Effect of ART scale-up and female migration intensity on risk of HIV acquisition: results from a population-based cohort in KwaZulu-Natal, South Africa

Armstrong Dzomba,Alain Vandormael,Frank Tanser,Kaymarlin Govender,Andrew Tomita

doi:10.1186/s12889-019-6494-x

Abstract

BackgroundDespite increased antiretroviral therapy (ART) coverage, the incidence of HIV infection among women in rural South Africa remains high. While many socio-demographic and behavioral factors have been identified, the effect of female migration intensity on the risk of HIV acquisition before and after ART scale-up has not been evaluated in the country.MethodsWe followed 13,315 female participants aged 15–49 who were HIV-uninfected at baseline and recorded their migration events between 2004 and 2015. Using a Cox proportional hazard model, we estimated the time to HIV acquisition among the women, adjusting for annual migration intensity (high: ≥2 events/year, moderate = 1 event/year, and low = 0 event/year) before and after ART scale-up in 2010.Results1998 (15%) new HIV-infection events were recorded during the observation period. Overall, high migration intensity was associated with an increased HIV acquisition risk among women when compared with low migration intensity (HR = 2.88, 95% CI: 1.56–5.53). Among those with high migration intensity, the risk of HIV acquisition was significantly lower in the post-ART period compared to the pre-ART period, after controlling for key socio-demographic and behavioural covariates (aHR = 0.18, 95% CI 0.04–0.83).ConclusionsWomen who migrated frequently after ART scale-up had a significantly reduced HIV acquisition risk compared to those before its implementation. While this reduction is encouraging, women who migrate frequently remain at high risk of HIV acquisition. In the era of ART, there remains a critical need for public health interventions to reduce the risk of HIV acquisition in this highly vulnerable population.

Highlights

Despite increased antiretroviral therapy (ART) coverage, the incidence of Human Immune Virus (HIV) infection among women in rural South Africa remains high
Our study in a rural South African community found that among women who had high annual migration intensity, the risk of HIV acquisition was lower in the post-ART period (2010–2015) than in the pre-ART period (2004–2009)
Our findings are comparable to a similar study from Rakai, Uganda, where the HIV incidence rate ratio in recent female migrants during the 2011–2015 period was lower than in those who migrated between 2004 and 2011, this difference was not statistically significant [15]

Summary

Introduction

Despite increased antiretroviral therapy (ART) coverage, the incidence of HIV infection among women in rural South Africa remains high. While many socio-demographic and behavioral factors have been identified, the effect of female migration intensity on the risk of HIV acquisition before and after ART scale-up has not been evaluated in the country. Several studies have shown that migration is associated with a higher risk of HIV acquisition [9,10,11,12,13,14,15], with a number of socio-demographic or behavioral factors explaining this relationship. Despite an abundance of studies on migration and HIV acquisition risk [20, 21], most have focused on male migration [15, 17], with a few notable exceptions [22, 23]. There is lack of empirical evidence on whether the frequency of migration will attenuate the preventative benefits of ART, which is highly relevant in the era of universal access to HIV test and treat services

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Discussion

Conclusion