Impact of natural disasters on HIV risk behaviors, seroprevalence, and virological supression in a hyperendemic fishing village in Uganda

Abstract

Background: Understanding the impact of natural disasters on the HIV epidemic in populations with high HIV burden is critical for the effective delivery of HIV control efforts. We assessed HIV risk behaviors, seroprevalence, and viral suppression in a high-HIV prevalence Lake Victoria fishing community before and after COVID-19 emergence/lockdown and a severe lake flooding event, both of which occurred in 2020. Methods: We used data from the largest Lake Victoria fishing community in the Rakai Community Cohort Study, an open population-based HIV surveillance cohort in south-central Uganda, collected prior to (September-December 2018) and after (October-December 2021) COVID-19 emergence/lockdown and a severe flooding event, to evaluate the impact of natural disasters on the key population-level HIV outcomes listed above. Households impacted by flooding were identified using drone data and through consultation with village community health workers. The entire study population was subject to extensive COVID-19-related lockdowns in the first half of 2020. Differences in HIV-related outcomes before and after COVID, and between residents of flooded and non-flooded households, were assessed using a difference-in-difference statistical modeling approach. Findings: 1,226 people participated in the pre- and post-COVID surveys, of whom 506 (41%) were affected by flooding and 513 (41%) were female. HIV seroprevalence in the initial period was 37% in flooded and 36.8% in non-flooded households. Following the COVID-19 pandemic/lockdown, we observed a decline in HIV-associated risk behaviors. Transactional sex declined from 29.4% to 24.8% (p=0.011), and inconsistent condom use with non-marital partners declined from 41.6% to 37% (p=0.021) in the pre- and post-COVID periods. ART coverage increased from 91.6% to 97.2% (p<0.001). There was 17% decline in transactional sex (aPR=0.83, 95% CI: 0.75-0.92) and 28% decline in the overall HIV risk score (aPR=0.83, 95% CI: 0.75-0.92) among HIV-seronegatives and 5% increase in ART coverage between the pre- and post-COVID periods. We observed no statistically significant differences in changes of HIV risk behavior, seroprevalence, or viral suppression outcomes comparing those affected by floods to those not affected by floods in the periods before and after COVID in difference-in-difference analyses. Interpretation: Despite a high background burden of HIV, the COVID-19 pandemic, and severe flooding, we observed no adverse impact on HIV risk behaviors, seroprevalence, or virologic outcomes. This may be attributed to innovative HIV programming during the period and or population resilience. Understanding exactly what HIV programs and personal/community-level strategies worked to maintain good public health outcomes despite extreme environmental and pandemic conditions may help improve HIV epidemic control during future natural disaster events.