Combining Prevention Measures Reduces New Cases of HIV

A new report published by the New England Journal of Medicine shows how combining HIV prevention measures can significantly reduce new infections.

The real-world data suggest that using multiple prevention services may be beneficial, especially among communities in which HIV rates are increasing.

Previous studies show that voluntary medical male circumcision for HIV-negative men and starting antiretroviral therapy (ART) were effective at stopping sexual transmission of HIV to uninfected partners, according to the authors of the current study. Other research also shows that changing sexual behavior can prevent HIV transmission.

“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,” said Anthony S. Fauci, MD, director of the National Institute of Allergy and Infectious Diseases (NIAID). “This new analysis demonstrates that scaling up combination HIV prevention is possible and can turn the tide of the epidemic.”

Included in the study were nearly 34,000 patients aged 15 to 49 years living in 30 communities participating in the Rakai Community Cohort Study (RCCS), which promoted HIV testing, ART, and voluntary medical male circumcision to patients.

Patients were tested for HIV and surveyed about their sexual behavior, use of ART, and male circumcision status every 1 or 2 years from April 1999 until September 2016, according to the study.

The investigators found that the number of HIV-positive patients taking ART increased from none in 2003 to 69% in 2016, according to the study.

The number of male study participants voluntarily undergoing circumcision increased from 15% in 1999 to 59% in 2016.

The authors noted that the frequency of condom use with casual partners and patients reporting multiple sexual partners was unchanged throughout the study; however, the number of participants aged 15 to 19 years who reported abstaining from sex increased from 30% in 1999 to 55% in 2016, according to the study.

The authors hypothesized that the uptick in ART use and circumcision resulted in the number of new infections dropping 42%, according to the study.

Additionally, the prevalence of viralogically suppressed patients with HIV increased from 42% in 2009 to 75% in 2016. The authors noted that this finding demonstrated the feasibility of the UNAIDS 90-90-90 initiative by achieving 73% viral suppression, according to the study.

“These findings are extremely encouraging and suggest that with sustained commitment to increase the number of people who use combination HIV prevention, it may be possible to achieve epidemic control and eventual elimination of HIV,” said David Serwadda, MBChB, MMed, MPH, co-founder of the Rakai Health Science Program and professor at Makerere University School of Public Health in Kampala, Uganda.

Overall, HIV cases dropped the most significantly among circumcised men. The authors said the 57% decrease was likely related to circumcision and HIV-positive female partners taking ART.

HIV prevalence was reduced 54% among all men during the study, but dropped only 32% among women. These gender disparities were likely due to more HIV-positive women taking ART than HIV-positive men and men had extra protection against HIV due to circumcision, according to the study.

The authors suggest these gaps can be addressed by having more HIV-positive men take ART and by giving HIV-negative women prevention tools, such as access to pre-exposure prophylaxis (PrEP). The authors said that it is likely RCCS will add PrEP as a prevention strategy in the future, according to the study.

“We expect that this multifaceted approach to HIV prevention will work as well in other populations as it has in rural Uganda,” Dr Grabowski concluded. “Our results make a strong case for further expanding ART and male circumcision for HIV prevention in Rakai District and beyond. Additional proven HIV prevention interventions, such as PrEP, should be added to the mix to reduce HIV infections in women and other high-risk groups.”