HIV Prevention Efforts and Incidence of HIV in Uganda
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Date
2017
Journal Title
Journal ISSN
Volume Title
Publisher
New England Journal of Medicine
Abstract
To assess the effect of a combination strategy for prevention of human immunodeficiency
virus (HIV) on the incidence of HIV infection, we analyzed the association
between the incidence of HIV and the scale-up of antiretroviral therapy (ART) and
medical male circumcision in Rakai, Uganda. Changes in population-level viral-load
suppression and sexual behaviors were also examined.
METHODS
Between 1999 and 2016, data were collected from 30 communities with the use of
12 surveys in the Rakai Community Cohort Study, an open, population-based cohort
of persons 15 to 49 years of age. We assessed trends in the incidence of HIV on the
basis of observed seroconversion data, participant-reported use of ART, participantreported
male circumcision, viral-load suppression, and sexual behaviors.
RESULTS
In total, 33,937 study participants contributed 103,011 person-visits. A total of 17,870
persons who were initially HIV-negative were followed for 94,427 person-years; among
these persons, 931 seroconversions were observed. ART was introduced in 2004, and
by 2016, ART coverage was 69% (72% among women vs. 61% among men, P<0.001).
HIV viral-load suppression among all HIV-positive persons increased from 42% in
2009 to 75% by 2016 (P<0.001). Male circumcision coverage increased from 15% in
1999 to 59% by 2016 (P<0.001). The percentage of adolescents 15 to 19 years of age
who reported never having initiated sex (i.e., delayed sexual debut) increased from
30% in 1999 to 55% in 2016 (P<0.001). By 2016, the mean incidence of HIV infection
had declined by 42% relative to the period before 2006 (i.e., before the scale-up of the
combination strategy for HIV prevention) — from 1.17 cases per 100 person-years
to 0.66 cases per 100 person-years (adjusted incidence rate ratio, 0.58; 95% confidence
interval [CI], 0.45 to 0.76); declines were greater among men (adjusted incidence rate
ratio, 0.46; 95% CI, 0.29 to 0.73) than among women (adjusted incidence rate ratio,
0.68; 95% CI, 0.50 to 0.94).
CONCLUSIONS
In this longitudinal study, the incidence of HIV infection declined significantly
with the scale-up of a combination strategy for HIV prevention, which provides
empirical evidence that interventions for HIV prevention can have a populationlevel
effect. However, additional efforts are needed to overcome disparities according
to sex and to achieve greater reductions in the incidence of HIV infection.
(Funded by the National Institute of Allergy and Infectious Diseases and others.)
Description
Keywords
HIV Prevention, Efforts, HIV, Uganda
Citation
Grabowski, M. K., Serwadda, D. M., Gray, R. H., Nakigozi, G., Kigozi, G., Kagaayi, J., ... & Chang, L. W. (2017). HIV prevention efforts and incidence of HIV in Uganda. New England Journal of Medicine, 377(22), 2154-2166. DOI: 10.1056/NEJMoa1702150