The authors were interested in the feasibility of reducing the population-level incidence of HIV infection by increasing community coverage of antiretroviral therapy (ART) and male circumcision. They conducted a pair-matched, community-randomised trial in 30 rural or peri-urban communities in Botswana. Participants in 15 villages in the intervention group received HIV testing and counselling, linkage to care, ART (started at a higher CD4+ T cell count than in standard care), and increased access to male circumcision services. Universal ART became available in both groups in mid-2016. A random sample of participants from 20% of households in each community had their HIV incidence measured once per year. 12,610 people were enrolled (81% of eligible household members), with 29% of them being HIV-infected. Of the 8974 HIV-uninfected people (4487 per group), 95% were retested for HIV infection over a median of 29 months. A total of 57 participants in the intervention group and 90 in the standard-care group acquired HIV infection (annualised HIV incidence 0.59% vs. 0.92%). The unadjusted HIV incidence ratio in the intervention group when compared with the standard-care group was not significant at 0.69 (95%CI 0.46–0.90). An end-of-trial survey in six communities (three per group) did identify a significantly greater increase in the percentage of HIV-infected participants with an HIV-1 RNA level of ≤400 copies/mL in the intervention group (18 percentage points) compared with the standard-care group (8 percentage points, relative risk [RR] 1.12, 95% CI, 1.09 to 1.16). The percentage of men who underwent circumcision increased by 10 percentage points in the intervention group and 2 percentage points in the standard-care group (RR 1.26, 95%CI 1.17 to 1.35). Therefore expanded HIV testing, linkage to care and ART coverage were associated with increased population viral suppression.
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