Cross-sectional estimates revealed high HIV incidence in Botswana rural communities in the era of successful ART scale-up in 2013-2015

PLOS ONE, Oct 2018

Background Botswana is close to reaching the UNAIDS “90-90-90” HIV testing, antiretroviral treatment (ART), and viral suppression goals. We sought to determine HIV incidence in this setting with both high HIV prevalence and high ART coverage. Methods We used a cross-sectional approach to assessing HIV incidence. A random, population-based sample of adults age 16–64 years was enrolled in 30 rural and peri-urban communities as part of the Botswana Combination Prevention Project (BCPP), from October 2013 –November 2015. Data and samples from the baseline household survey were used to estimate cross-sectional HIV incidence, following an algorithm that combined Limiting-Antigen Avidity Assay (LAg-Avidity EIA), ART status (documented or by testing ARV drugs in plasma) and HIV-1 RNA load. The LAg-Avidity EIA cut-off normalized optical density (ODn) was set at 1.5. The HIV-1 RNA cut-off was set at 400 copies/mL. For estimation purposes, the Mean Duration of Recent Infection was 130 days and the False Recent Rate (FRR) was evaluated at values of either 0 or 0.39%. Results Among 12,610 individuals participating in the baseline household survey, HIV status was available for 12,570 participants and 3,596 of them were HIV positive. LAg-Avidity EIA data was generated for 3,581 (99.6%) of HIV-positive participants. Of 326 participants with ODn ≤1.5, 278 individuals were receiving ART verified through documentation and were considered to represent longstanding HIV infections. Among the remaining 48 participants who reported no use of ART, 14 had an HIV-1 RNA load ≤400 copies/mL (including 3 participants with ARVs in plasma) and were excluded, as potential elite/viremic controllers or undisclosed ART. Thus, 34 LAg-Avidity-EIA-recent, ARV-naïve individuals with detectable HIV-1 RNA (>400 copies/mL) were classified as individuals with recent HIV infections. The annualized HIV incidence among 16–64 year old adults was estimated at 1.06% (95% CI 0.68–1.45%) with zero FRR, and at 0.64% (95% CI 0.24–1.04%) using a previously defined FRR of 0.39%. Within a subset of younger individuals 16–49 years old, the annualized HIV incidence was estimated at 1.29% (95% CI 0.82–1.77%) with zero FRR, and at 0.90% (95% CI 0.42–1.38%) with FRR set to 0.39%. Conclusions Using a cross-sectional estimate of HIV incidence from 2013–2015, we found that at the time of near achievement of the UNAIDS 90-90-90 targets, ~1% of adults (age 16–64 years) in Botswana’s rural and peri-urban communities became HIV infected annually.

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Cross-sectional estimates revealed high HIV incidence in Botswana rural communities in the era of successful ART scale-up in 2013-2015

October Cross-sectional estimates revealed high HIV incidence in Botswana rural communities in the era of successful ART scale-up in 2013- 2015 Sikhulile MoyoID 0 1 Simani Gaseitsiwe 0 1 Terence Mohammed 0 1 Molly Pretorius Holme 0 1 Rui Wang 1 Kenanao Peggy Kotokwe 0 1 Corretah Boleo 0 1 Lucy Mupfumi 0 1 Etienne Kadima Yankinda 0 1 Unoda Chakalisa 0 1 Erik van Widenfelt 0 1 Tendani Gaolathe 0 1 Mompati O. Mmalane 0 1 Scott Dryden-Peterson 0 1 Madisa Mine 1 Refeletswe Lebelonyane 1 Kara BennettID 1 Jean Leidner 1 Kathleen E. Wirth 1 Eric Tchetgen Tchetgen 1 Kathleen Powis 0 1 Janet Moore 1 William A. Clarke 1 Shahin Lockman 0 1 Joseph M. Makhema 0 1 Max Essex 0 1 Vlad Novitsky 0 1 0 Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana, 2 Department of Immunology and Infectious Diseases, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, United States of America, 3 Department of Population Medicine, Harvard Pilgrim Health Care Institute, Boston, Massachusetts, United States of America, 4 Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston Massachusetts, United States of America, 5 Harvard Medical School , Boston , Massachusetts, United States of America, 6 Division of Infectious Diseases, Brigham and Women's Hospital , Boston , Massachusetts, United States of America, 7 Botswana Ministry of Health and Wellness , Gaborone, Botswana, 8 Bennett Statistical Consulting , Inc., Ballston Lake, New York, United States of America , 9 Goodtables Data Consulting, Norman, OK , United States of America, 10 Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, United States of America, 11 Departments of Internal Medicine and Pediatrics, Massachusetts General Hospital , Boston , Massachusetts, United States of America, 12 U.S. Centers for Disease Control, Atlanta, Georgia, United States of America, 13 Johns Hopkins Hospital , Baltimore, MD , United States of America 1 Editor: Alana T. Brennan, Boston University , UNITED STATES Background Botswana is close to reaching the UNAIDS ª90-90-90º HIV testing, antiretroviral treatment (ART), and viral suppression goals. We sought to determine HIV incidence in this setting with both high HIV prevalence and high ART coverage. Methods We used a cross-sectional approach to assessing HIV incidence. A random, populationbased sample of adults age 16±64 years was enrolled in 30 rural and peri-urban communities as part of the Botswana Combination Prevention Project (BCPP), from October 2013 ± November 2015. Data and samples from the baseline household survey were used to estimate cross-sectional HIV incidence, following an algorithm that combined Limiting-Antigen Avidity Assay (LAg-Avidity EIA), ART status (documented or by testing ARV drugs in plasma) and HIV-1 RNA load. The LAg-Avidity EIA cut-off normalized optical density (ODn) was set at 1.5. The HIV-1 RNA cut-off was set at 400 copies/mL. For estimation purposes, Development Committee (HRDC). IRB contact: Seeletso Mosweunyane (Head of Health Research Unit, Ministry of Health and Wellness, Botswana; phone: +267-3914467; email: ). Funding: This study was supported by the US President's Emergency Plan for AIDS Relief (PEPFAR) through the Centers for Disease Control and Prevention (CDC) under the terms of cooperative agreement U01 GH000447 to SM, SG, TM, MPH, EKY, UC, EVW, TG, MOM, RL, KEW, ETT, JM, SL, JMM, ME, and VN. Its contents are solely the responsibility of the authors and do not necessarily represent the official views of the funding agencies. SM was supported by the Fogarty International Center and National Institute of Mental Health, of the National Institutes of Health under Award Number D43 TW010543. SM, SG and LM were partially funded by Wellcome Trust DELTAS Initiatives/Sub-Saharan Africa Network for TB/HIV Research Excellence (SANTHE) (107752/Z/15/Z). SDP was funded by the National Institutes of Health under the award K23AI091434. RW was supported by R37 AI51164 from the National Institutes of Health. The funders had no role in the study design, data collection and decision to publish, or in the preparation of the manuscript. Additionally, Bennett Statistical Consulting Inc. and Goodtables Data Consulting provided support in the form of salaries for authors KB and JL respectively, but did not have any additional role in the study design, data collection and analysis, decision to publish, or preparation of the manuscript. The specific roles of these authors are articulated in the `author contributions' section. Competing interests: Kara Bennett is employed by Bennett Statistical Consulting, Inc and Jean Leidner was employed by Goodtables Data Consulting. The entities above provided support in the form of salaries for authors Kara Bennett and Jean Leidner, but did not have any additional role in the study design, data collection and analysis, decision to publish, or preparation of the manuscript. This does not alter our ad (...truncated)


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Sikhulile Moyo, Simani Gaseitsiwe, Terence Mohammed, Molly Pretorius Holme, Rui Wang, Kenanao Peggy Kotokwe, Corretah Boleo, Lucy Mupfumi, Etienne Kadima Yankinda, Unoda Chakalisa, Erik van Widenfelt, Tendani Gaolathe, Mompati O. Mmalane, Scott Dryden-Peterson, Madisa Mine, Refeletswe Lebelonyane, Kara Bennett, Jean Leidner, Kathleen E. Wirth, Eric Tchetgen Tchetgen, Kathleen Powis, Janet Moore, William A. Clarke, Shahin Lockman, Joseph M. Makhema, Max Essex, Vlad Novitsky. Cross-sectional estimates revealed high HIV incidence in Botswana rural communities in the era of successful ART scale-up in 2013-2015, PLOS ONE, 2018, Volume 13, Issue 10, DOI: 10.1371/journal.pone.0204840