HIV incidence declines among men, women in Rakai, Uganda
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The rate of HIV is decreasing quickly among women and men in Rakai, Uganda, due in part to the scale-up of voluntary medical male circumcision, or VMMC, and ART, according to findings presented during CROI.
“We're continuing to see huge declines in incidence,” Mary K. Grabowski, PhD, assistant professor in Johns Hopkins School of Medicine’s department of pathology, told Healio. “The really interesting thing we saw in this most recent surveillance period was a dramatic reduction in HIV incidence among women. The declines were not nearly as steep in women as they were in men in the last study — they were flat toward the end of the surveillance period. Now, women overall have a 60% reduction in HIV incidence compared with the pre-ART era.”
Grabowski and colleagues previously demonstrated a 42% decrease in HIV incidence in Rakai as part of the Rakai Community Cohort Study. The research involved increasing voluntary medical male circumcision (VMMC) and antiretroviral therapy (ART) for patients with CD4 counts of less than 500 in 30 communities that were surveyed without interruption from 1994 to 2016.
For this part of the study, the researchers examined population-level trends in HIV incidence between April 1999 and May 2018 among 37,283 individuals in Rakai. Trends in rates of HIV based on seroconversion, self-reported ART use and self-reported male circumcision were evaluated from 13 surveys. Viral loads among HIV-positive patients were examined in three surveys, including the two most recent ones. Relative changes in HIV incidence at each survey after 2006 were compared with mean HIV incidence before 2006 (ie, before the scale-up of VMMC and ART).
Of all the participants, 19,645 were originally identified as HIV negative and contributed at least one follow-up visit. A total of 990 HIV incident cases were identified over 107,284person-years of follow-up. HIV incidence was 0.423 per 100 person-years by 2018 — a 58% decline relative to the time period before VMMC and ART availability (adjusted incidence rate ratio = 0.41; 95% CI, 0.30-0.55). Declines were most prevalent in women, in whom incidence dropped from 0.83 per 100 person-years to 0.48 per 100 person-years between the last two surveys (aiRR = 0.64; 95% CI, 0.41-0.99) and by 60% since the time period before VMMC and ART availability (aiRR = 0.40; 95% CI, 0.27-0.59).
Grabowski said changes in sexual behaviors in young people may be contributing to the decline in HIV incidence.
“We have also seen delays in sexual debut among very young people, with fewer people continuing to report initiation of sex between the ages of 15 and 19,” Grabowski said. “We also have high VMMC coverage rates among male partners and we have dramatically been increasing coverage of ART among men since the last survey with rollout of [Universal Test and Treat studies].”
Grabowski also noted several factors contributing to the decline in incidence among women.
“I think increasing male coverage changes sexual behaviors among youth in particular,” Grabowski said. “VMMC coverage as well as the [Determined, Resilient, AIDS-free, Mentoring and Safe] program could all be leading to the dramatic reductions and incidence we're seeing among women.”
Viral load suppression levels in 2018 increased from 76% to 81% overall, 79% to 85% in women and 67% to 71% among men in comparison with the previous study. The rate of male circumcision was 65% among all men in 2018, representing a continued increase in uptake.
“We have this really rapidly decline in incidence, not just in our study site, but across Africa,” Grabowski said. “I think now may be the time to start thinking about what it would take to actually get to zero in an African setting.” – by Eamon Dreisbach
Reference:
Nakigozi G, et al. Abstract 150. Presented at: Conference on Retroviruses and Opportunistic Infections; March 8-11, 2020; Boston.
Disclosure: Grabowski reports no relevant financial disclosures.
Perspective
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Gitanjali Pai, MD, AAHIVS
The findings of this study from Grabowski and colleagues are certainly heartening as we work toward HIV elimination. While the decline in HIV incidence, noted not only in men but also in women in this study, is likely multifactorial, availability of ART and voluntary medical male circumcision, or VMMC, are important factors in HIV control and halting transmission. WHO has recommended VMMC as an additional HIV prevention strategy since 2007, a strategy that has been shown to reduce the risk of heterosexually acquired HIV infection in men by approximately 60%.
The availability of ART is crucial to ending the HIV epidemic, by helping to reduce/suppress viral load, thereby reducing transmission and effectively contributing to reduced incidence of HIV. Directed and persistent efforts toward viral load suppression, including widespread availability of ART, as well as other prevention methods like VMMC, will help us to inch towards our goal of eliminating HIV.
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