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      Migration, hotspots, and dispersal of HIV infection in Rakai, Uganda

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          Abstract

          HIV prevalence varies markedly throughout Africa, and it is often presumed areas of higher HIV prevalence (i.e., hotspots) serve as sources of infection to neighboring areas of lower prevalence. However, the small-scale geography of migration networks and movement of HIV-positive individuals between communities is poorly understood. Here, we use population-based data from ~22,000 persons of known HIV status to characterize migratory patterns and their relationship to HIV among 38 communities in Rakai, Uganda with HIV prevalence ranging from 9 to 43%. We find that migrants moving into hotspots had significantly higher HIV prevalence than migrants moving elsewhere, but out-migration from hotspots was geographically dispersed, contributing minimally to HIV burden in destination locations. Our results challenge the assumption that high prevalence hotspots are drivers of transmission in regional epidemics, instead suggesting that migrants with high HIV prevalence, particularly women, selectively migrate to these areas.

          Abstract

          HIV prevalence varies throughout Africa, but the contribution of migration remains unclear. Using population-based data from ~22,000 persons, Grabowski et al. show that HIV-positive migrants selectively migrate to high prevalence areas and that out-migrants from these areas geographically disperse.

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          Heterogeneities in the transmission of infectious agents: Implications for the design of control programs

          R Anderson, M. E. J. Woolhouse, C. Dye … (1997)
          Article 0 comments Cited 196 times – based on 0 reviews     Review now
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            Impact of a universal testing and treatment intervention on HIV incidence in Zambia and South Africa: results of the HPTN 071 (PopART) community-randomized trial

            Richard J. Hayes, Deborah Donnell, Sian Floyd … (2019)
            Background Universal testing and treatment (UTT) is a potential strategy to reduce HIV incidence, yet prior trial results are inconsistent. We report results from HPTN 071 (PopART), the largest HIV prevention trial to date. Methods In this community-randomized trial (2013-18), 21 communities in Zambia and South Africa were randomized to Arm A (PopART intervention, universal antiretroviral therapy [ART]), Arm B (PopART intervention, ART per local guidelines), and Arm C (standard-of-care). The PopART intervention included home-based HIV-testing delivered by community workers who supported linkage-to-care, ART adherence, and other services. The primary outcome, HIV incidence between months 12-36, was measured in a Population Cohort (PC) of ~2,000 randomly-sampled adults/community aged 18-44y. Viral suppression (VS, <400 copies HIV RNA/ml) was measured in all HIV-positive PC participants at 24m. Results The PC included 48,301 participants. Baseline HIV prevalence was similar across study arms (21%-22%). Between months 12-36, 553 incident HIV infections were observed over 39,702 person-years (py; 1.4/100py; women: 1.7/100py; men: 0.8/100py). Adjusted rate-ratios were A vs. C: 0.93 (95%CI: 0.74-1.18, p=0.51); B vs. C: 0.70 (95%CI: 0.55-0.88, p=0.006). At 24m, VS was 71.9% in Arm A; 67.5% in Arm B; and 60.2% in Arm C. ART coverage after 36m was 81% in Arm A and 80% in Arm B. Conclusions The PopART intervention with ART per local guidelines reduced HIV incidence by 30%. The lack of effect with universal ART was surprising and inconsistent with VS data. This study provides evidence that UTT can reduce HIV incidence at population level. Trial registration ClinicalTrials.gov NCT01900977
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              Universal Testing, Expanded Treatment, and Incidence of HIV Infection in Botswana

              Joseph Makhema, Kathleen Wirth, Molly Pretorius Holme … (2019)
              The feasibility of reducing the population-level incidence of human immunodeficiency virus (HIV) infection by increasing community coverage of antiretroviral therapy (ART) and male circumcision is unknown. We conducted a pair-matched, community-randomized trial in 30 rural or periurban communities in Botswana from 2013 to 2018. Participants in 15 villages in the intervention group received HIV testing and counseling, linkage to care, ART (started at a higher CD4 count than in standard care), and increased access to male circumcision services. The standard-care group also consisted of 15 villages. Universal ART became available in both groups in mid-2016. We enrolled a random sample of participants from approximately 20% of households in each community and measured the incidence of HIV infection through testing performed approximately once per year. The prespecified primary analysis was a permutation test of HIV incidence ratios. Pair-stratified Cox models were used to calculate 95% confidence intervals. Of 12,610 enrollees (81% of eligible household members), 29% were HIV-positive. Of the 8974 HIV-negative persons (4487 per group), 95% were retested for HIV infection over a median of 29 months. A total of 57 participants in the intervention group and 90 participants in the standard-care group acquired HIV infection (annualized HIV incidence, 0.59% and 0.92%, respectively). The unadjusted HIV incidence ratio in the intervention group as compared with the standard-care group was 0.69 (P=0.09) by permutation test (95% confidence interval [CI], 0.46 to 0.90 by pair-stratified Cox model). An end-of-trial survey in six communities (three per group) showed a significantly greater increase in the percentage of HIV-positive participants with an HIV-1 RNA level of 400 copies per milliliter or less in the intervention group (18 percentage points, from 70% to 88%) than in the standard-care group (8 percentage points, from 75% to 83%) (relative risk, 1.12; 95% CI, 1.09 to 1.16). The percentage of men who underwent circumcision increased by 10 percentage points in the intervention group and 2 percentage points in the standard-care group (relative risk, 1.26; 95% CI, 1.17 to 1.35). Expanded HIV testing, linkage to care, and ART coverage were associated with increased population viral suppression. (Funded by the President’s Emergency Plan for AIDS Relief and others; Ya Tsie ClinicalTrials.gov number, .)
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                Author and article information

                Contributors
                Mary Kate Grabowski: mgrabow2@jhu.edu
                Journal
                Journal ID (nlm-ta): Nat Commun
                Journal ID (iso-abbrev): Nat Commun
                Title: Nature Communications
                Publisher: Nature Publishing Group UK (London )
                ISSN (Electronic): 2041-1723
                Publication date (Electronic): 20 February 2020
                Publication date PMC-release: 20 February 2020
                Publication date Collection: 2020
                Volume: 11
                Electronic Location Identifier: 976
                Affiliations
                [1 ]ISNI 0000 0001 2171 9311, GRID grid.21107.35, Department of Pathology, , Johns Hopkins School of Medicine, ; Baltimore, MD 21287 USA
                [2 ]ISNI 0000 0001 2171 9311, GRID grid.21107.35, Department of Epidemiology, , Johns Hopkins Bloomberg School of Public Health, ; 627 North Washington St., Baltimore, MD 21205 USA
                [3 ]GRID grid.452655.5, Rakai Health Sciences Program, ; Old Bukoba Road, P.O. Box 279, Kalisizo, Uganda
                [4 ]ISNI 0000 0001 2297 5165, GRID grid.94365.3d, Laboratory of Immunoregulation, Division of Intramural Research, National Institute for Allergy and Infectious Diseases, , National Institutes of Health, ; Bethesda, MD USA
                [5 ]ISNI 0000 0001 2171 9311, GRID grid.21107.35, Division of Infectious Diseases, Department of Medicine, , Johns Hopkins School of Medicine, ; Baltimore, MD 21205 USA
                [6 ]ISNI 0000000419368729, GRID grid.21729.3f, Heilbrunn Department of Population and Family Health, , Columbia University, ; 60 Haven Avenue, New York, NY 10032 USA
                [7 ]ISNI 0000 0001 2171 9311, GRID grid.21107.35, Department of International Health, , Johns Hopkins Bloomberg School of Public Health, ; 615 N. Wolfe St., Baltimore, MD 21205 USA
                [8 ]ISNI 0000 0004 0620 0548, GRID grid.11194.3c, Makerere University School of Public Health, ; Kampala, Uganda
                Article
                Publisher ID: 14636
                DOI: 10.1038/s41467-020-14636-y
                PMC ID: 7033206
                PubMed ID: 32080169
                SO-VID: 0b5a2cbd-737e-4e23-b09f-392fe2a866de
                Copyright © © The Author(s) 2020
                License:

                Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons license, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons license and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this license, visit http://creativecommons.org/licenses/by/4.0/.

                History
                Date received : 9 July 2018
                Date accepted : 18 January 2020
                Categories
                Subject: Article
                Custom metadata
                issue-copyright-statement © The Author(s) 2020

                ScienceOpen disciplines: Uncategorized
                Keywords: population dynamics,hiv infections,epidemiology
                Data availability:
                ScienceOpen disciplines: Uncategorized
                Keywords: population dynamics, hiv infections, epidemiology

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