We previously reported on declines in HIV incidence associated with the scale-up of voluntary medical male circumcision (VMMC) and antiretroviral therapy (ART) at CD4 counts of <500 in 30 communities continuously surveyed between 1994 and 2016 in the Rakai Community Cohort Study (RCCS). Prior analyses showed a 42% reduction in HIV incidence by 2016 relative to the period prior to VMMC and ART availability with greater declines observed among men than women (54% vs. 32%). We report here on HIV incidence following the implementation of universal test and treat in 2016.
Population-level trends in HIV incidence among RCCS study communities were assessed between April 1999 and May 2018. Trends in HIV incidence based on observed seroconversion, self-reported male circumcision, and self-reported ART use were assessed using data collected over 13 surveys. Viral loads among all HIV-positive persons were assessed at three surveys, including the two most recent surveys. Relative changes in HIV incidence at each survey after 2006 was compared to the mean HIV incidence before 2006 (i.e., before scale-up of VMMC and ART) using multivariate Poisson regression models and are reported as adjusted incidence rate ratios (adjIRR) with 95% confidence intervals (CI).
37,283 individuals participated, including 19,645 initially HIV-negative persons who contributed at least one-follow-up visit. There were 992 HIV incident cases detected over 107,297 person-years of follow-up. By 2018, HIV incidence was 0.43 per 100 person years (py), a decline of 58% relative to the period prior to VMMC and ART availability (adjIRR=0.42; 95CI: 0.31-0.57). Recent incidence declines were most pronounced among women whose incidence fell from 0.83 per 100 py to 0.48 per 100 py between the final two surveys (adjIRR=0.63; 95%CI: 0.41-0.98) and by 59% since the period prior to VMMC and ART availability (adjIRR=0.41; 95CI:0.28-0.60). Viral load suppression levels in 2018 improved modestly compared to the prior survey, increasing from 76% to 80% overall, from 79% to 85% among women, and from 67% to 71% among men. Prevalence of male circumcision continued to increase with 65% coverage among all men in 2018.
HIV incidence is rapidly declining among women and men with the continued scale-up of ART and VMMC in Rakai. Sustained investment and targeted efforts to achieve increased levels of viral load suppression and male circumcision coverage could potentially eliminate transmission in this African setting.