Date Published: March 27, 2019
Publisher: Public Library of Science
Author(s): Monica O. Kuteesa, Helen A. Weiss, Andrew Abaasa, Stephen Nash, Rebecca N. Nsubuga, Rob Newton, Janet Seeley, Anatoli Kamali, Zixin Wang.
We assessed feasibility of an HIV-combination-prevention trial among fishing communities in Uganda.
Cluster randomised trial in four fishing communities on Lake Victoria, Uganda. Two intervention communities received a combination-prevention-package (behaviour change communication, condom promotion, HIV testing, voluntary male medical circumcision and referral for anti-retroviral therapy if HIV-positive). All four communities received routine government HIV care services.
Using household census data we randomly selected a cohort of consenting residents aged ≥18 years. A baseline sero-survey in July 2014 was followed by two repeat surveys in March and December 2015. We measured uptake of HIV prevention methods, loss-to-follow-up and HIV incidence, accounting for multistage survey design.
A total of 862 participants were enrolled and followed for 15 months. Participation was 62% and 74% in the control and intervention arms respectively; Overall loss to follow up (LTFU) was 21.6% and was similar by arm. Self-reported abstinence/faithfulness increased between baseline and endline in both arms from 53% to 73% in the control arm, and 55% to 67% in the intervention arm. Reported condom use throughout the study period was 36% in the intervention arm vs 28% in the control arm; number of male participants reporting circumsicion in both arms from 58% to 79% in the intervention arm, and 39% to 46% in the control arm. Independent baseline predictors of loss-to-follow-up were: being HIV positive, residence in the community for <1 year, younger age, living in an urban area, and being away from the area for >1 month/year
Recruitment and retention of participants in longitudinal trials in highly mobile HIV fishing communities is challenging. Future research should investigate modes for locating and retaining participants, and delivery of HIV-combination prevention.
With major advances in HIV treatment and prevention, the number of new HIV infections among adults globally declined by an estimated 11%, from 3.4 million in 1996 to 1.8 million in 2017 . However, HIV incidence remains high in many settings, including eastern and southern Africa. An estimated 43% of new HIV infections globally occur in this region . In Uganda, the number of new HIV infections reduced by 63% from 140,000 in 2013 to 52,000 in 2016 . Some studies have demonstrated the feasibility of achieving the UNAIDS 2020 target: 90% of all people living with HIV will know their HIV status, 90% of all people with diagnosed HIV infection will receive sustained antiretroviral therapy, 90% of all people receiving antiretroviral therapy will have viral suppression 90-90-90) [3,4].
The overall population size of the four fishing communities was 2989; of these, we enrolled 862 participants. We excluded 73 people from the baseline results as their age or sex was different to the census (>8-year age difference). The response rate at baseline, based on census data, was 62% in the control arm; after subsequent exclusions (see Fig 1), 56% of sampled participants are included in the baseline results. In the intervention arm 74% of sampled participants were included in the baseline survey; after exclusions, 63% were included in the baseline analysis. A total of 614 (63%) and 555 (57%) of enrolled participants were seen at midline and endline respectively (Fig 2). Contamination existed, 13 people were documented to have crossed from the control arm to the intervention arm. Three people crossed from the intervention arm to the control arm. The study was conducted at a time when displacements following land acquisition by private landowners, as well as migration associated with law enforcement to curb illegal fishing, were underway.
Fishing communities are an important population for HIV transmission in Uganda. We demonstrate that implementation of HIV combination prevention in this highly mobile hyper-endemic community is practically feasible, although not without challenges. High rates of non-participation and poor retention may hinder evaluation of population level impact of combination prevention on HIV incidence in high prevalence settings.
Recruitment and retention of study participants in longitudinal trials in highly mobile fishing communities remains challenging. Improving recruitment and retention and investigating modes for delivering and supporting delivery of HIV combination prevention should be a primary focus of future trials. Our findings have implications for HIV prevention, treatment and care programmatic planning for similar communities at risk of HIV infection.