Manhong Jia

The changing face of HIV in China

HIV has advanced from high-risk groups such as intravenous drug users to some in the general population, according to comprehensive new data from the south of China. What needs to be done to halt its spread?

The 2007 estimates for people at risk for and living with HIV in China: progress and challenges.

Objective:To present the methods used for the 2007 estimates for the number of people at risk for and infected with HIV. Design:Estimation work took place throughout 2007, led by the National Center for AIDS and Sexually Transmitted Disease Control and Prevention in collaboration with United Nations AIDS and the World Health Organization. Methods:The workbook method was used to process prefecture and county-level surveillance data to generate HIV prevalence by risk group for each prefecture, which was in turn imported into the spectrum model to generate estimates of new infections and HIV-related deaths. Results:The working group estimated that as of 2007, there were 700,000 people living with HIV/AIDS in China, with 50,000 new infections and 20,000 HIV-related deaths in that year. Injection drug use and sexual contact are still primary modes of HIV transmission, with heterosexual contact quickly becoming the dominant route, making up 44.7% of new infections in 2007. The HIV/AIDS epidemic is still highly concentrated in certain areas, with wide variation in prevalence across regions. Conclusions:The 2007 estimates are based on the most accurate and local-level data available to date, including case reports, sentinel surveillance data, results from mass screening of key target groups, and special epidemiological studies.

Dominance of HIV-1 Subtype CRF01_AE in Sexually Acquired Cases Leads to a New Epidemic in Yunnan Province of China

Background Dating back to the first epidemic among injection drug users in 1989, the Yunnan province has had the highest number of human immunodeficiency virus type 1 (HIV-1) infections in China. However, the molecular epidemiology of HIV-1 in Yunnan has not been fully characterized. Methods and Findings Using immunoassays, we identified 103,015 accumulated cases of HIV-1 infections in Yunnan between 1989 and 2004. We studied 321 patients representing Yunnans 16 prefectures from four risk groups, 11 ethnic populations, and ten occupations. We identified three major circulating subtypes: C/CRF07_BC/CRF08_BC (53%), CRF01_AE (40.5%), and B (6.5%) by analyzing the sequence of p17, which is part of the gag gene. For patients with known risk factors, 90.9% of injection drug users had C/CRF07_BC/CRF08_BC viruses, whereas 85.4% of CRF01_AE infections were acquired through sexual transmission. No distinct segregation of CRF01_AE viruses was found among the Dai ethnic group. Geographically, C/CRF07_BC/CRF08_BC was found throughout the province, while CRF01_AE was largely confined to the prefectures bordering Myanmar. Furthermore, C/CRF07_BC/CRF08_BC viruses were found to consist of a group of viruses, including C, CRF08_BC, CRF07_BC, and new BC recombinants, based on the characterization of their reverse transcriptase genes. Conclusions This is the first report of a province-wide HIV-1 molecular epidemiological study in Yunnan. While C/CRF07_BC/CRF08_BC and CRF01_AE are codominant, the discovery of many sexually transmitted CRF01_AE cases is new and suggests that this subtype may lead to a new epidemic in the general Chinese population. We discuss implications of our results for understanding the evolution of the HIV-1 pandemic and for vaccine development.

The HIV epidemic in Yunnan Province, China, 1989-2007.

Objective:To investigate the characteristics and trends in the HIV epidemic in Yunnan province, China, between 1989 and 2007. Methods:Statistical analysis of serological data from voluntary testing and counseling sites, medical case reports, mass screenings, sentinel surveillance, and other sources. Results:By 2007, a cumulative total of 57,325 cases of HIV infection were reported in Yunnan, and unsafe drug injection practices and unsafe sexual behaviors were identified as the dominant modes of transmission. HIV affects injecting drug users most, particularly in Jingpo, Dai, and Yi ethnicities, more than 40% in 7 counties. HIV prevalence rates among female sex workers (FSWs) increased from 0.5% in 1995 to 4.0% in 2007; among men who have sex with men, from 4.0% in 2005 to 13.2% in 2007; among male clients of FSWs, from 0% in 1995-1997 to 1.8% in 2007; among male sexually transmitted disease clinic attendees, from 0% in 1992 to 2.1% in 2007; among pregnant women from 0.16% in 1992 to 0.5% in 2007; and among blood donors, from 0.0075% in 1992 to 0.084% in 2007. Conclusions:The HIV epidemic in Yunnan has progressed to a concentrated epidemic. Future efforts must focus on not only groups at risk for primary infection (injecting drug users, men who have sex with men, and FSWs) but also on their low-risk sexual partners.

Stigmatization and shame : Consequences of caring for HIV/AIDS patients in China

Abstract Using a representative sample of 478 doctors, nurses, and lab technicians working with people living with HIV/AIDS (PLWHA), a cross-sectional study was conducted to assess the impact of the AIDS epidemic on medical care systems and service providers in China. Correlation analyses showed significant association between internalized shame reported by service providers and their perception of being stigmatized due to working with PLWHA. Multivariate analyses revealed that the perceived level of institutional support for AIDS care was significantly related to the stigmatization and shame reported by the service providers. The study findings suggest that improved institutional support for AIDS care at the facility level and HIV-related stigma reduction intervention are crucial to maintain a high quality performance by the workforce in the health care system.

Understanding family support for people living with HIV / AIDS in Yunnan China.

This study examines how family support affects people living with HIV/AIDS (PLHA) in China. In-depth, semi-structured interviews (n=30) were conducted with people living with HIV/AIDS who were infected through different routes (e.g., intravenous drug use, sex) and of different age groups. Findings showed that all of the participants were in great need of help and the primary source of support came from their families. Family support included financial assistance, support in the disclosure process, daily routine activities, medical assistance, or psychological support. This study illustrates that the support provided by family makes multiple levels of positive impact on people living with HIV/AIDS, suggesting the importance of including families in HIV/AIDS interventions.

Reconstituting the Epidemic History of HIV Strain CRF01_AE among Men Who Have Sex with Men (MSM) in Liaoning, Northeastern China: Implications for the Expanding Epidemic among MSM in China

ABSTRACT HIV CRF01_AE accounted for 84% of the recent infections among men who have sex with men (MSM) in Liaoning Province of northeastern China. CRF01_AE strains were grouped into two distinct clusters (designated clusters 1 and 2) that were also detected in other regions in China. Phylodynamics study revealed that these two CRF01_AE strains were independently introduced into the population of MSM in China in the early and mid-1990s. Our study elucidated unique features of dynamics and interrelationships of MSM epidemics in China.

Risk factors for intravenous drug use and sharing equipment among young male drug users in Longchuan county south-west China.

Objectives:To identify the risk factors for intravenous drug use and sharing of equipment in Longchuan County in south-west China. Methods:Demographic information and sexual and drug-use-related behavior between 1 January 1991 and 1 August 1994 were collected retrospectively from a cohort of young male drug users aged 18–29 years in 82 villages. Results:A total of 433 drug users were identified. The cumulative incidence of intravenous drug use was 40.0% during the 3.7-year study period. The annual incidence increased from 10% in 1991 to over 30% in 1994. Risk factors for intravenous drug use among drug users, according to the multivariate model, included having had premarital/extramarital sex [odds ratio (OR), 1.5; 95% confidence interval (CI), 1.01–2.3], having a family member who used drugs in 1991 (OR, 1.8; 95% CI, 1.1–2.9), and currently not married (OR, 1.6; 95% CI, 0.98–2.7). Being Buddhist protected against intravenous drug use (OR, 0.4; 95% CI, 0.2–0.9). The population attributable fraction was 30% for not being currently married, 17% for having had premarital/extramarital sex and 14% for having a family member who used drugs. The risk factor for sharing of equipment was being of Jingpo ethnicity (OR, 5.8; 95% CI, 2.5–13.8). The average incidence of sharing equipment was 19.6% per year. The population attributable fraction for sharing equipment was 58.5% for being Jingpo. Conclusions:The incidence of intravenous drug use and sharing equipment is increasing. Therefore, it is urgent that vigorous, effective intervention programs be initiated in southern Yunnan. Unmarried, sexually promiscuous Jingpo drug users with a family history of drug use should be especially targeted. Given the problems of transport and communication in this remote area of China, intervention programs which use existing social, governmental and community networks should be implemented.

Emerging variability in HIV-1 genetics among recently infected individuals in Yunnan, China.

Background Yunnan has the longest endured Human Immunodeficiency Virus-1 (HIV-1) epidemic in China, and the genetic diversity of HIV-1 constitutes an essential characteristic of molecular epidemiology in this region. To obtain a more comprehensive picture of the dynamic changes in Yunnan’s HIV-1 epidemic, a cross-sectional molecular epidemiological investigation was carried out among recently infected individuals. Methodology/Principal Findings We sequenced partial gag (HXB2∶781–1861) and env (HXB2∶7002–7541) genes from 308 plasma samples of recently infected patients. With phylogenetic analysis, 130 specimens generated interpretable genotyping data. We found that the circulating genotypes included: CRF08_BC (40.8%), unique recombinant forms (URFs, 27.7%), CRF01_AE (18.5%), CRF07_BC (9.2%), subtype B (2.3%) and C (1.5%). CRF08_BC was the most common genotype, and was predominant in both intravenous drug users (IDUs) and heterosexually transmitted populations. CRF08_BC and CRF07_BC still predominated in eastern Yunnan, but CRF08_BC showed increasing prevalence in western Yunnan. Strikingly, the URFs raised dramatically in most regions of Yunnan. Seven different types of URFs were detected from 12 prefectures, suggesting that complicated and frequent recombination is a salient feature of Yunnan’s HIV-1 epidemic. Among URFs, two BC clusters with distinctive recombination patterns might be potential new CRF_BCs. CRF01_AE was no longer confined to the prefectures bordering Myanmar, and had spread to the eastern part of Yunnan, especially the capital city of Kunming, with a large number of infections in the transient population. The ratios of the main genotypes showed no statistical differences between infected IDUs and heterosexually transmitted infections. Conclusions/Significance The changing patterns of the dominant HIV-1 genotypes in Yunnan indicate the complex evolving dynamic nature of the epidemic. Understanding new trends in molecular epidemiology of HIV-1 infection is critical for adjusting current prevention strategies and vaccine development in Yunnan.

Universal Precautions in the Era of HIV/AIDS: Perception of Health Service Providers in Yunnan, China

With a rising HIV/AIDS epidemic, it has become especially important for health service providers in China to understand and correctly adhere to universal precautions. Using qualitative interview data, perspectives from both health administrators and service providers working at all levels of China’s health care system were examined. Service providers admitted selective adherence and non-adherence to universal precautions in their daily medical practice, and gave their explanations for such behaviors. Lack of time to put on protective gear, gear’s interference with medical procedures, lack of administrative support, heavy workload in hospitals, inaccurate risk assessment, and beliefs that compliance with universal precautions is unnecessary, time consuming and costly were mentioned as reasons behind noncompliance. Effective universal precaution interventions need to target both administrators and providers, and address both structural barriers and individual attitudinal and behavioral factors.