Abstract
SummaryBackgroundInternational and global organisations advocate targeting interventions to areas of high HIV prevalence (ie, hotspots). To better understand the potential benefits of geo-targeted control, we assessed the extent to which HIV hotspots along Lake Victoria sustain transmission in neighbouring populations in south-central Uganda.MethodsWe did a population-based survey in Rakai, Uganda, using data from the Rakai Community Cohort Study. The study surveyed all individuals aged 15–49 years in four high-prevalence Lake Victoria fishing communities and 36 neighbouring inland communities. Viral RNA was deep sequenced from participants infected with HIV who were antiretroviral therapy-naive during the observation period. Phylogenetic analysis was used to infer partial HIV transmission networks, including direction of transmission. Reconstructed networks were interpreted through data for current residence and migration history. HIV transmission flows within and between high-prevalence and low-prevalence areas were quantified adjusting for incomplete sampling of the population.FindingsBetween Aug 10, 2011, and Jan 30, 2015, data were collected for the Rakai Community Cohort Study. 25 882 individuals participated, including an estimated 75·7% of the lakeside population and 16·2% of the inland population in the Rakai region of Uganda. 5142 participants were HIV-positive (2703 [13·7%] in inland and 2439 [40·1%] in fishing communities). 3878 (75·4%) people who were HIV-positive did not report antiretroviral therapy use, of whom 2652 (68·4%) had virus deep-sequenced at sufficient quality for phylogenetic analysis. 446 transmission networks were reconstructed, including 293 linked pairs with inferred direction of transmission. Adjusting for incomplete sampling, an estimated 5·7% (95% credibility interval 4·4–7·3) of transmissions occurred within lakeside areas, 89·2% (86·0–91·8) within inland areas, 1·3% (0·6–2·6) from lakeside to inland areas, and 3·7% (2·3–5·8) from inland to lakeside areas.InterpretationCross-community HIV transmissions between Lake Victoria hotspots and surrounding inland populations are infrequent and when they occur, virus more commonly flows into rather than out of hotspots. This result suggests that targeted interventions to these hotspots will not alone control the epidemic in inland populations, where most transmissions occur. Thus, geographical targeting of high prevalence areas might not be effective for broader epidemic control depending on underlying epidemic dynamics.FundingThe Bill & Melinda Gates Foundation, the National Institute of Allergy and Infectious Diseases, the National Institute of Mental Health, the National Institute of Child Health and Development, the Division of Intramural Research of the National Institute for Allergy and Infectious Diseases, the World Bank, the Doris Duke Charitable Foundation, the Johns Hopkins University Center for AIDS Research, and the President's Emergency Plan for AIDS Relief through the Centers for Disease Control and Prevention.
Highlights
Spatial mapping of infectious diseases, including malaria, tuberculosis, cholera, and HIV has shown considerable spatial heterogeneity in disease prevalence and incidence.[1,2,3] From a public health perspective, a primary objective of mapping efforts is the identification of so-called hotspots—typically defined as spatial clusters of elevated disease burden or transmission efficiency—to target the highest risk populations, and maximise the public health effect of interventions.[3]
Study design and participants We did a population-based study using data from the Rakai Community Cohort Study (RCCS) in 36 inland communities of the Rakai region in south-central Uganda shown in figure 1A, and the main four fishing communities within 3 km of Lake Victoria.[13]
From Aug 10, 2011, to Jan 30, 2015, 25 882 individuals in 40 communities participated in the RCCS
Summary
Spatial mapping of infectious diseases, including malaria, tuberculosis, cholera, and HIV has shown considerable spatial heterogeneity in disease prevalence and incidence.[1,2,3] From a public health perspective, a primary objective of mapping efforts is the identification of so-called hotspots—typically defined as spatial clusters of elevated disease burden or transmission efficiency—to target the highest risk populations, and maximise the public health effect of interventions.[3]. Published Online January 14, 2020 https://doi.org/10.1016/ S2352-3018(19)30378-9. The corrected version first appeared at thelancet.com/hiv on February 6, 2020. Prof T C Quinn MD, S J Reynolds) and Department of Pathology (M K Grabowski PhD), Johns Hopkins School of Medicine, Baltimore, MD, USA; Division of Intramural Research, National. S J Reynolds); Department of Epidemiology, Johns Hopkins. Bloomberg School of Public Health, Baltimore, MD, USA (J Lessler PhD, L W Chang, Prof M J Wawer, Prof R H Gray); KwaZulu-Natal Research Innovation and Sequencing Platform College of Health.
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