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

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. ### Competing Interest Statement The authors have declared no competing interest. ### Funding Statement Yes ### Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes The details of the IRB/oversight body that provided approval or exemption for the research described are given below: The RCCS was reviewed and approved by the Research and Ethics Committee at the Uganda Virus Research Institute, and it is registered at the Uganda National Council for Science and Technology. Additional approvals were obtained from the Johns Hopkins Committee on Human Subjects Protections. Community consent was obtained through dialogue meetings with local leaders and the community advisory board prior to the start of each survey visit and sometimes intermediately. Verbal informed consent is provided at household census level by informants or an adult in the household and both verbal and individual written informed consent at the RCCS survey participation level by those eligible and willing. All the datasets were anonymized by the Rakai Health Sciences Program data managers. Permission to use drones in the community was obtained from the local leaders and the Uganda Police. I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable. Yes All relevant data are within the paper and its supporting information files. Additional information may be requested from the corresponding author.