Association of Medical Male Circumcision and Antiretroviral Therapy Scale-up With Community HIV Incidence in Rakai, Uganda
Association of Medical Male Circumcision and Antiretroviral Therapy Scale-up With Community HIV Incidence in Rakai, Uganda
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DOI：
10.1001/jama.2016.7292
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发表时间：
2016-07-12
影响因子：
120.7
通讯作者：
Gray, Ronald H.
中科院分区：
文献类型：
--
作者：
Kong, Xiangrong;Kigozi, Godfrey;Gray, Ronald H.
重要性医学男性包皮环切术(MMC)和抗逆转录病毒疗法(ART)是被证实的艾滋病毒预防措施，但关于这些干预措施在撒哈拉以南非洲扩大的人口一级影响的数据有限。目的利用1999年至2013年在45个农村Rakai社区进行的基于人口的调查数据，设计、设置和参与者，在3个时期估计社区水平的ART和MMC覆盖率、社会人口统计学、性行为以及HIV流行率和发病率：在ART和MMC可用之前(1999-2004年)，在ART和MMC早期可用期间(2004-2007年)，在成熟项目的扩大期间(2007-2013)。基于自我报告的MMC状况和抗逆转录病毒疗法的使用，讨论男性社区MMC覆盖率和异性HIV阳性者的ART覆盖率。主要结果和测量调整后的发病率比(IRR)使用带有广义估计方程的多变量泊松回归估计的特定性别社区HIV发病率。结果从1999年到2013年，44 688人参加了1次或1次以上调查(首次调查的平均年龄为24.6岁[范围为15-49岁]；女性，56.5%；平均调查参与率为92.6%[95%可信区间为92.4%-92.7%]。社区MMC覆盖率中位数从19%上升到39%，男性社区抗逆转录病毒治疗覆盖率中位数从0%上升到21%，女性从0%上升到26%。社区艾滋病毒发病率中位数从男性的1.25/100人年下降到0.84/100人年，女性从1.25/100人年下降到0.99/100人年。在男性中，社区MMC覆盖率每增加10%，调整后的IRR为0.87(95%CI，0.82-0.93)。比较MMC覆盖率超过40%的社区(平均男性社区发病率为1.03/100人年)与覆盖率在10%或以下的社区(平均男性发病率为1.69/100人年)，调整后的IRR为0.61(95%CI，0.43~0.88)。女性自我报告的抗逆转录病毒疗法覆盖率每增加10%，男性艾滋病毒发病率就没有显著下降(调整后的IRR，0.95[95%CI，0.81-1.13])。比较女性ART覆盖率大于20%(平均男性发病率0.87/100人年)和女性ART覆盖率小于20%(平均男性发病率1.17/100人年)的社区，调整后的IRR为0.77(95%CI，0.61-0.98)。结论在乌干达Rakai，社区MMC和女性ART覆盖率的增加与男性社区HIV发病率的降低相关。如果在其他地方发现类似的关联，这将支持在撒哈拉以南非洲进一步扩大MMC和ART预防艾滋病毒的规模。
IMPORTANCE Medical male circumcision (MMC) and antiretroviral therapy (ART) are proven HIV prevention interventions, but there are limited data on the population-level effect of scale-up of these interventions in sub-Saharan Africa. Such evaluation is important for planning and resource allocation.OBJECTIVE To examine whether increasing community MMC and ART coverage was associated with reduced community HIV incidence in Rakai District, Uganda.DESIGN, SETTING, AND PARTICIPANTS Using person-level data from population-based surveys conducted from 1999 through 2013 in 45 rural Rakai communities, community-level ART and MMC coverage, sociodemographics, sexual behaviors, and HIV prevalence and incidence were estimated in 3 periods: prior to the availability of ART and MMC (1999-2004), during early availability of ART and MMC (2004-2007), and during mature program scale-up (2007-2013).EXPOSURES Community MMC coverage in males and ART coverage in HIV-positive persons of the opposite sex based on self-reported MMC status and ART use.MAIN OUTCOMES AND MEASURES Adjusted incidence rate ratios (IRRs) for sex-specific community HIV incidence estimated using multivariable Poisson regression with generalized estimating equations.RESULTS From 1999 through 2013, 44 688 persons participated in 1 or more surveys (mean age at the first survey, 24.6 years [range, 15-49]; female, 56.5%; mean survey participation rate, 92.6%[95% CI, 92.4%-92.7%]). Median community MMC coverage increased from 19% to 39%, and median community ART coverage rose from 0% to 21% in males and from 0% to 26% in females. Median community HIV incidence declined from 1.25 to 0.84 per 100 person-years in males, and from 1.25 to 0.99 per 100 person-years in females. Among males, each 10% increase in community MMC coverage was associated with an adjusted IRR of 0.87 (95% CI, 0.82-0.93). Comparing communities with MMC coverage more than 40% (mean male community incidence, 1.03 per 100 person-years) with communities with coverage of 10% or less (mean male incidence, 1.69 per 100 person-years), the adjusted IRR was 0.61 (95% CI, 0.43-0.88). For each 10% increase in female self-reported ART coverage, there was no significant reduction in male HIV incidence (adjusted IRR, 0.95 [95% CI, 0.81-1.13]). Comparing communities with female ART coverage more than 20%(mean male incidence, 0.87 per 100 person-years) to communities with female ART coverage of 20% or less (mean male incidence, 1.17 per 100 person-years), the adjusted IRR was 0.77 (95% CI, 0.61-0.98). Neither MMC nor male ART coverage was associated with lower female community HIV incidence.CONCLUSIONS AND RELEVANCE In Rakai, Uganda, increasing community MMC and female ART coverage was associated with lower community HIV incidence in males. If similar associations are found elsewhere, this would support further scale-up of MMC and ART for HIV prevention in sub-Saharan Africa.