Zhengwei Ding

Antiretroviral therapy to prevent HIV transmission in serodiscordant couples in China (2003–11) : a national observational cohort study

BACKGROUND On the basis of the results of the randomised clinical trial HPTN 052 and observational studies, WHO has recommended that antiretroviral therapy be offered to all HIV-infected individuals with uninfected partners of the opposite sex (serodiscordant couples) to reduce the risk of transmission. Whether or not such a public health approach is feasible and the outcomes are sustainable at a large scale and in a developing country setting has not previously been assessed. METHODS In this retrospective observational cohort study, we included treated and treatment-naive HIV-positive individuals with HIV-negative partners of the opposite sex who had been added to the national HIV epidemiology and treatment databases between Jan 1, 2003 and Dec 31, 2011. We analysed the annual rate of HIV infection in HIV-negative partners during follow-up, stratified by treatment status of the index partner. Cox proportional hazards analyses were done to examine factors related to HIV transmission. FINDINGS Based on data from 38,862 serodiscordant couples, with 101,295·1 person-years of follow-up for the seronegative partners, rates of HIV infection were 2·6 per 100 person-years (95% CI 2·4-2·8) among the 14,805 couples in the treatment-naive cohort (median baseline CD4 count for HIV-positive partners 441 cells per μl [IQR 314-590]) and 1·3 per 100 person-years (1·2-1·3) among the 24,057 couples in the treated cohort (median baseline CD4 count for HIV-positive partners 168 cells per μl [62-269]). We calculated a 26% relative reduction in HIV transmission (adjusted hazard ratio 0·74, 95% CI 0·65-0·84) in the treated cohort. The reduction in transmission was seen across almost all demographic subgroups and was significant in the first year (0·64, 0·54-0·76), and among couples in which the HIV-positive partner had been infected by blood or plasma transfusion (0·76, 0·59-0·99) or heterosexual intercourse (0·69, 0·56-0·84), but not among couples in which the HIV-positive partner was infected by injecting drugs (0·98, 0·71-1·36). INTERPRETATION Antiretroviral therapy for HIV-positive individuals in serodiscordant couples reduced HIV transmission across China, which suggests that the treatment-as-prevention approach is a feasible public health prevention strategy on a national scale in a developing country context. The durability and generalisability of such protection, however, needs to be further studied. FUNDING Chinese Governments 12th Five-Year Plan, the National Natural Science Foundation of China, and the Canadian International Development Research Centre.

Tracking the Evolution of HIV/AIDS in China from 1989–2009 to Inform Future Prevention and Control Efforts

Background To determine policy implications, this analysis tracks the evolution of HIV/AIDS infection across China to understand current trends and potential risk factors. Methods and Principal Findings A retrospective study with spatial analytical model and multilevel spatial models was conducted among 326,157 HIV/AIDS cases reported from 1989–2009. The results indicate that the distribution of HIV/AIDS was clustered at the county level with different directional distributions across China from 2003 to 2009. Compared to 2003, by 2009 there was a 122% increase in HIV cases among rural residents, 294% increase among urban residents, 211% increase among migrants, and 237% increase among permanent residents. The overall proportion of HIV by different routes of transmission showed dramatic changes with a 504% increase in sexual transmission of HIV, 90% decrease in blood/plasma transmission, and 35% decrease in injecting drug user transmission. Sexual transmission was the major transmission route among women (44%) and the elderly (59% in men, 44% in women) as well as among permanent (36%) and urban residents (33%). Among those <65 years old, women increased more than men, but among those ≥65 years, men increased more than women. Migrants contributed to the variance of HIV infection between counties but not within counties. The length of highway and urbanization combined with illiteracy were risk factors for HIV/AIDS. Conclusions/Significance Rates of HIV/AIDS among permanent urban residents, particularly women and elderly men, have increased significantly in recent years. To prevent HIV from spreading further among the general population, additional attention should be paid to these populations as well as to migrants.

Estimation and projection of the HIV epidemic trend among the migrant population in China.

OBJECTIVE The migrant population is a vulnerable group for HIV infection in China. Understanding potential epidemic trends among migrants is critical for developing HIV preventative measures in this population. METHODS The Estimation and Projection Package (EPP) model was used to process prefecture and county-level surveillance data to generate HIV prevalence and epidemic trends for migrant populations in China. RESULTS The prevalence of HIV among migrants in 2009 was estimated at 0.075% (95% CI: 0.042%, 0.108%) in China. The HIV epidemic among migrants is likely to increase over the next 5 years, with the prevalence expected to reach 0.110% (95% CI: 0.070%, 0.150%) by 2015. CONCLUSION Although the 2009 estimates for the HIV/AIDS epidemic in China indicate a slower rate of increase compared with the national HIV/AIDS epidemic, it is estimated to persistently increase among migrants over the next 5 years. Migrants will have a strong impact on the overall future of the HIV epidemic trend in China and evidence-based prevention and monitoring efforts should be expanded for this vulnerable population.

HIV/AIDS Epidemic Among Older Adults in China During 2005-2012: Results From Trend and Spatial Analysis

BACKGROUND Recent studies have indicated an increasing burden of human immunodeficiency virus (HIV)/AIDS among older adults. METHODS All identified people living with HIV/AIDS (PLWHA) recorded through the Chinese HIV/AIDS CRS during 2005-2012 were included in the study, except for the cases that lacked specific spatial information. Trend tests and spatial analyses were conducted. RESULTS Information about 73,521 PLWHA (aged ≥50 years) was collected during 2005-2012. Three provinces-Guangxi, Henan, and Yunnan-accounted for 54.4% of the identified cases during the study period. Compared with 2005, the ratio between residents and migrants among the study population decreased to 40.1% in 2012. The ratio of HIV-infected patients to AIDS patients and the ratio of males to females increased gradually among older infected adults. Results of spatial analysis indicate a clustered distribution of HIV/AIDS among older adults throughout the country. Hot spots were observed in 4 provinces (Guangxi, Henan, Yunnan, and Sichuan) and 1 municipality (Chongqing). A trend from central provinces toward southern provinces was also identified. CONCLUSIONS The number and proportion of HIV/AIDS among older adults have increased in recent years. The hot spots showed movement from central to southern China. A focused intervention strategy targeting the older PLWHA is urgently required in China.

Diversity of HIV/AIDS epidemic in China: a result from hierarchical clustering analysis and spatial autocorrelation analysis.

Objective:To find out the diversity of HIV/AIDS epidemic among different areas in China according to their varied epidemic characteristics. Design and methods:Seventeen provincial variables, generated from original HIV/AIDS epidemic data and socioeconomic indicators to indicate HIV/AIDS epidemic characteristics, were introduced to hierarchical clustering analysis to form subepidemic areas. Then spatial autocorrelation analysis was applied to show the clustering distribution of cases from different most-at-risk populations. Results:Three HIV/AIDS subepidemic areas (A, B, C) were formed, each of which was further divided into two clusters, showing the diversity of HIV/AIDS epidemic in China. A1 was the earliest and severest HIV/AIDS epidemic area and occupied 37% hotspot counties. The epidemic in A1 was driven by IDU in its early period and heterosexual transmission later. Henan, the only province in A2, characterized by its HIV/AIDS epidemic among former plasma donors during the early 1990s, presented strong spatial clustering of blood/plasma transmission occupying 80% blood/plasma hotspots. The epidemic within B3, located in southwest China, was driven by IDU and heterosexual populations, and recently by MSM. The epidemic within B4, covering all four municipalities, had been largely spread among MSM since 2005. B3 and B4 occupied 76% MSM hotspots. For C5 and C6, only sporadic HIV/AIDS infections occurred in the last years among former plasma donors and heterosexual populations, whereas the prevalence among MSM had been increasing. Conclusion:Chinas different HIV/AIDS subepidemic areas had obvious diversity of affected populations, which should be considered when determining prevention policies.

Estimating HIV incidence among key affected populations in China from serial cross-sectional surveys in 2010-2014.

HIV incidence is an important measure for monitoring the development of the epidemic, but it is difficult to ascertain. We combined serial HIV prevalence and mortality data to estimate HIV incidence among key affected populations (KAPs) in China.

Spatial analysis on hepatitis C virus infection in mainland China: from 2005 to 2011.

Background The burden of Hepatitis C virus (HCV) has become more and more considerable in China. A macroscopic spatial analysis of HCV infection that can provide scientific information for further intervention and disease control is lacking. Methods All geo-referenced HCV cases that had been recorded by the China Information System for Disease Control and Prevention (CISDCP) during 2005–2011 were included in the study. In order to learn about the changes of demographic characteristics and geographic distribution, trend test and spatial analysis were conducted to reflect the changing pattern of HCV infection. Results Over 770,000 identified HCV infection cases had specific geographic information during the study period (2005–2011). Ratios of gender (Male/Female, Z-value  = −18.53, P<0.001), age group (≤30 years old/≥31 years old, Z-value  = −51.03, P<0.001) and diagnosis type (Clinical diagnosis/Laboratory diagnosis, Z-value  = −130.47, P<0.001) declined. HCV infection was not distributed randomly. Provinces Henan, Guangdong, Guangxi, Xinjiang, and Jilin reported more than 40,000 HCV infections during 2005 to 2011, accounting for 43.91% of all cases. The strength of cluster of disease was increasing in China during the study period. Overall, 11 provinces had once been detected as hotspots during 7 years, most of which were located in the central or border parts of China. Tibet, Qinghai, Jiangxi were the regions that had coldspots. Conclusions The number of clustering of HCV infection among older adults increased in recent years. Specific interventions and prevention programs targeting at main HCV epidemic areas are urgently in need in mainland China.

Spatial Analysis of the Human Immunodeficiency Virus Epidemic among Men Who Have Sex with Men in China, 2006–2015

Background Studies have shown a recent upsurge in human immunodeficiency virus (HIV) burden among men who have sex with men (MSM) in China, especially in urban areas. For intervention planning and resource allocation, spatial analyses of HIV/AIDS case-clusters were required to identify epidemic foci and trends among MSM in China. Methods Information regarding MSM recorded as HIV/AIDS cases during 2006-2015 were extracted from the National Case Reporting System. Demographic trends were determined through Cochran-Armitage trend tests. Distribution of case-clusters was examined using spatial autocorrelation. Spatial-temporal scan was used to detect disease clustering. Spatial correlations between cases and socioenvironmental factors were determined by spatial regression. Results Between 2006 and 2015, in China, 120 371 HIV/AIDS cases were identified among MSM. Newly identified HIV/AIDS cases among self-reported MSM increased from 487 cases in 2006 to >30 000 cases in 2015. Among those HIV/AIDS cases recorded during 2006-2015, 47.0% were 20-29 years old and 24.9% were aged 30-39 years. Based on clusters of HIV/AIDS cases identified through spatial analysis, the epidemic was concentrated among MSM in large cities. Spatial-temporal clusters contained municipalities, provincial capitals, and main cities such as Beijing, Shanghai, Chongqing, Chengdu, and Guangzhou. Spatial regression analysis showed that sociodemographic indicators such as population density, per capita gross domestic product, and number of county-level medical institutions had statistically significant positive correlations with HIV/AIDS among MSM. Conclusions Assorted spatial analyses revealed an increasingly concentrated HIV epidemic among young MSM in Chinese cities, calling for targeted health education and intensive interventions at an early age.

Mortality among People Living with HIV and AIDS in China: Implications for Enhancing Linkage.

To assess the patterns and predictors of AIDS-related mortality and identify its correlates among adult people living with HIV/AIDS (PLWHA) in China, a retrospective record-based cohort study was conducted among 18 years or older PLWHA, who had at least one follow up reported to the national database between January-1989 and June-2012. Cumulative Incidence Function was used to calculate AIDS-related mortality rate. Gray’s test was used to determine the variation in cumulative incidence across strata. The Fine and Gray model was used to measure the burden of cumulative incidence of AIDS-related mortality and strength of its association with potential correlates. Among 375,629 patients, 107,634 died during study period, of which 54,759 (50.87%) deaths were AIDS-related. Cumulative mortality rates of AIDS-related death at one, two, five, 10 and 15 years post-diagnosis were 5.7%, 8.2%, 14.3%, 22.9% and 30.9%, respectively. Among PLWHA, male gender, ethnic minority and having AIDS were associated with significantly higher mortality. Further, homosexual transmission, being on ART and increasing CD4-testing frequency were associated with lower mortality. To reduce mortality among PLWHA, efficient interventions targeting males, ethnic minority, heterosexually infected and AIDS patients should be combined with immunologic monitoring, enhancement of coverage of HIV-testing and ART.

Causes of Death among AIDS Patients after Introduction of Free Combination Antiretroviral Therapy (cART) in Three Chinese Provinces, 2010–2011

Introduction Although AIDS-related deaths have had significant economic and social impact following an increased disease burden internationally, few studies have evaluated the cause of AIDS-related deaths among patients with AIDS on combination anti-retroviral therapy (cART) in China. This study examines the causes of death among AIDS-patients in China and uses a methodology to increase data accuracy compared to the previous studies on AIDS-related mortality in China, that have taken the reported cause of death in the National HIV Registry at face-value. Methods Death certificates/medical records were examined and a cross-sectional survey was conducted in three provinces to verify the causes of death among AIDS patients who died between January 1, 2010 and June 30, 2011. Chi-square analysis was conducted to examine the categorical variables by causes of death and by ART status. Univariate and multivariate logistic regression were used to evaluate factors associated with AIDS-related death versus non-AIDS related death. Results This study used a sample of 1,109 subjects. The average age at death was 44.5 years. AIDS-related deaths were significantly higher than non-AIDS and injury-related deaths. In the sample, 41.9% (465/1109) were deceased within a year of HIV diagnosis and 52.7% (584/1109) of the deceased AIDS patients were not on cART. For AIDS-related deaths (n = 798), statistically significant factors included CD4 count <200 cells/mm3 at the time of cART initiation (AOR 1.94, 95%CI 1.24–3.05), ART naïve (AOR 1.69, 95%CI 1.09–2.61; p = 0.019) and age <39 years (AOR 2.96, 95%CI 1.77–4.96). Conclusion For the AIDS patients that were deceased, only those who initiated cART while at a CD4 count ≥200 cells/mm3 were less likely to die from AIDS-related causes compared to those who didn’t initiate ART at all.