The changing face of HIV in the era of COVID-19: Maximising HIV incidence reduction through dynamic targeting of current and future distributions of acquisition risk.

Project Summary South Africa has the largest HIV epidemic worldwide with 7.8 million people currently living with HIV. The scaling up of HIV treatment and prevention over the past decade has led to a reduction of nearly half of new HIV infections and AIDS related deaths between 2010 and 2020. Notwithstanding this success, our team has presented evidence showing that reduction in new infections is not homogeneous over time and space and across the age-sex strata. This uneven risk reduction has led to a shift in the HIV risk landscape resulting in the emergence of new vulnerable groups. Two major events are likely to cause further changes to the risk landscape. The first is the shift to Dolutegravir-based antiretroviral treatment regimens. The second is the disruptions of health services caused by the COVID-19 pandemic creating unprecedented challenges in HIV care delivery. Our long-term goal for this proposal is to design the next-generation HIV combination prevention strategies for poor rural communities in sub-Saharan Africa, which will maximize HIV incidence reduction through identification and targeting of the most vulnerable sub-groups. We envisage that early identification of emergent vulnerable subpopulations would become a key element for an effective programmatic response. Our project will take advantage of one of the largest ongoing population-based HIV cohorts in the world - the Africa Health Research Institute's population cohort in rural KwaZulu-Natal, with individual-level sociodemographic, biological, and clinical data as well as comprehensive genomics data in the fully integrated individual data platform. The project will leverage the institute's established, population-based cohort infrastructure in a high-prevalence region of South Africa-along with its high-resolution longitudinal data-to maximize cost-effectiveness and scientific impact. Specifically, we will (i) Quantify the shifts in the spatial, temporal and demographic burden of new HIV infections; and (ii) Harness the changes in the dynamics of the HIV epidemic to design future intervention programs which will maximize HIV incidence reduction based on the dynamic needs of the most vulnerable sub-populations