Background Understanding the extent to which HIV burden diff ers across communities and the drivers of lo cal
disparities is crucial for an eff ective and targeted HIV response. We assessed community-level variations in HIV
prevalence, risk factors, and treatment and prevention service uptake in Rakai, Uganda.
Methods The Rakai Community Cohort Study (RCCS) is an open, population-based cohort of people aged 15–49 years
in 40 communities. Participants are HIV tested and interviewed to obtain sociodemographic, behavioural, and health
information. RCCS data from Aug 10, 2011, to May 30, 2013, were used to classify communities as agrarian (n=27),
trading (n=9), or lakeside fi shing sites (n=4). We mapped HIV prevalence with Bayesian methods, and characterised
variability across and within community classifi cations. We also assessed diff erences in HIV risk factors and uptake
of antiretroviral therapy and male circumcision between community types.
Findings 17 119 individuals were included, 9215 (54%) of whom were female. 9931 participants resided in agrarian,
3318 in trading, and 3870 in fi shing communities. Median HIV prevalence was higher in fishing communities (42%,
range 38–43) than in trading (17%, 11–21) and agrarian communities (14%, 9–26). Antiretroviral therapy use was
signifi cantly lower in both men and women in fi shing communities than in trading (age-adjusted prevalence risk
ratio in men 0·64, 95% CI 0·44–0·97; women 0·53, 0·42–0·66) and agrarian communities (men 0·55, 0·42–0·72;
women 0·65, 0·54–0·79), as was circumcision coverage among men (vs trading 0·48, 0·42–0·55; vs agrarian 0·64,
0·56–0·72). Self-reported risk behaviours were signifi cantly higher in men than in women and in fi shing communities
than in other community types.
Interpretation Substantial heterogeneity in HIV prevalence, risk factors, and service uptake in Rakai, Uganda,
emphasises the need for local surveillance and the design of targeted HIV responses. High HIV burden, risk
behaviours, and low use of combination HIV prevention in fi shing communities make these populations a priority
for intervention.
Funding National Institute of Mental Health, the National Institute of Allergy and Infectious Diseases, the National
Institute of Child Health and Development, and the National Institute for Allergy and Infectious Diseases Division of
Intramural Research, National Institutes of Health; the Bill & Melinda Gates Foundation; and the Johns Hopkins
University Center for AIDS Research.