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HIV TREATMENT, PREVENTION, AND INCIDENCE IN A HYPERENDEMIC UGANDAN FISHING COMMUNITY
Joseph Kagaayi1, Gertrude Nakigozi1, Godfrey Kigozi1, Mary K. Grabowski2, Victor Ssempijja3, Fred Nalugoda1, Ronald H. Gray2, Robert Ssekubugu1, Caitlin E. Kennedy2, Thomas C. Quinn3, David Serwadda4, Maria Wawer2, Steven J. Reynolds3, Larry W. Chang2
1Rakai Health Sciences Program, Kalisizo, Uganda,2Johns Hopkins University, Baltimore, MD, USA,3NIAID, Bethesda, MD, USA,4Makerere University College of Health Sciences, Kampala, Uganda
In a prospective population-based cohort study conducted in an HIV hyperendemic fishing community (HIV prevalence ~40%), we measured trends in uptake of antiretroviral therapy (ART) and voluntary medical male circumcision (MC), population-level viral load suppression, sexual risk behaviors, and HIV incidence.
From Nov 2011 to Feb 2017, four surveys were conducted in a fishing community on Lake Victoria in Rakai, Uganda as part of an open cohort of all consenting persons aged 15-49. We assessed trends in self-reported ART/MC coverage, population-level HIV viral load suppression (proportion of HIV-positive population with <1000 copies/ml), sexual risk behaviors, and HIV incidence. Poisson multivariate regression with generalized estimating equations and robust variance estimators was used to estimate incidence rate ratios (IRR) and 95%CI of HIV incidence comparing the first to the final survey interval.
5005 individuals participated in the cohort, including 1823 HIV-negative persons with at least one follow-up who contributed 5188 person-years (py) and 134 incident HIV cases. Over the study period, ART coverage increased among all HIV-infected participants from 19% (95%CI: 16-22%) to 81% (95%CI:75-87%), and MC coverage increased among all men from 39% (95%CI: 35-42%) to 63% (95%CI: 59-67%). ART and MC increases occurred in all age groups (Figure). Population-level HIV viral suppression was 78% (95%CI: 72-83%) by study end. Sexual behaviors remained unchanged. Overall HIV incidence declined (Figure) from 3.98/100 py to 1.61/100 py (adjIRR=0.46; 95%CI: 0.27-0.80). Declines in HIV incidence were similar in men (3.78/100py to 1.57/100py) and women (4.27/100py to 1.68/100py). Declines in HIV incidence were observed in persons aged 15-24 years (5.53/100py to 1.87/100py), 25-34 years (3.56/100py to 1.56/100py) and 35+ years (2.96/100py to 1.47/100pys). Overall, HIV prevalence declined from 41% to 36% (p=0.002). Figure: HIV incidence trends; ART and MC coverage over calendar time by age group.
Over about 5 years, HIV incidence significantly declined by approximately 54% as ART and MC coverage increased in a hyperendemic fishing community. These results suggest that HIV treatment and prevention interventions can be rapidly scaled and have substantial population-level impact on HIV incidence in high prevalence settings.