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Larmarange J, Bachanas P, Skalland T, Balzer LB, Iwuji C, Floyd S, Mills LA, Pillay D, Havlir D, Kamya MR, Ayles H, Wirth K, Dabis F, Hayes R, Petersen M. Population-level viremia predicts HIV incidence at the community level across the Universal Testing and Treatment Trials in eastern and southern Africa. PLOS GLOBAL PUBLIC HEALTH 2023; 3:e0002157. [PMID: 37450436 PMCID: PMC10348573 DOI: 10.1371/journal.pgph.0002157] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Accepted: 06/20/2023] [Indexed: 07/18/2023]
Abstract
Universal HIV testing and treatment (UTT) strategies aim to optimize population-level benefits of antiretroviral treatment. Between 2012 and 2018, four large community randomized trials were conducted in eastern and southern Africa. While their results were broadly consistent showing decreased population-level viremia reduces HIV incidence, it remains unclear how much HIV incidence can be reduced by increasing suppression among people living with HIV (PLHIV). We conducted a pooled analysis across the four UTT trials. Leveraging data from 105 communities in five countries, we evaluated the linear relationship between i) population-level viremia (prevalence of non-suppression-defined as plasma HIV RNA >500 or >400 copies/mL-among all adults, irrespective of HIV status) and HIV incidence; and ii) prevalence of non-suppression among PLHIV and HIV incidence, using parametric g-computation. HIV prevalence, measured in 257 929 persons, varied from 2 to 41% across the communities; prevalence of non-suppression among PLHIV, measured in 31 377 persons, from 3 to 70%; population-level viremia, derived from HIV prevalence and non-suppression, from < 1% to 25%; and HIV incidence, measured over 345 844 person-years (PY), from 0.03/100PY to 3.46/100PY. Decreases in population-level viremia were strongly associated with decreased HIV incidence in all trials (between 0.45/100PY and 1.88/100PY decline in HIV incidence per 10 percentage points decline in viremia). Decreases in non-suppression among PLHIV were also associated with decreased HIV incidence in all trials (between 0.06/100PY and 0.17/100PY decline in HIV incidence per 10 percentage points decline in non-suppression). Our results support both the utility of population-level viremia as a predictor of incidence, and thus a tool for targeting prevention interventions, and the ability of UTT approaches to reduce HIV incidence by increasing viral suppression. Implementation of universal HIV testing approaches, coupled with interventions to leverage linkage to treatment, adapted to local contexts, can reduce HIV acquisition at population level.
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Affiliation(s)
- Joseph Larmarange
- Centre Population et Développement, Université Paris Cité, IRD, Inserm, Paris, France
| | - Pamela Bachanas
- Division of Global HIV/AIDS and TB, Centers for Disease Control and Prevention, Atlanta, GA, United States of America
| | - Timothy Skalland
- Fred Hutchinson Cancer Center, Seattle, WA, United States of America
| | - Laura B. Balzer
- Division of Biostatistics, School of Public Health, University of California, Berkeley, California, United States of America
| | - Collins Iwuji
- Department of Global Health and Infection, Brighton and Sussex Medical School, University of Sussex, Falmer, United Kingdom
| | - Sian Floyd
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Lisa A. Mills
- Division of Global HIV and TB, Centers for Disease Control and Prevention, Gaborone, Botswana
| | - Deenan Pillay
- Division of Infection & Immunity, University College London, London, United Kingdom
| | - Diane Havlir
- Department of Medicine, University of California San Francisco, San Francisco, CA, United States of America
| | - Moses R. Kamya
- Department of Medicine, Makerere University Kampala, Uganda and the Infectious Diseases Research Collaboration, Kampala, Uganda
| | - Helen Ayles
- Clinical Research Department London School of Hygiene & Tropical Medicine, London, United Kingdom
- Zambart, University of Zambia School of Public Health, Lusaka, Zambia
| | - Kathleen Wirth
- Harvard T.H. Chan School of Public Health, Boston, MA, United States of America
| | - François Dabis
- Université Bordeaux, ISPED, Centre INSERM U1219-Bordeaux Population Health, Bordeaux, France
| | - Richard Hayes
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Maya Petersen
- Division of Biostatistics, School of Public Health, University of California, Berkeley, California, United States of America
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Roberts DA, Cuadros D, Vandormael A, Gareta D, Barnabas RV, Herbst K, Tanser F, Akullian A. Predicting the Risk of Hiv-1 Acquisition in Rural South Africa Using Geospatial Data. Clin Infect Dis 2022; 75:1224-1231. [PMID: 35100612 PMCID: PMC9525068 DOI: 10.1093/cid/ciac069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Indexed: 12/04/2022] Open
Abstract
Background Accurate human immunodeficiency virus (HIV) risk assessment can guide optimal HIV prevention. We evaluated the performance of risk prediction models incorporating geospatial measures. Methods We developed and validated HIV risk prediction models in a population-based cohort in South Africa. Individual-level covariates included demographic and sexual behavior measures, and geospatial covariates included community HIV prevalence and viral load estimates. We trained models on 2012–2015 data using LASSO Cox models and validated predictions in 2016–2019 data. We compared full models to simpler models restricted to only individual-level covariates or only age and geospatial covariates. We compared the spatial distribution of predicted risk to that of high incidence areas (≥ 3/100 person-years). Results Our analysis included 19 556 individuals contributing 44 871 person-years and 1308 seroconversions. Incidence among the highest predicted risk quintile using the full model was 6.6/100 person-years (women) and 2.8/100 person-years (men). Models using only age group and geospatial covariates had similar performance (women: AUROC = 0.65, men: AUROC = 0.71) to the full models (women: AUROC = 0.68, men: AUROC = 0.72). Geospatial models more accurately identified high incidence regions than individual-level models; 20% of the study area with the highest predicted risk accounted for 60% of the high incidence areas when using geospatial models but only 13% using models with only individual-level covariates. Conclusions Geospatial models with no individual measures other than age group predicted HIV risk nearly as well as models that included detailed behavioral data. Geospatial models may help guide HIV prevention efforts to individuals and geographic areas at highest risk.
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Affiliation(s)
- D Allen Roberts
- Department of Epidemiology, University of Washington, Seattle, USA
| | - Diego Cuadros
- Department of Geography, University of Cincinnati, Cincinnati, USA
| | - Alain Vandormael
- Heidelberg Institute of Global Health, Heidelberg University, Heidelberg, Germany
| | - Dickman Gareta
- Africa Health Research Institute, KwaZulu-Natal, South Africa
| | - Ruanne V Barnabas
- Department of Epidemiology, University of Washington, Seattle, USA.,Department of Global Health, University of Washington, Seattle, USA.,Department of Medicine, University of Washington, Seattle, USA
| | - Kobus Herbst
- Africa Health Research Institute, KwaZulu-Natal, South Africa.,DSI-MRC South African Population Research Infrastructure Network (SAPRIN), Durban, South Africa
| | - Frank Tanser
- Africa Health Research Institute, KwaZulu-Natal, South Africa.,Lincoln International Institute for Rural Health, University of Lincoln, Lincoln, United Kingdom.,School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa.,Centre for the AIDS Programme of Research in South Africa (CAPRISA), University of KwaZulu-Natal, South Africa
| | - Adam Akullian
- Department of Global Health, University of Washington, Seattle, USA.,Institute for Disease Modeling, Bill & Melinda Gates Foundation, Seattle, USA
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