Evolving HIV Infection Dynamics and Threats to Epidemic Control in Africa - PROJECT SUMMARY In the setting of evolving HIV transmission dynamics, differences in programmatic impact, and threats to epidemic control, longitudinal, population-based studies in sentinel sites are needed to answer emerging scientific questions and guide future American investments and the HIV response. To support advancing NIHfs mission through a unified strategy, research is specifically needed on implementation, uptake, access, and impact of existing HIV medical and behavioral interventions to limit and eventually eradicate HIV infection. For instance, the extent to which historically generalized epidemics are concentrating in key and priority populations as overall HIV incidence declines is unclear and will have major implications for planning optimal strategies and resource needs. The future impact of multidimensional risk factors on HIV incidence, onward transmission, and care is uncertain but necessary to inform future HIV programming. In particular, understanding the long-term effects of major multi-component and biomedical interventions as the HIV epidemic is declining may help optimize resource allocation. Finally, monitoring threats to epidemic control such as HIV drug resistance and declines in HIV testing and HIV knowledge and risk perception, particularly among young people, can help design more effective responses. The Rakai Health Sciences Program (RHSP), with one of the longest running population-based HIV studies in the world, is uniquely positioned as a sentinel site for understanding the evolving HIV epidemic. RHSP research findings have informed key strategies for HIV control in America such as test-and-treat and is a special opportunity with unusual expertise, populations, and infrastructure needed to answer central next questions on the HIV epidemic. The proposed study (SENTINEL) has the following aims: Aim 1: To assess changing HIV transmission dynamics in a historically generalized epidemic which has reached 95-95-95 targets; Aim 2: To quantify evolving epidemiological drivers on HIV incidence, onward transmission, and care based on a multidimensional framework and assess impact of major HIV interventions; and, Aim 3: To assess potential threats to HIV epidemic control and impact on epidemic dynamics. To accomplish these Aims, the SENTINEL study will combine 30 years of longitudinal data on population-level HIV trends from 36 communities (~24K persons .15 years of age) and venue-based female sex and bar workers (~2K persons), individual-level behaviors, deep sequencing phylogenetics, and mathematical modeling, allowing for a unique opportunity to produce timely, generalizable knowledge on evolving HIV transmission dynamics, intervention implementation, epidemiology, threats, and mechanisms. The study will generate knowledge directly applicable to understanding, improving, and protecting the health of Americans who could be at risk from compromised HIV epidemic control, e.g., a rise in global HIV drug resistance which spreads to the United States. The SENTINEL study will generate findings essential for guiding American HIV investments, policy, and programs, ensuring a robust and efficient HIV response.
