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      The state of the HIV epidemic in rural KwaZulu-Natal, South Africa: a novel application of disease metrics to assess trajectories and highlight areas for intervention

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          Abstract

          Background

          South Africa is at the epicentre of the HIV pandemic, with the world's highest number of new infections and the largest treatment programme. Using metrics proposed by the Joint United Nations Programme on AIDS (UNAIDS), we evaluate progress toward epidemic control and highlight areas for intervention in a hyperendemic South African setting.

          Methods

          The Africa Health Research Institute (AHRI) maintains a comprehensive population-based surveillance system in the Hlabisa sub-district of KwaZulu-Natal. Between 2005 and 2017, we tested 39 735 participants (aged 15–49 years) for HIV and followed 22 758 HIV-negative and 13 460 HIV-positive participants to identify new infections and all-cause AIDS-related deaths, respectively. Using these data, we estimated the percentage reduction in incidence, the absolute incidence rate, the incidence-mortality ratio and the incidence-prevalence ratio over place and time.

          Results

          We observed a 62% reduction in the number of new infections among men between 2012 and 2017 and a 34% reduction among women between 2014 and 2017. Among men, the incidence-mortality ratio peaked at 4.1 in 2013 and declined to 3.1 in 2017, and among women it fell from a high of 6.4 in 2014 to 4.3 in 2017. Between 2012 and 2017, the female-incidence/male-prevalence ratio declined from 0.24 to 0.13 and the male-incidence/female-prevalence ratio from 0.05 to 0.02.

          Conclusions

          Using data from a population-based cohort study, we report impressive progress toward HIV epidemic control in a severely affected South African setting. However, overall progress is off track for 2020 targets set by the UNAIDS. Spatial estimates of the metrics, which demonstrate remarkable heterogeneity over place and time, indicate areas that could benefit from additional or optimized HIV prevention services.

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          Most cited references9

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          Combination HIV Prevention and HIV Incidence in Uganda

          BACKGROUND To assess the impact of combination HIV prevention (CHP) on HIV incidence, we analyzed the association between HIV incidence and 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 through 12 surveys from 30 communities in the Rakai Community Cohort Study, an open population-based cohort of persons aged 15-49 years. We assessed HIV incidence trends based on observed seroconversion data, self-reported ART and male circumcision coverage, viral load suppression, and sexual behaviors. RESULTS In total, 33,937 study participants contributed 103,011 person-visits (HIV prevalence ~13%). Follow-up of 17,870 HIV-negative persons contributed 94,427 person-years with 931 seroconversions. ART was introduced in 2004; by 2016 coverage was 69% (72% in women vs. 61% in 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). Persons 15-19 years reporting n 71 ever having sex increased from 30% to 55% (p<0.0001). HIV incidence declined by 42% in 2016 relative to the pre-CHP period prior to 2010 (1.17/100 py to 0.66/100 py; adjIRR:0.58: 95%CI: 0.45-0.76); declines were greater in men (adjIRR=0.46; 95%CI: 0.29-0.73) than women (adjIRR=0.68, 95%CI: 0.50-0.94). CONCLUSIONS In this longitudinal study, HIV incidence significantly declined with CHP scale-up, providing empiric evidence that HIV control interventions can have substantial population-level impact. However, additional efforts are needed to overcome gender disparities and achieve HIV elimination.
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            HIV incidence in western Kenya during scale-up of antiretroviral therapy and voluntary medical male circumcision: a population-based cohort analysis.

            In Kenya, coverage of antiretroviral therapy (ART) among people with HIV infection has increased from 7% in 2006, to 57% in 2016; and, in western Kenya, coverage of voluntary medical male circumcision (VMMC) increased from 45% in 2008, to 72% in 2014. We investigated trends in HIV prevalence and incidence in a high burden area in western Kenya in 2011-16.
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              Epidemiological metrics and benchmarks for a transition in the HIV epidemic

              Peter Godfrey-Faussett and colleagues present six epidemiological metrics for tracking progress in reducing the public health threat of HIV.
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                Author and article information

                Journal
                Int J Epidemiol
                Int J Epidemiol
                ije
                International Journal of Epidemiology
                Oxford University Press
                0300-5771
                1464-3685
                April 2020
                13 January 2020
                13 January 2020
                : 49
                : 2
                : 666-675
                Affiliations
                [1 ] Africa Health Research Institute (AHRI) , KwaZulu-Natal, Durban, South Africa
                [2 ] School of Nursing and Public Health, University of KwaZulu-Natal (UKZN) , Durban, South Africa
                [3 ] KwaZulu-Natal Research Innovation and Sequencing Platform (KRISP) , UKZN, Durban, South Africa
                [4 ] Heidelberg Institute of Global Health, Faculty of Medicine, University of Heidelberg , Heidelberg, Germany
                [5 ] Department of Geography and Geographic Information Science, University of Cincinnati , Cincinnati, OH, USA
                [6 ] Department of Population Health, New York University School of Medicine , New York, USA
                [7 ] Department of Global Health and Population, Harvard T.H. Chan School of Public Health , Boston, MA, USA
                [8 ] Lincoln Institute for Health, University of Lincoln , Lincoln, UK
                [9 ] Centre for the AIDS Programme of Research in South Africa (CAPRISA) , UKZN, Durban, South Africa
                Author notes
                Corresponding author. Africa Health Research Institute (AHRI), KwaZulu-Natal, 719 Umbilo Road, Nelson R. Mandela Medical Campus, Durban 4013, South Africa. E-mail: vandormaela@ 123456ukzn.ac.za
                Author information
                http://orcid.org/0000-0002-5742-0511
                Article
                dyz269
                10.1093/ije/dyz269
                7266544
                31930292
                8db86e8d-9d90-4dca-8de9-e5f4298915f1
                © The Author(s) 2020. Published by Oxford University Press on behalf of the International Epidemiological Association.

                This is an Open Access article distributed under the terms of the Creative Commons Attribution License ( http://creativecommons.org/licenses/by/4.0/), which permits unrestricted reuse, distribution, and reproduction in any medium, provided the original work is properly cited.

                History
                : 28 November 2019
                : 06 December 2019
                Page count
                Pages: 10
                Funding
                Funded by: National Institute of Health;
                Funded by: NIH, DOI 10.13039/100000002;
                Award ID: R01HD084233
                Award ID: R01AI124389
                Funded by: The Africa Health Research Institute’s Demographic Surveillance Information System and Population Intervention Programme;
                Funded by: Wellcome Trust, DOI 10.13039/100010269;
                Award ID: 201433/Z/16/Z
                Funded by: South Africa Population Research Infrastructure Network;
                Funded by: South African Department of Science and Technology;
                Funded by: South African Medical Research Council, DOI 10.13039/501100001322;
                Funded by: Alexander von Humboldt Foundation, DOI 10.13039/100005156;
                Funded by: German Federal Ministry of Education and Research;
                Funded by: European Commission, DOI 10.13039/501100000780;
                Funded by: Clinton Health Access Initiative;
                Funded by: National Institutes of Health’s Fogarty International Center;
                Award ID: D43-TW009775
                Categories
                Miscellaneous

                Public health
                hiv,epidemic control,incidence-mortality ratio,incidence-prevalence ratio,unaids,south africa

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