Combination HIV Prevention Reduces Infections

DECEMBER 01, 2017
Jenna Payesko
Anthony Fauci, MD, director, National Institute of Allergy and Infectious DiseasesAnthony Fauci, MD
A new study provides real-world evidence that implementing a combination of proven HIV prevention measures across various communities can reduce new infections in a population.

Researchers found that throughout the 7-year period in which rates of treatment and voluntary medical male circumcision increased significantly, HIV incidence dropped by 42% among nearly 18,000 people in Uganda.

“It’s very clear that there are a number of interventions that are available to contribute to the decrease of HIV infection,” Anthony Fauci, MD, director, National Institute of Allergy and Infectious Diseases (NIAID) told MD Magazine. “This study dramatically proves that combinations of preventative efforts and preventive interventions, including circumcision, a treatment as prevention, can synergize to give you a very dramatic effect on decreasing incidence.”

The HIV prevention strategy observed in the study is based on previous findings from the National Institutes of Health (NIH) and others, who demonstrated the protective effect of voluntary medical male circumcision for HIV-uninfected men and of HIV-suppressing antiretroviral therapy (ART), halting sexual transmission of the virus to uninfected partners.

The study is also based on the strategies that show changes in sexual behavior, like how only having a single sexual partner can help prevent the spread of the infection.

“Before this study, we knew that these HIV prevention measures work 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,” Fauci said. “This new analysis demonstrates that scaling up combination HIV prevention is possible and can turn the tide of the epidemic.”

The researched involved 34,000 people, ages 15–49 years old, residing in 30 communities that participated in the Rakai Community Cohort Study (RCCS) in Uganda. This program, funded by the NIH and others, promoted HIV testing, ART and voluntary medical male circumcision to study participants.

Every 1 or 2 years from April 1999–Sept. 2016, participants were tested for HIV and surveyed about their sexual behavior, use of HIV treatment and male circumcision status.

Investigators found that the proportion of participants living with HIV who reported being treated with ART grew from 0 in 2003 to 69% in 2016. The proportion of male study participants who were voluntarily circumcised grew from 15% in 1999 to 59% in 2016. 
While the levels of condom use with casual partners and the proportion of people reporting multiple sexual partners remained unchanged, the percent of adolescents aged 15–19 who reported to never have sex rose from 30% in 1999 to 55% in 2016.

As ART use and voluntary male circumcision increased, the annual number of new HIV infections in the cohort fell from 1.17 per 100 person-years in 2009 to 0.66 per 100 person-years in 2016, or a 42% decrease. Researchers calculated the annual number of new HIV infections from data of nearly 18,000 of approximately 34,000 total participants.

Additionally, the proportion of cohort members living with HIV whose treatment suppressed the virus increased from 42% in 2009 to 75% in 2016, demonstrating the likelihood to meet the UNAIDS 90-90-90 initiative of achieving 73% viral suppression.

Among circumcised men HIV dropped the most, by 57% percent, since their own circumcision and ART taken by female partners living with HIV, protected the men from the virus.

HIV frequency declined by 54% among all men, but only by 32% among all women, which according to the researchers, could have occurred because a greater percent of women living with HIV took ART and because nearly two-thirds of men chose the extra preventive benefit of circumcision.

By influencing more men living with HIV to take ART and by giving HIV-uninfected women HIV prevention tools like PrEP, the gender imbalance can be addressed.

It’s anticipated that the RCCS will add PrEP to its combination HIV prevention package as the study goes forward.

“We expect that this multifaceted approach to HIV prevention will work as well in other populations as it has in rural Uganda,” M. Kate Grabowski, PhD, assistant professor of pathology, Johns Hopkins University School of Medicine, assistant professor epidemiology, Johns Hopkins University Bloomberg School of Public Health, epidemiologist, Rakai Health Sciences Program, said in a statement. “Our results make a strong case for further expanding ART and male circumcision for HIV prevention interventions, such as PrEP, should be added to the mix to reduce HIV infections in women and other high-risk groups.”

A press release has been made available.

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