Associations of inter-annual rainfall decreases with subsequent HIV outcomes for persons with HIV on antiretroviral therapy in Southern Africa: a collaborative analysis of cohort studies.

BACKGROUND: Periods of droughts can lead to decreased food security, and altered behaviours, potentially affecting outcomes on antiretroviral therapy (ART) among persons with HIV (PWH). We investigated whether decreased rainfall is associated with adverse outcomes among PWH on ART in Southern Africa. METHODS: Data were combined from 11 clinical cohorts of PWH in Lesotho, Malawi, Mozambique, South Africa, Zambia, and Zimbabwe, participating in the International epidemiology Databases to Evaluate AIDS Southern Africa (IeDEA-SA) collaboration. Adult PWH who had started ART prior to 01/06/2016 and were in follow-up in the year prior to 01/06/2016 were included. Two-year rainfall from June 2014 to May 2016 at the location of each HIV centre was summed and ranked against historical 2-year rainfall amounts (1981-2016) to give an empirical relative percentile rainfall estimate. The IeDEA-SA and rainfall data were combined using each HIV centre's latitude/longitude. In individual-level analyses, multivariable Cox or generalized estimating equation regression models (GEEs) assessed associations between decreased rainfall versus historical levels and four separate outcomes (mortality, CD4 counts < 200 cells/mm3, viral loads > 400 copies/mL, and > 12-month gaps in follow-up) in the two years following the rainfall period. GEEs were used to investigate the association between relative rainfall and monthly numbers of unique visitors per HIV centre. RESULTS: Among 270,708 PWH across 386 HIV centres (67% female, median age 39 [IQR: 32-46]), lower rainfall than usual was associated with higher mortality (adjusted Hazard Ratio: 1.18 [95%CI: 1.07-1.32] per 10 percentile rainfall rank decrease) and unsuppressed viral loads (adjusted Odds Ratio: 1.05 [1.01-1.09]). Levels of rainfall were not strongly associated with CD4 counts < 200 cell/mm3 or > 12-month gaps in care. HIV centres in areas with less rainfall than usual had lower numbers of PWH visiting them (adjusted Rate Ratio: 0.80 [0.66-0.98] per 10 percentile rainfall rank decrease). CONCLUSIONS: Decreased rainfall could negatively impact on HIV treatment behaviours and outcomes. Further research is needed to explore the reasons for these effects. Interventions to mitigate the health impact of severe weather events are required.

Managing hydroclimatic risks in federal rivers: a diagnostic assessment.

Hydroclimatic risks and adaptive capacity are not distributed evenly in large river basins of federal countries, where authority is divided across national and territorial governments. Transboundary river basins are a major test of federal systems of governance because key management roles exist at all levels. This paper examines the evolution and design of interstate water allocation institutions in semi-arid federal rivers prone to drought extremes, climatic variability and intensified competition for scarce water. We conceptualize, categorize and compare federal rivers as social-ecological systems to analyse the relationship between governance arrangements and hydroclimatic risks. A diagnostic approach is used to map over 300 federal rivers and classify the hydroclimatic risks of three semi-arid federal rivers with a long history of interstate allocation tensions: the Colorado River (USA/Mexico), Ebro River (Spain) and Murray-Darling River (Australia). Case studies review the evolution and design of water allocation institutions. Three institutional design trends have emerged: adoption of proportional interstate allocation rules; emergence of multi-layered river basin governance arrangements for planning, conflict resolution and joint monitoring; and new flexibility to adjust historic allocation patterns. Proportional allocation rules apportion water between states based on a share of available water, not a fixed volume or priority. Interstate allocation reform efforts in the Colorado and Murray-Darling rivers indicate that proportional allocation rules are prevalent for upstream states, while downstream states seek reliable deliveries of fixed volumes to increase water security. River basin governance arrangements establish new venues for multilayered planning, monitoring and conflict resolution to balance self governance by users and states with basin-wide coordination. Flexibility to adjust historic allocation agreements, without risk of defection or costly court action, also provides adaptive capacity to manage climatic variability and shifting values. Future research should develop evidence about pathways to adaptive capacity in different classes of federal rivers, while acknowledging limits to transferability and the need for context-sensitive design.

Water availability in +2°C and +4°C worlds.

While the parties to the UNFCCC agreed in the December 2009 Copenhagen Accord that a 2°C global warming over pre-industrial levels should be avoided, current commitments on greenhouse gas emissions reductions from these same parties will lead to a 50 : 50 chance of warming greater than 3.5°C. Here, we evaluate the differences in impacts and adaptation issues for water resources in worlds corresponding to the policy objective (+2°C) and possible reality (+4°C). We simulate the differences in impacts on surface run-off and water resource availability using a global hydrological model driven by ensembles of climate models with global temperature increases of 2°C and 4°C. We combine these with UN-based population growth scenarios to explore the relative importance of population change and climate change for water availability. We find that the projected changes in global surface run-off from the ensemble show an increase in spatial coherence and magnitude for a +4°C world compared with a +2°C one. In a +2°C world, population growth in most large river basins tends to override climate change as a driver of water stress, while in a +4°C world, climate change becomes more dominant, even compensating for population effects where climate change increases run-off. However, in some basins where climate change has positive effects, the seasonality of surface run-off becomes increasingly amplified in a +4°C climate.