DISCUSSION
herpes simplex, decreased community HIV
VIRUS, HERPES SIMPLEX
The HPTN 071 (PopART) trial provided a unique opportunity to directly measure community‐level risk factors associated with HIV incidence. While these data are from 2013 to 2018, in the current HIV epidemic where treatment coverage (both PrEP and ART) is increasing yet HIV incidence remains high in certain areas, the community‐level predictors evaluated here could be particularly helpful in identifying communities with persistently high HIV incidence where interventions should be directed.We found several community‐level factors were associated with increased HIV incidence, including less wealth, having sex partners outside the community and having a higher number of sex partners (compared to fewer). The strongest association with decreased community HIV incidence observed in our study was higher community‐level SES (compared to lower SES), an association that was consistent for males and females. These SES results support the previous findings of Santelli et al. [The Four Cities study looked at population‐level risk factors for HIV prevalence and identified metrics, such as average age of first marriage, circumcision prevalence and population prevalence of herpes simplex virus type 2 (HSV‐2) [Kelley and colleagues first proposed the concept of using PDV in a study of men who have sex with men in the United States to capture transmission risk and inequalities in healthcare coverage [Our study is the first to use PDV in a randomized trial where differences in PDV and measured HIV incidence can be assumed to be due to the intervention applied compared to the standard of care. This direct demonstration of the association between universal testing and treatment and PDV, with the associated reduction in HIV incidence, provides a powerful metric for assessing the effectiveness of HIV prevention interventions without having to measure longitudinal HIV incidence, a challenging and costly undertaking due to the requirements of following large cohorts over time.At the individual level, moderate‐to‐strong associations were observed between HIV incidence and reported SES, AUDIT score categories, medical male circumcision and sex history in the last year. Our finding of a 45% reduction in HIV risk for medically circumcised men compared to uncircumcised men aligns with previously published findings [Our study has some limitations. The community‐level models did not include multivariate adjustments because of the relatively small number of communities. Analyses were unweighted, reflecting measures and incidence specific to the participants in the population cohort rather than the entire community with the main imbalance being the proportion of females enrolled in the population cohort. However, we did perform analyses that separated males and females in addition to the overall analyses. Few sexual behaviour covariates were measured in the whole cohort; these may not have been sufficiently sensitive to measure the risk of HIV exposure at the community level. We also acknowledge the sensitive nature of some aspects of the questionnaire and there may be bias in how participants answered. Approximately 30% of participants enrolled at baseline did not have a follow‐up visit with an HIV test result during the study period and thus their data were censored. Although we cannot rule out selection bias, there was little evidence retention differed by trial arm, demographic or behaviour risk factors, as examined in Table 