Hypertension and Socioeconomic Status in South Central Uganda: A Population-Based Cohort Study.

Background: Limited studies exploring the impact of socioeconomic status (SES) on hypertension in Africa suggest a positive association between higher SES and hypertension. The economic development in sub-Saharan African countries has led to changes in SES and associated changes in lifestyle, diet, and physical activity, which may affect the relationship between hypertension and SES differently compared with higher income countries. This cross-sectional study from a large population-based cohort, the Rakai Community Cohort Study (RCCS), examines SES, hypertension prevalence, and associated risk factors in the rural Rakai Region in south-central Uganda. Methods: Adults aged 30-49 years residing in 41 RCCS fishing, trading, and agrarian communities, were surveyed with biometric data obtained between 2016 and 2018. The primary outcome was hypertension (systolic blood pressure (BP) ≥ 130 mmHg or diastolic BP ≥ 80 mmHg). Modified Poisson regression assessed the adjusted prevalence ratios (PR) of hypertension associated with SES; body mass index (BMI) was explored as a potential mediator. Results: Among 9,654 adults, 20.8% had hypertension (males 21.2%; females 20.4 %). Participants with hypertension were older (39.0 ± 6.0 vs. 37.8 ± 5.0; p < 0.001). Higher SES was associated with overweight or obese BMI categories (p < 0.001). In the multivariable model, hypertension was associated with the highest SES category (aPR 1.23; confidence interval 1.09-1.38; p = 0.001), older age, male sex, alcohol use, and living in fishing communities and inversely associated with smoking and positive HIV serostatus. When BMI was included in the model, there was no association between SES and hypertension (aPR 1.02; CI 0.90-1.15, p = 0.76). Conclusion: Hypertension is common in rural Uganda among individuals with higher SES and appears to be mediated by BMI. Targeted interventions could focus on lifestyle modification among highest-risk groups to optimize public health impact. Key Messages: What is already known about this subject? Hypertension is an important modifiable risk factor for cardiovascular disease.There are few large epidemiological studies that investigate the relationship between hypertension and socioeconomic status in low-income countries. What are the new findings? Hypertension is common among adults in rural South-Central Uganda, particularly among those with higher socioeconomic status.BMI is a mediator of the relationship between hypertension and socioeconomic status. How might it impact on clinical practice in the foreseeable future? These findings suggest that public health interventions and community efforts to prevent chronic cardiovascular disease and hypertension should focus on lifestyle modification by elucidating obesity risk perception and health risk awareness, particularly among those of higher socioeconomic status.

Alcohol use and alcohol-related consequences are associated with not being virally suppressed among persons living with HIV in the Rakai region of Uganda.

BACKGROUND: Alcohol use is common among persons living with HIV (PWH) in Uganda and associated with poor HIV care outcomes; findings regarding the relationship between alcohol use and viral suppression (VS) have been inconclusive. METHODS: Data from two rounds (2017-2020) of the Rakai Community Cohort Study, an open population-based cohort study in the Rakai region, Uganda, were analyzed. Two alcohol exposures were explored: past year alcohol use and alcohol-related consequences. Multivariable models (GEE) were used to estimate associations between alcohol exposures and VS for the overall sample and stratified by sex, adjusting for repeated measurement. Causal mediation by ART use was explored. RESULTS: Over half (55 %) of participants (n = 3823 PWH) reported alcohol use at baseline; 37.8 % of those reporting alcohol use reported alcohol-related consequences. ART use and VS at baseline significantly differed by alcohol use with person reporting alcohol use being less likely to be on ART or VS. Alcohol use was significantly associated with decreased odds of VS among women but not men (adj. OR 0.72 95 % CI 0.58-0.89, p = 0.0031). However, among males who use alcohol, experiencing alcohol-related consequences was significantly associated with decreased odds of VS (adj. OR 0.69 95 % CI 0.54-0.88, p = 0.0034). The relationships between both alcohol exposures and VS were not significant in models restricted to persons on ART. CONCLUSIONS: We provide sex-stratified estimates of associations between two alcohol measures and VS in the context of current HIV treatment guidelines. This study confirms that alcohol use is adversely associated with VS but ART use mediates this pathway, suggesting that initiation and retention on ART are critical steps to addressing alcohol-related disparities in VS.

Assessment, prevalence, and correlates of frailty among middle-aged adults with HIV in rural Uganda.

We investigated the prevalence and risk factors for frailty among people with HIV (PWH) in rural Uganda (n = 55, 47% male, mean age 44 years). Frailty was defined according to the Fried criteria with self-reported physical activity level replacing the Minnesota Leisure Time Activity Questionnaire. Alternate classifications for physical activity utilized were the sub-Saharan Africa Activity Questionnaire and the International Physical Activity Questionnaire. Eleven participants (19%) were frail. Frail participants were older (p < 0.001), less likely to be on antiretroviral therapy (p = 0.03), and had higher rates of depression (p < .001) and HIV-associated neurocognitive disorder (p = 0.003). Agreement between physical activity measures was sub-optimal. Prevalence of frailty was high among PWH in rural Uganda, but larger sample sizes and local normative data are needed.

Process evaluation of the SHARE intervention for preventing intimate partner violence and HIV infection in Rakai, Uganda.

The Safe Homes And Respect for Everyone (SHARE) intervention introduced an intimate partner violence (IPV) prevention approach into Rakai Health Sciences Program, an established HIV research and service organization in Uganda. A trial found exposure to SHARE was associated with reductions in IPV and HIV incidence. This mixed methods process evaluation was conducted between August 2007 and December 2009, with people living in SHARE intervention clusters, to assess awareness about/participation in SHARE, motivators and barriers to involvement, and perceptions of how SHARE contributed to behavior change. Surveys were conducted with 1407 Rakai Community Cohort Study participants. Qualitative interviews were conducted with 20 key informants. Most (77%) were aware of SHARE, among whom 73% participated in intervention activities. Two-thirds of those who participated in SHARE felt it influenced behavior change related to IPV. While some felt confident to take part in new IPV-focused activities of a well-established program, others were suspicious of SHARE's motivations, implying awareness raising is critical. Many activities appealed to the majority (e.g., community drama) while interest in some activities was limited to men (e.g., film shows), suggesting multiple intervention components is ideal for wide-reaching programming. The SHARE model offers a promising, acceptable approach for integrating IPV prevention into HIV and other established health programs in sub-Saharan Africa.

HIV viral suppression and geospatial patterns of HIV antiretroviral therapy treatment facility use in Rakai, Uganda.

OBJECTIVE: To assess geospatial patterns of HIV antiretroviral therapy (ART) treatment facility use and whether they were impacted by viral load suppression. METHODS: We extracted data on the location and type of care services utilized by HIV-positive persons accessing ART between February 2015 and September 2016 from the Rakai Community Cohort Study in Uganda. The distance from Rakai Community Cohort Study households to facilities offering ART was calculated using the open street map road network. Modified Poisson regression was used to identify predictors of distance traveled and, for those traveling beyond their nearest facility, the probability of accessing services from a tertiary care facility. RESULTS: In total, 1554 HIV-positive participants were identified, of whom 68% had initiated ART. The median distance from households to the nearest ART facility was 3.10 km (interquartile range, 1.65-5.05), but the median distance traveled was 5.26 km (interquartile range, 3.00-10.03, P < 0.001) and 57% of individuals travelled further than their nearest facility for ART. Those with higher education and wealth were more likely to travel further. In total, 93% of persons on ART were virally suppressed, and there was no difference in the distance traveled to an ART facility between those with suppressed and unsuppressed viral loads (5.26 vs. 5.27 km, P = 0.650). CONCLUSION: Distance traveled to HIV clinics was increased with higher socioeconomic status, suggesting that wealthier individuals exercise greater choice. However, distance traveled did not vary by those who were or were not virally suppressed.

Heterogeneity of the HIV epidemic in agrarian, trading, and fishing communities in Rakai, Uganda: an observational epidemiological study.

BACKGROUND: Understanding the extent to which HIV burden differs across communities and the drivers of local disparities is crucial for an effective and targeted HIV response. We assessed community-level variations in HIV prevalence, risk factors, and treatment and prevention service uptake in Rakai, Uganda. METHODS: The Rakai Community Cohort Study (RCCS) is an open, population-based cohort of people aged 15-49 years in 40 communities. Participants are HIV tested and interviewed to obtain sociodemographic, behavioural, and health information. RCCS data from Aug 10, 2011, to May 30, 2013, were used to classify communities as agrarian (n=27), trading (n=9), or lakeside fishing sites (n=4). We mapped HIV prevalence with Bayesian methods, and characterised variability across and within community classifications. We also assessed differences in HIV risk factors and uptake of antiretroviral therapy and male circumcision between community types. FINDINGS: 17 119 individuals were included, 9215 (54%) of whom were female. 9931 participants resided in agrarian, 3318 in trading, and 3870 in fishing communities. Median HIV prevalence was higher in fishing communities (42%, range 38-43) than in trading (17%, 11-21) and agrarian communities (14%, 9-26). Antiretroviral therapy use was significantly lower in both men and women in fishing communities than in trading (age-adjusted prevalence risk ratio in men 0·64, 95% CI 0·44-0·97; women 0·53, 0·42-0·66) and agrarian communities (men 0·55, 0·42-0·72; women 0·65, 0·54-0·79), as was circumcision coverage among men (vs trading 0·48, 0·42-0·55; vs agrarian 0·64, 0·56-0·72). Self-reported risk behaviours were significantly higher in men than in women and in fishing communities than in other community types. INTERPRETATION: Substantial heterogeneity in HIV prevalence, risk factors, and service uptake in Rakai, Uganda, emphasises the need for local surveillance and the design of targeted HIV responses. High HIV burden, risk behaviours, and low use of combination HIV prevention in fishing communities make these populations a priority for intervention. FUNDING: National Institute of Mental Health, the National Institute of Allergy and Infectious Diseases, the National Institute of Child Health and Development, and the National Institute for Allergy and Infectious Diseases Division of Intramural Research, National Institutes of Health; the Bill & Melinda Gates Foundation; and the Johns Hopkins University Center for AIDS Research.

Risk Denial and Socio-Economic Factors Related to High HIV Transmission in a Fishing Community in Rakai, Uganda: A Qualitative Study.

BACKGROUND: In Kasensero fishing community, home of the first recorded case of HIV in Uganda, HIV transmission is still very high with an incidence of 4.3 and 3.1 per 100 person-years in women and men, respectively, and an HIV prevalence of 44%, reaching up to 74% among female sex workers. We explored drivers for the high HIV transmission at Kasensero from the perspective of fishermen and other community members to inform future policy and preventive interventions. METHODS: 20 in-depth interviews including both HIV positive and HIV negative respondents, and 12 focus-group discussions involving a total of 92 respondents from the Kasensero fishing community were conducted during April-September 2014. Content analysis was performed to identify recurrent themes. RESULTS: The socio-economic risk factors for high HIV transmission in Kasensero fishing community cited were multiple and cross-cutting and categorized into the following themes: power of money, risk denial, environmental triggers and a predisposing lifestyle and alcoholism and drug abuse. Others were: peer pressure, poor housing and the search for financial support for both the men and women which made them vulnerable to HIV exposure and or risk behavior. CONCLUSIONS: There is a need for context specific combination prevention interventions in Kasensero that includes the fisher folk and other influential community leaders. Such groups could be empowered with the knowledge and social mobilization skills to fight the negative and risky behaviors, perceptions, beliefs, misconceptions and submission attitudes to fate that exposes the community to high HIV transmission. There is also need for government/partners to ensure effective policy implementation, life jackets for all fishermen, improve the poor housing at the community so as to reduce overcrowding and other housing related predispositions to high HIV rates at the community. Work place AIDS-competence teams have been successfully used to address high HIV transmission in similar settings.

Desire for female sterilization among women wishing to limit births in rural Rakai, Uganda.

OBJECTIVE: Uganda has an unmet need for family planning of 34% and a total fertility rate of 6.2. We assessed the desire for female sterilization among sexually active women who wanted to stop childbearing in rural Rakai district, Uganda. STUDY DESIGN: 7192 sexually active women enrolled in a community cohort between 2002 and 2008 were asked about fertility intentions. Those stating that they did not want another child (limiters) were asked whether they would be willing to accept female sterilization, if available. Trends in desire for sterilization were determined by chi-square test for trend, and Modified Poisson regression was used to estimate prevalence rate ratios and 95% confidence intervals of the associations between desire for sterilization and socio-demographic characteristics and HIV status. RESULTS: From 2002 to 2008, the proportion of limiters dropped (from 47.2% to 43.7%; p<.01). Use of pills and injectables among limiters significantly increased, 38.9% to 50.3% (p<.0001), while use of intrauterine devices and implants declined from 3.3% to 1.7% (p<0.001). The desire for sterilization significantly increased from 54.2% to 63.1% (p<0.0001), and this was consistently higher among the HIV-positive (63.6-70.9%, p<0.01) than HIV-negative women (53.3-61.2%, p<0.0001). Factors significantly associated with the desire for sterilization included higher number of living children (>=3), being HIV-infected and having received HIV counseling and testing. CONCLUSION: There is latent and growing desire for sterilization in this population. Our findings suggest a need to increase permanent contraception services for women who want to limit childbearing in this setting. IMPLICATIONS: A large unmet need for permanent female contraception services exists in Uganda. Efforts to increase the method mix by increasing permanent contraception services could reduce fertility rates and undesired births.

Impact of Patient-Selected Care Buddies on Adherence to HIV Care, Disease Progression, and Conduct of Daily Life Among Pre-antiretroviral HIV-Infected Patients in Rakai, Uganda: A Randomized Controlled Trial.

BACKGROUND: Data are limited on effects of household or community support persons ("care buddies") on enrollment into and adherence to pre-antiretroviral HIV care. We assessed the impact of care buddies on adherence to HIV clinic appointments, HIV progression, and conduct of daily life among pre-antiretroviral therapy (pre-ART) HIV-infected individuals in Rakai, Uganda. METHODS: A total of 1209 HIV-infected pre-ART patients aged ≥15 years were randomized to standard of care (SOC) (n = 604) or patient-selected care buddy (PSCB) (n = 605) and followed at 6 and 12 months. Outcomes were adherence to clinic visits, HIV disease progression, and self-reported conduct of daily life. Incidence and prevalence rate ratios and 95% confidence intervals (CIs) were used to assess outcomes in the intent-to-treat and as-treated analyses. RESULTS: Baseline characteristics were comparable. In the intent to treat analysis, both arms were comparable with respect to adherence to CD4 monitoring visits [adjusted prevalence risk ratio (adjPRR), 0.98; 95% CI: 0.93 to 1.04; P = 0.529], and ART eligibility (adjPRR, 1.00; 95% CI: 0.77 to 1.31; P = 0.946). Good conduct of daily life was significantly higher in the PSCB than the SOC arm (adjPRR, 1.08; 95% CI: 1.03 to 1.13; P = 0.001). More men (61%) compared with women (30%) selected spouses/partners as buddies (P < 0.0001). Twenty-two percent of PSCB arm participants discontinued use of buddies. CONCLUSIONS: In pre-ART persons, having care buddies improved the conduct of daily life of the HIV-infected patients but had no effect on HIV disease progression and only limited effect on clinic appointment adherence.

Multiple sexual partnerships among female adolescents in rural Uganda: the effects of family structure and school attendance.

BACKGROUND: A better understanding is needed of the contextual factors that influence HIV risk behaviors among female adolescents in sub-Saharan Africa. The objectives of this study were to assess the influence of family structure on lifetime sexual partners and on the number of sexual partners in the last year among female adolescents in rural Rakai, Uganda. In addition, the study assessed whether the influence of family structure on these outcomes differed by the school attendance status of the adolescents. METHODS: The sample consisted of 2337 unmarried adolescent girls, aged 15-19, enrolled in the Rakai Community Cohort Study. The last survey interview within the time period of 2001-2008 available for each girl was used. Analyses were stratified by age (15-17 year olds and 18-19 year olds) and school status. Multinomial logistic and poisson regressions were used. RESULTS: Living in a household with a biological father was protective against both outcomes. Family structure was not associated with the outcomes among in-school adolescents but it was significantly associated with the outcomes among out-of-school adolescents. CONCLUSION: The findings suggest that understanding the familial context in which female adolescents develop, as well as its interaction with school attendance, is important for HIV prevention efforts. Both research and programmatic initiatives must consider the interplay between the family and school domains when considering ways to reduce HIV acquisition among adolescent women.

Indices to measure risk of HIV acquisition in Rakai, Uganda.

INTRODUCTION: Targeting most-at-risk individuals with HIV preventive interventions is cost-effective. We developed gender-specific indices to measure risk of HIV among sexually active individuals in Rakai, Uganda. METHODS: We used multivariable Cox proportional hazards models to estimate time-to-HIV infection associated with candidate predictors. Reduced models were determined using backward selection procedures with Akaike's information criterion (AIC) as the stopping rule. Model discrimination was determined using Harrell's concordance index (c index). Model calibration was determined graphically. Nomograms were used to present the final prediction models. RESULTS: We used samples of 7,497 women and 5,783 men. 342 new infections occurred among females (incidence 1.11/100 person years,) and 225 among the males (incidence 1.00/100 person years). The final model for men included age, education, circumcision status, number of sexual partners, genital ulcer disease symptoms, alcohol use before sex, partner in high risk employment, community type, being unaware of a partner's HIV status and community HIV prevalence. The Model's optimism-corrected c index was 69.1 percent (95% CI = 0.66, 0.73). The final women's model included age, marital status, education, number of sex partners, new sex partner, alcohol consumption by self or partner before sex, concurrent sexual partners, being employed in a high-risk occupation, having genital ulcer disease symptoms, community HIV prevalence, and perceiving oneself or partner to be exposed to HIV. The models optimism-corrected c index was 0.67 (95% CI = 0.64, 0.70). Both models were well calibrated. CONCLUSION: These indices were discriminative and well calibrated. This provides proof-of-concept that population-based HIV risk indices can be developed. Further research to validate these indices for other populations is needed.

A qualitative study of barriers to enrollment into free HIV care: perspectives of never-in-care HIV-positive patients and providers in Rakai, Uganda.

BACKGROUND: Early entry into HIV care is low in Sub-Saharan Africa. In Rakai, about a third (31.5%) of HIV-positive clients who knew their serostatus did not enroll into free care services. This qualitative study explored barriers to entry into care from HIV-positive clients who had never enrolled in care and HIV care providers. METHODS: We conducted 48 in-depth interviews among HIV-infected individuals aged 15-49 years, who had not entered care within six months of result receipt and referral for free care. Key-informant interviews were conducted with 12 providers. Interviews were audio-recorded and transcripts subjected to thematic content analysis based on the health belief model. RESULTS: Barriers to using HIV care included fear of stigma and HIV disclosure, women's lack of support from male partners, demanding work schedules, and high transport costs. Programmatic barriers included fear of antiretroviral drug side effects, long waiting and travel times, and inadequate staff respect for patients. Denial of HIV status, belief in spiritual healing, and absence of AIDS symptoms were also barriers. CONCLUSION: Targeted interventions to combat stigma, strengthen couple counseling and health education programs, address gender inequalities, and implement patient-friendly and flexible clinic service hours are needed to address barriers to HIV care.

Risk factors for intimate partner violence in women in the Rakai Community Cohort Study, Uganda, from 2000 to 2009.

BACKGROUND: Intimate partner violence (IPV) is a significant public health problem. There is a lack of data on IPV risk factors from longitudinal studies and from low and middle income countries. Identifying risk factors is needed to inform the design of appropriate IPV interventions. METHODS: Data were from the Rakai Community Cohort Study annual surveys between 2000 and 2009. Female participants who had at least one sexual partner during this period and had data on IPV over the study period were included in analyses (N = 15081). Factors from childhood and early adulthood as well as contemporary factors were considered in separate models. Logistic regression was used to assess early risk factors for IPV during the study period. Longitudinal data analysis was used to assess contemporary risk factors in the past year for IPV in the current year, using a population-averaged multivariable logistic regression model. RESULTS: Risk factors for IPV from childhood and early adulthood included sexual abuse in childhood or adolescence, earlier age at first sex, lower levels of education, and forced first sex. Contemporary risk factors included younger age, being married, relationships of shorter duration, having a partner who is the same age or younger, alcohol use before sex by women and by their partners, and thinking that violence is acceptable. HIV infection and pregnancy were not associated with an increased odds of IPV. CONCLUSIONS: Using longitudinal data, this study identified a number of risk factors for IPV. These findings are useful for the development of prevention strategies to prevent and mitigate IPV in women.

Programme science research on medical male circumcision scale-up in sub-Saharan Africa.

Three randomised trials demonstrate that voluntary medical male circumcision (MMC) reduces male HIV acquisition by 50-60%, and post-trial surveillance has shown that the effects are long lasting. Scale-up of services has been initiated in 14 high-priority sub-Saharan African countries with high rates of HIV and low prevalence of MMC. However, circumcision coverage in the region remains low. Challenges to MMC rollout include suboptimal demand among higher-risk men, the need to expand access and reduce costs of MMC through personnel task shifting and task sharing, assuring and maintaining a high quality of service provision, and the testing and introduction of non-surgical devices. In addition, early infant male circumcision has not been adequately evaluated in Africa. Here, we describe challenges to implementation and discuss the ongoing and future role of implementation and programme science in addressing such challenges.

Community understandings of and responses to gender equality and empowerment in Rakai, Uganda.

Women's rights and gender empowerment programmes are now part of the international agenda for improving global public health, the benefits of which are well documented. However, the public health community has, yet, to address how people define and understand gender equality and how they enact the process of empowerment in their lives. This study uses safe homes and respect for everyone (SHARE), an anti-violence intervention in rural Rakai, Uganda, as a case study to investigate perceptions of gender equality. Investigators analysed 12 focus groups of adult women and men to explore how macro-level concepts of gender equality are being processed on an interpersonal level and the effects on health outcomes. Respondents generally agreed that women lack basic rights. However, they also expressed widespread disagreement about the meanings of gender equality, and reported difficulties integrating the concepts of gender equality into their interpersonal relationships. Community members reported that equality, with the resulting shift in gender norms, could expose women to adverse consequences such as violence, infidelity and abandonment with increased sexual health risks, and potential adverse effects on education. Efforts to increase women's rights must occur in conjunction with community-based work on understandings of gender equality.

Assessment of changes in risk behaviors during 3 years of posttrial follow-up of male circumcision trial participants uncircumcised at trial closure in Rakai, Uganda.

Risk compensation associated with male circumcision has been a concern for male circumcision scale-up programs. Using posttrial data collected during 2007-2011 on 2,137 male circumcision trial participants who were uncircumcised at trial closure in Rakai, Uganda, the authors evaluated their sexual behavioral changes during approximately 3 years' follow-up after trial closure. Eighty-one percent of the men self-selected for male circumcision during the period, and their sociodemographic and risk profiles were comparable to those of men remaining uncircumcised. Linear models for marginal probabilities of repeated outcomes estimate that 3.3% (P < 0.0001) of the male circumcision acceptors reduced their engagement in nonmarital relations, whereas there was no significant change among men remaining uncircumcised. Significant decreases in condom use occurred in both male circumcision acceptors (-9.2% with all partners and -7.0% with nonmarital partners) and nonacceptors (-12.4% and -13.5%, respectively), and these were predominantly among younger men. However, the magnitudes of decrease in condom use were not significantly different between the 2 groups. Additionally, significant decreases in sex-related alcohol consumption were observed in both groups (-7.8% in male circumcision acceptors and -6.1% in nonacceptors), mainly among older men. In summary, there was no evidence of risk compensation associated with male circumcision among this cohort of men during 3 years of posttrial follow-up.

Designing and usage of a low-cost penile model for male medical circumcision skills training in Rakai, Uganda.

OBJECTIVE: To describe the designing and usage of a locally made low-cost penile model used for male medical circumcision (MMC) skills training. MATERIAL AND METHODS: The Rakai MMC training team has experienced a number of challenges during conduct of MMC skills training, one of which was the lack of a model to use for MMC skills training. To address this challenge, the Rakai MMC skills training team has designed and developed a low-cost penile model for use in MMC skills training. RESULTS: The model has been successfully used to demonstrate external penile anatomy, to describe the biological mechanisms through which male circumcision (MC) prevents HIV acquisition, and for demonstration and practice of the MMC procedures. CONCLUSIONS: With an initial cost of only $10 and a recurrent cost of $5, this is a cost-efficient and useful penile model that provides a simulation of normal penile anatomy for use in MC training in resource-limited settings. It has also been used as a visual aid in preoperative education of patients before receiving male circumcision. The model can be improved and scaled up to develop cheaper commercial penile models.

Quantitative assessment of the role of male circumcision in HIV epidemiology at the population level.

OBJECTIVE: Three recent randomized trials have shown that male circumcision (circumcision) reduces HIV incidence in heterosexual men by about 60%. Mathematical models are needed to assess the historical role of circumcision in the observed disparate levels of prevalence in sub-Saharan Africa and to translate these findings into estimates of the population-level impact of circumcision on HIV prevalence. METHODS AND FINDINGS: A deterministic compartmental model of HIV dynamics with circumcision was parameterized by empirical data from the Rakai, Masaka, and Four-City studies. Circumcision was found to account for about two-thirds of the differential HIV prevalence between West Africa and East and Southern Africa. We found that in Kisumu, Kenya, and in Rakai, Uganda, universal circumcision implemented in 2008 would reduce HIV prevalence by 19% and 14%, respectively, by 2020. In Kisumu, a setting with high HIV prevalence, about 6 circumcisions would be needed for each infection averted while in Rakai, 11 circumcisions would be needed. Females will also benefit from circumcision with a substantial reduction in prevalence of about 8% in Kisumu and 4% in Rakai within a few years of universal circumcision. The beneficial impact of circumcision for both males and females will not be undermined by risk behavior compensation unless the increase in risk behavior is in excess of 30%. The effectiveness of circumcision as an intervention is maximized by universal circumcision within 2-3 years. CONCLUSIONS: In West Africa, circumcision may have "quarantined" the spread of HIV by limiting sustainable transmission to within high risk groups and bridge populations. Our findings indicate that circumcision is an effective intervention in both high and intermediate HIV prevalence settings. Circumcision coverage should be expanded as soon as possible to optimize the epidemiological impact.

WHO HIV clinical staging or CD4 cell counts for antiretroviral therapy eligibility assessment? An evaluation in rural Rakai district, Uganda.

The ability of WHO clinical staging to predict CD4 cell counts of 200 cells/microl or less was evaluated among 1221 patients screened for antiretroviral therapy (ART). Sensitivity was 51% and specificity was 88%. The positive predictive value was 64% and the negative predictive value was 81%. Clinical criteria missed half the patients with CD4 cell counts of 200 cells/microl or less, highlighting the importance of CD4 cell measurements for the scale-up of ART provision in resource-limited settings.

The impact of male circumcision on HIV incidence and cost per infection prevented: a stochastic simulation model from Rakai, Uganda.

OBJECTIVES: To estimate the impact of male circumcision on HIV incidence, the number of procedures per HIV infection averted, and costs per infection averted. METHODS: A stochastic simulation model with empirically derived parameters from a cohort in Rakai, Uganda was used to estimate HIV incidence, assuming that male circumcision reduced the risks of HIV acquisition with rate ratios (RR) ranging from 0.3 to 0.6 in men, their female partners, and in both sexes combined, with circumcision coverage 0-100%. The reproductive number (R0) was also estimated. The number of HIV infections averted per circumcision was estimated from the incident cases in the absence of surgery minus the projected number of incident cases over 10 years following circumcision. The cost per procedure ($69.00) was used to estimate the cost per HIV infection averted. RESULTS: Baseline HIV incidence was 1.2/100 person-years. Male circumcision could markedly reduce HIV incidence in this population, particularly if there was preventative efficacy in both sexes. Under many scenarios, with RR < or = 0.5, circumcision could reduce R0 to < 1.0 and potentially abort the epidemic. The number of surgeries per infection averted over 10 years was 19-58, and the costs per infection averted was $1269-3911, depending on the efficacy of circumcision for either or both sexes, assuming 75% service coverage. However, behavioral disinhibition could offset any benefits of circumcision. CONCLUSION: Male circumcision could have substantial impact on the HIV epidemic and provide a cost-effective prevention strategy if benefits are not countered by behavioral disinhibition.