December 12, 2017

HIV prevention approach reduces new infections in Ugandan district

At a Glance

  • A combination of HIV prevention measures substantially reduced new HIV infections in a district of Uganda during a seven-year period.
  • The results prove the approach can reduce new HIV infections in a population.
Drawing blood from a study participant A research assistant draws blood for HIV testing from a participant in the Rakai Community Cohort Study. Rakai Health Sciences Program

Researchers have found several strategies that can help stop the spread of HIV, the virus that causes AIDS. Voluntary, medically performed male circumcision, for example, significantly reduces a man’s risk of acquiring HIV from his HIV-positive female partner. HIV-suppressing antiretroviral therapy (ART) prevents transmission of the virus to uninfected partners. Changes in sexual behavior, such as having only one sexual partner, can also help prevent HIV infection.

The Rakai Health Sciences Program has been working to prevent the spread of HIV in the Rakai district of Uganda. The program promotes HIV testing, counseling, use of ART, and voluntary medical male circumcision to participants in the Rakai Community Cohort Study. In a new analysis, a team led by Dr. M. Kate Grabowski at Johns Hopkins University and the Rakai Health Sciences Program assessed the success of the program. The study, as well as the new analysis, were funded in part by NIH’s National Institute of Allergy and Infectious Diseases (NIAID), Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD), and National Institute of Mental Health (NIMH). Results were published on November 30, 2017, in the New England Journal of Medicine.

The analysis involved nearly 34,000 people, ages 15 to 49 years, from 30 communities. Every one or two years from April 1999 until September 2016, participants were tested for HIV and surveyed about their sexual behavior, use of ART, and male circumcision status.

The proportion of participants living with HIV who reported taking ART climbed from zero in 2003 to 69% in 2016. The proportion of males who were voluntarily circumcised grew from 15% in 1999 to 59% in 2016. The proportion of adolescents (ages 15 to 19) who reported never having sex rose from 30% in 1999 to 55% in 2016. Levels of condom use with casual partners and people reporting multiple sexual partners remained largely unchanged.

The researchers estimated that the annual number of new HIV infections fell 42%—from about 1.17 per 100 people in 2009 to about 0.66 per 100 in 2016. In addition, the proportion of participants living with HIV whose treatment suppressed the virus increased from 42% in 2009 to 75% in 2016.

HIV incidence dropped the most among circumcised men, by 57%. HIV incidence declined by 54% among all men but by only 32% among all women. The researchers anticipate that this gender imbalance will be addressed in the future. For example, pre-exposure prophylaxis (PrEP) could be added to the program’s HIV prevention package.

“We expect that this multifaceted approach to HIV prevention will work as well in other populations as it has in rural Uganda,” Grabowski says.

“Before this study, we knew that these HIV prevention measures worked at an individual level, yet it was not clear that they would substantially reduce HIV incidence in a population—or even if it would be possible to get large numbers of people to adopt them,” says NIAID Director Dr. Anthony S. Fauci. “This new analysis demonstrates that scaling up combination HIV prevention is possible and can turn the tide of the epidemic.”

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References: HIV Prevention Efforts and Incidence of HIV in Uganda. Grabowski MK, Serwadda DM, Gray RH, Nakigozi G, Kigozi G, Kagaayi J, Ssekubugu R, Nalugoda F, Lessler J, Lutalo T, Galiwango RM, Makumbi F, Kong X, Kabatesi D, Alamo ST, Wiersma S, Sewankambo NK, Tobian AAR, Laeyendecker O, Quinn TC, Reynolds SJ, Wawer MJ, Chang LW; Rakai Health Sciences Program. N Engl J Med. 2017 Nov 30;377(22):2154-2166. doi: 10.1056/NEJMoa1702150. PMID: 29171817.

Funding: NIH’s National Institute of Allergy and Infectious Diseases (NIAID), Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD), and National Institute of Mental Health (NIMH); World Bank; Doris Duke Charitable Foundation; Bill & Melinda Gates Foundation; Johns Hopkins University Center for AIDS Research; President’s Emergency Plan for AIDS Relief (PEPFAR); Henry M. Jackson Foundation for the Advancement of Military Medicine; and the U.S. Department of Defense.