Hard-to-Reach Populations: Implications for Ending the AIDS Epidemic

难以接触的人群：对结束艾滋病流行的影响

• 批准号: 9920670
• 负责人: Larry William Chang
• 金额: $ 57.82万
• 依托单位: JOHNS HOPKINS UNIVERSITY
• 依托单位国家: 美国
• 财政年份: 2019
• 资助国家: 美国
• 起止时间: 2019-04-25 至 2023-03-31
• 项目状态: 已结题
• 来源: https://reporter.nih.gov/project-details/9920670
• 关键词: AIDS prevention; Acquired Immunodeficiency Syndrome; Address; Africa; African; Area; Car Phone; Censuses; Characteristics; Cohort Studies; Communities; Cross-Sectional Studies; Data; Environment; Epidemic; Epidemiology; Evaluation; Family; Future; Goals; HIV; HIV Infections; HIV Seronegativity; HIV Seropositivity; HIV prevention trial; Home visitation; Incidence; Individual; Intervention; Male Circumcision; Measures; Methods; Modeling; Participant; Partner Notification; Pathway Analysis; Pathway interactions; Patient Self-Report; Persons; Phylogenetic Analysis; Population; Population Decreases; Population Study; Positioning Attribute; Prevalence; Prevention; Preventive Intervention; Randomized; Reporting; Research Infrastructure; Role; Sampling; Schools; Services; Sex Behavior; Source; Structure; Surveys; Techniques; Testing; Travel; Uganda; Viral; Viral Load result; Work; antiretroviral therapy; demographics; follow-up; high risk; high risk population; innovation; novel; population based; pre-exposure prophylaxis; prevent; programs; prospective; recruit; scale up; transmission process

The Rakai region in Uganda was the initial epicenter of the HIV epidemic in East Africa and continues to be a high burden area with an HIV prevalence of ~13%. Through the open, population-based Rakai Community Cohort Study (RCCS), we reported that combination HIV prevention (CHP) decreased population-level HIV incidence in Rakai by 42% from 1.17/100 person-years (pys) prior to CHP scale-up to 0.66/100 pys by 2016 (Grabowski et al. NEJM 2017). Implications and limitations from this study raise two issues of global importance. First, mobile persons, typically away for work or school, and, rarely, refusers are a “hard-to-reach” population that is difficult to survey, reducing RCCS participation rates to ~62%. These populations may likewise be hard-to-reach for engagement in HIV services. Ongoing cluster-randomized HIV prevention trials and population-based HIV impact assessments have similar challenges of potential bias due to missing these hard-to-reach populations. Second, despite reaching 59% male circumcision coverage and UNAIDS 90-90-90 goals with 75% viral suppression of all HIV-positive participants in RCCS, HIV incidence reductions were moderate and remained well above the estimated rate needed for HIV elimination (~0.1/100py). To address ongoing HIV transmission in the Rakai region, the PEPFAR program in which RCCS is nested recently began implementing additional CHP interventions: (i) Pre-Exposure Prophylaxis (PrEP); (ii) assisted Partner Notification; and (iii) Same-day antiretroviral therapy (ART). This environment provides a unique opportunity to address the following important questions: (1) To what extent do hard-to-reach populations bias HIV coverage and incidence estimates? (2) Why do some individuals continue to acquire HIV and from whom? (3) Given hard-to-reach populations, can state-of-the-art CHP in a programmatic setting reduce HIV incidence to the levels needed for HIV elimination? Our setting and research infrastructure strongly position us to answer these highly significant questions and inform current and future HIV prevention trials, evaluations, and programs. We thus propose a novel study with the following Aims. Aim 1-We will first determine CHP coverage and HIV incidence among hard-to-reach persons using enhanced surveillance techniques. Aim 2-We will then characterize ongoing sources of incident HIV infection through partner tracing, viral phylogenetics, and sexual network analyses. Aim 3-Finally, we will determine if state-of-the-art CHP can engage hard-to-reach populations and reduce population-level HIV incidence to a level sufficient for HIV elimination by 2030. To our knowledge, no prior HIV population-based studies have empirically determined the potential effects of participation bias on HIV epidemiology and incidence due to non-inclusion of hard-to-reach populations. This study will uniquely address questions on hard-to-reach populations which are critical to understanding the true state of the epidemic, interpreting HIV prevention trials and cross-sectional studies, and informing prospects and pathways to ending the African HIV epidemic.

乌干达拉凯地区是东非艾滋病毒流行的最初震中，并且仍然是艾滋病毒流行的中心。 HIV 感染率约为 13% 的高负担地区。通过开放的、以人口为基础的 Rakai 社区 队列研究 (RCCS)，我们报告说，艾滋病毒联合预防 (CHP) 降低了人群水平的艾滋病毒 到 2016 年，Rakai 的发病率从 CHP 扩大之前的 1.17/100 人年 (pys) 增加到 0.66/100 人年 (pys) （Grabowski 等人，NEJM，2017）。这项研究的意义和局限性提出了两个全球问题 重要性。首先，流动人口，通常是外出工作或上学，很少有拒绝者是“难以接触到的” 难以调查的人群，将 RCCS 参与率降低至约 62%。这些人群可能 同样，参与艾滋病毒服务也很难。正在进行的整群随机艾滋病毒预防试验 和基于人群的艾滋病毒影响评估也存在类似的挑战，即由于缺少这些因素而存在潜在偏差。 难以接触到的人群。其次，尽管男性包皮环切覆盖率达到 59% 且联合国艾滋病规划署 90-90-90 RCCS 中所有 HIV 阳性参与者的病毒抑制率达到 75%，HIV 发病率降低了 中等，仍然远高于消除艾滋病毒所需的估计速度（~0.1/100py）。致地址 拉凯地区持续存在艾滋病毒传播，RCCS 所在的 PEPFAR 计划最近开始 实施额外的 CHP 干预措施： (i) 暴露前预防 (PrEP)； (ii) 协助伙伴 通知; (iii) 当日抗逆转录病毒治疗 (ART)。这种环境提供了一个独特的机会 解决以下重要问题：(1) 难以接触的人群在多大程度上影响了艾滋病毒覆盖率 和发病率估计？ (2) 为什么有些人会继续感染艾滋病毒？是从谁那里感染的？ (3)给定 难以接触到的人群，最先进的 CHP 能否在规划环境中将艾滋病毒发病率降低到 消除艾滋病毒所需的水平？我们的环境和研究基础设施使我们能够回答这些问题 非常重要的问题，并为当前和未来的艾滋病毒预防试验、评估和计划提供信息。我们 因此提出一项具有以下目标的新颖研究。目标 1 - 我们将首先确定 CHP 覆盖范围和 HIV 使用强化监测技术，减少难以接触到的人群中的发病率。目标2-我们将 通过伴侣追踪、病毒系统发育学和性行为来描述艾滋病毒感染事件的持续来源 网络分析。目标 3 - 最后，我们将确定最先进的热电联产是否可以参与难以到达的地区 并将人口水平的艾滋病毒发病率降低到足以在 2030 年消除艾滋病毒的水平。 据了解，之前没有基于艾滋病毒人群的研究凭经验确定了潜在影响 由于未纳入难以接触的人群，导致艾滋病毒流行病学和发病率存在参与偏差。这 研究将独特地解决有关难以接触人群的问题，这对于了解真实情况至关重要 流行病状况，解释艾滋病毒预防试验和横断面研究，并为前景提供信息 以及结束非洲艾滋病毒流行的途径。