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

BACKGROUND: Understanding the extent to which HIV burden differs across communities and the drivers of local disparities is critical 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 surveying persons aged 15–49 in 40 communities. Participants are HIV tested and interviewed to obtain sociodemographic, behavioral, and health information. RCCS data from August 2011 to May 2013 were used to classify communities as agrarian (n=27), trading (n=9), or lakeside fishing sites (n=4). HIV prevalence was mapped using Bayesian methods, and variability across and within community classifications was characterized. Differences in HIV risk factors and uptake of antiretroviral therapy and male circumcision between community types were assessed. FINDINGS: 17,119 individuals were included; 9215 (54%) were female. 9931 participants resided in agrarian, 3318 in trading, and 3870 in fishing communities. There was large variation in HIV prevalence, ranging from 9% to 43% across communities. Fishing communities had a higher median HIV prevalence (41%, range: 37–43%) compared to trading (17%, range: 11–22%) and agrarian communities (14%, range: 9–26%); ART and male circumcision coverage were significantly lower in fishing communities. Self-reported risk behaviors were significantly higher in men compared to women and in fishing communities compared to other community types. INTERPRETATION: There is substantial heterogeneity in HIV prevalence, risk factors, and service uptake across communities within one region of Uganda. These findings underscore the need for local surveillance and have important implications for the design of targeted HIV responses. In particular, the extremely high HIV burden and risk behaviors, and low use of combination HIV prevention in fishing communities make these areas a priority for intervention.