Background International and global organisations advocate targeting interventions to areas of high HIV prevalence (ie, hotspots). To better understand the potential benefits of geo-targeted control, we assessed the extent to which HIV hotspots along Lake Victoria sustain transmission in neighbouring populations in south-central Uganda. Methods We did a population-based survey in Rakai, Uganda, using data from the Rakai Community Cohort Study. The study surveyed all individuals aged 15-49 years in four high-prevalence Lake Victoria fishing communities and 36 neighbouring inland communities. Viral RNA was deep sequenced from participants infected with HIV who were antiretroviral therapy-naive during the observation period. Phylogenetic analysis was used to infer partial HIV transmission networks, including direction of transmission. Reconstructed networks were interpreted through data for current residence and migration history. HIV transmission flows within and between high-prevalence and low-prevalence areas were quantified adjusting for incomplete sampling of the population. Findings Between Aug 10, 2011, and Jan 30, 2015, data were collected for the Rakai Community Cohort Study. 25 882 individuals participated, including an estimated 75•7% of the lakeside population and 16•2% of the inland population in the Rakai region of Uganda. 5142 participants were HIV-positive (2703 [13•7%] in inland and 2439 [40•1%] in fishing communities). 3878 (75•4%) people who were HIV-positive did not report antiretroviral therapy use, of whom 2652 (68•4%) had virus deep-sequenced at sufficient quality for phylogenetic analysis. 446 transmission networks were reconstructed, including 293 linked pairs with inferred direction of transmission. Adjusting for incomplete sampling, an estimated 5•7% (95% credibility interval 4•4-7•3) of transmissions occurred within lakeside areas, 89•2% (86•0-91•8) within inland areas, 1•3% (0•6-2•6) from lakeside to inland areas, and 3•7% (2•3-5•8) from inland to lakeside areas. Interpretation Cross-community HIV transmissions between Lake Victoria hotspots and surrounding inland populations are infrequent and when they occur, virus more commonly flows into rather than out of hotspots. This result suggests that targeted interventions to these hotspots will not alone control the epidemic in inland populations, where most transmissions occur. Thus, geographical targeting of high prevalence areas might not be effective for broader epidemic control depending on underlying epidemic dynamics.

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Background The efficacy of voluntary male medical circumcision (VMMC) for HIV prevention in men was demonstrated in three randomized trials. This led to the adoption of VMMC as an integral component of the President’s Emergency Plan for AIDS Relief (PEPFAR) combination HIV prevention program in sub-Saharan Africa. However, evidence on the individual-level effectiveness of VMMC programs in real world, programmatic settings is limited. Methods A cohort of initially uncircumcised, non-Muslim, HIV-uninfected men in the Rakai Community Cohort Study in Uganda were followed between 2009 and 2016 during VMMC scale-up. Self-reported VMMC status was collected and HIV tests performed at surveys conducted every 18 months. Multivariable Poisson regression was used to estimate the incidence rate ratio (IRR) of HIV acquisition in newly circumcised versus uncircumcised men. Results 3,916 non-Muslim men were followed for 17,088 person-years (py). There were 1338 newly reported VMMCs (9.8/100 py). Over the study period, the median age of men adopting VMMC declined from 28 years (IQR 21-35) to 22 years (IQR 18-29; p-trend <0.001). HIV incidence was 0.40/100 py (20/4992.8 py) among newly circumcised men and 0.98/100 py (118/12095.1 py) among uncircumcised men with an adjusted IRR of 0.47 (95%CI: 0.28-0.78). The effectiveness of VMMC was sustained with increasing time from surgery and was similar across age groups and calendar time. Conclusions VMMC programs are highly effective in preventing HIV-acquisition in men. The observed effectiveness is consistent with efficacy in clinical trials and supports current recommendations that VMMC is a key component of programs to reduce HIV incidence.

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Objectives The objective of this study is to determine the optimal timing for device‐based infant circumcision under topical anaesthesia. Subjects/patients We include infants aged 1–60 days who were enrolled in a field study of the no‐flip ShangRing device at four hospitals in the Rakai region of south‐central Uganda, between 5 February 2020 and 27 October 2020. Methods Two hundred infants, aged 0–60 days, were enrolled, and EMLA cream was applied on the foreskin and entire penile shaft. The anaesthetic effect was assessed every 5 min by gentle application of artery forceps at the tip of the foreskin, starting at 10 min post‐application until 60 min, the recommended time to start circumcision. The response was measured using the Neonatal Infant Pain Scale (NIPS). We determined the onset and duration of anaesthesia (defined as <20% of infants with NIPS score >4) and maximum anaesthesia (defined as <20% of infants with NIPS score >2). Results Overall, NIPS scores decreased to a minimum and reversed before the recommended 60 min. Baseline response varied with age, with minimal response among infants aged 40 days. Overall, anaesthesia was achieved after at least 25 min and lasted 20–30 min. Maximum anaesthesia was achieved after at least 30 min (except among those aged >45 days where it was not achieved) and lasted up to 10 min. Conclusion The optimal timing for maximum topical anaesthesia occurred before the recommended 60 min of waiting time. A shorter waiting time and speed may be efficient for mass device‐based circumcision.