c/h2\\u003e \\u003cp\\u003eRisky sexual behaviour was highly prevalent among PLHIV attending ART clinics in the Rulindo District. Several individual and treatment-related characteristics were associated with increased risk. These findings highlight the need to consider behavioural risk alongside clinical care in long-term ART settings.\\u003c/p\\u003e\",\"manuscriptTitle\":\"Factors Associated With Risky Sexual Behaviors Among People on Antiretroviral Therapy at Selected Health Centers in Rulindo District, Rwanda\",\"msid\":\"\",\"msnumber\":\"\",\"nonDraftVersions\":[{\"code\":1,\"date\":\"2026-03-08 14:44:09\",\"doi\":\"10.21203/rs.3.rs-8682260/v1\",\"editorialEvents\":[{\"type\":\"communityComments\",\"content\":0},{\"type\":\"reviewersInvited\",\"content\":\"\",\"date\":\"2026-02-26T08:48:08+00:00\",\"index\":\"\",\"fulltext\":\"\"},{\"type\":\"editorAssigned\",\"content\":\"\",\"date\":\"2026-02-26T08:44:21+00:00\",\"index\":\"\",\"fulltext\":\"\"},{\"type\":\"editorInvited\",\"content\":\"\",\"date\":\"2026-02-06T05:02:48+00:00\",\"index\":\"\",\"fulltext\":\"\"},{\"type\":\"checksComplete\",\"content\":\"\",\"date\":\"2026-02-05T16:52:41+00:00\",\"index\":\"\",\"fulltext\":\"\"},{\"type\":\"submitted\",\"content\":\"BMC Infectious Diseases\",\"date\":\"2026-02-05T14:43:15+00:00\",\"index\":\"\",\"fulltext\":\"\"}],\"status\":\"published\",\"journal\":{\"display\":true,\"email\":\"info@researchsquare.com\",\"identity\":\"bmc-infectious-diseases\",\"isNatureJournal\":false,\"hasQc\":true,\"allowDirectSubmit\":false,\"externalIdentity\":\"infd\",\"sideBox\":\"Learn more about [BMC Infectious Diseases](http://bmcinfectdis.biomedcentral.com/)\",\"snPcode\":\"\",\"submissionUrl\":\"https://www.editorialmanager.com/infd\",\"title\":\"BMC Infectious Diseases\",\"twitterHandle\":\"#bmcinfectdis\",\"acdcEnabled\":true,\"dfaEnabled\":false,\"editorialSystem\":\"em\",\"reportingPortfolio\":\"BMC Series\",\"inReviewEnabled\":true,\"inReviewRevisionsEnabled\":true}}],\"origin\":\"\",\"ownerIdentity\":\"97f96992-422d-4950-82b6-3a074d4ff499\",\"owner\":[],\"postedDate\":\"March 8th, 2026\",\"published\":true,\"recentEditorialEvents\":[],\"rejectedJournal\":[],\"revision\":\"\",\"amendment\":\"\",\"status\":\"under-review\",\"subjectAreas\":[],\"tags\":[],\"updatedAt\":\"2026-03-08T14:44:09+00:00\",\"versionOfRecord\":[],\"versionCreatedAt\":\"2026-03-08 14:44:09\",\"video\":\"\",\"vorDoi\":\"\",\"vorDoiUrl\":\"\",\"workflowStages\":[]},\"version\":\"v1\",\"identity\":\"rs-8682260\",\"journalConfig\":\"researchsquare\"},\"__N_SSP\":true},\"page\":\"/article/[identity]/[[...version]]\",\"query\":{\"redirect\":\"/article/rs-8682260\",\"identity\":\"rs-8682260\",\"version\":[\"v1\"]},\"buildId\":\"XKTyCvWXoU3ODBz1xrDgd\",\"isFallback\":false,\"isExperimentalCompile\":false,\"dynamicIds\":[84888],\"gssp\":true,\"scriptLoader\":[]}","source_license":"CC-BY-4.0","license_restricted":false}