Treatment outcomes of multidrug-resistant tuberculosis in Hangzhou, China, 2011 to 2015.

Treatment of multidrug-resistant tuberculosis (MDR-TB) is challenging. More research is needed to understand treatment outcomes and associated factors.A retrospective cohort study was conducted to assess trends and predictors of treatment success among 398 MDR-TB and extensively drug resistant TB patients who started treatment in 2011 to 2015 in Hangzhou, China. Sociodemographic and clinical characteristic data were obtained from the national reporting database. Chi-square test for trend was used to evaluate changes in treatment success rates over the study years, and Cox regression analysis was used to identify predictors for poor treatment outcomes.The treatment success rate was 76% (301/398) for all participants, 77% (298/387) for MDR-TB cases and 27% (3/11) for extensively drug-resistant tuberculosis -TB cases. Treatment success increased significantly from 66% among patients who started treatment in 2011 to 85% in 2015 (P < .01). Of the 97 (24.4%) patients with unsuccessful treatment outcomes, 10 (2.5%) died, 64 (16.1%) failed treatment, and 23 (5.8%) were lost to follow-up. Patients who started treatment in 2013 to 2015 were less likely to have unsuccessful outcomes than those who started in 2011-2012 (adjusted odds ratio [AOR] 0.4, 95% confidence interval [CI] 0.3-0.6), patients ≥25 years were more likely to have unsuccessful outcomes than younger patients (AOR 1.6, 95% CI 1.3-2.1), and cases with kanamycin resistance was associated with three times the odds of having unsuccessful outcomes than kanamycin-susceptible cases (AOR 3.0, 95% CI 1.5-5.8).With proper case management of MDR-TB, patients can achieve a high treatment success rate. Hangzhou's program offers clinical evidence that can be used to inform MDR-TB programs elsewhere in China and abroad.

"I'll Change His Sexual Orientation, I Don't Think About HIV": A Qualitative Study to Explore Attitudes, Behaviors, and Experiences Among Wives of Men Who Have Sex With Men in Mainland China.

In mainland China, HIV prevalence among men who have sex with men (MSM) has risen sharply in the past decade. However, few HIV studies have directly addressed the female spouses' (tongqi) experiences, a population estimated at 14 million [Cheng, F. K. (2016). I want to come forward: Voices from Chinese tongqi. Cogent Social Sciences, 2(1), 1158343. doi:10.1080/23311886.2016.1158343; Zhu, J. (2018). "Unqueer" kinship? Critical reflections on "marriage fraud" in mainland China. Sexualities, 21(7), 1075-1091. doi:10.1177/1363460717719240]. We conducted this exploratory qualitative study to understand tongqi's attitudes toward same-sex sexuality and HIV risk as well as their sexual history. Semistructured interviews were conducted with 24 tongqi between October 2015 and September 2016. Data were coded and analyzed using thematic analysis. We identified four primary themes: (a) surprise, initial disbelief, and negative attitudes toward their husbands' same-sex sexuality; (b) maintenance of regular sexual contact, particularly before pregnancy; (c) unprotected sex with marital and extramarital partners; and (d) low perception of HIV risk. Strategies to increase HIV knowledge and testing uptake are urgently needed among these vulnerable women but must be implemented with caution to avoid exacerbating high levels of homophobia.

Female Condom Use and Its Acceptability Among HIV-serodiscordant Couples in China.

Intimate partners of people living with HIV are at risk of HIV infection. We assessed the acceptability of female condom use among 89 married, heterosexual, HIV-serodiscordant couples from Sichuan and Hunan provinces in China for this prospective observational cohort study. Participants used female condoms for 3 months, reporting use and attitudes in written logs and questionnaires. At the end of the study, 58.4% of couples expressed willingness to continue using female condoms. Factors associated with willingness to use female condoms were (a) the female partner reporting having experienced forced sex by the male partner, (b) applying a lubricant to the penis, (c) understanding the correct application method, (d) being married more than 20 years, and (e) experiencing no difficulty during the first use. Most HIV-serodiscordant couples found female condoms to be acceptable. Increasing access to female condoms could be an acceptable alternative barrier method to male condoms for preventing HIV transmission.

Immediate Antiretroviral Therapy Decreases Mortality Among Patients With High CD4 Counts in China: A Nationwide, Retrospective Cohort Study.

Background: Clinical trials have demonstrated that immediate initiation of antiretroviral therapy (ART) reduces AIDS-related morbidity and mortality. We tested the hypothesis that initiating ART ≤30 days after human immunodeficiency virus (HIV) diagnosis would be associated with reduced mortality among people living with HIV (PLWH) with CD4 counts >500 cells/µL. Methods: PLWH enrolled in the Chinese National HIV Information System between January 2012 and June 2014 with CD4 counts >500 cells/µL were followed for 12 months. Cox proportional hazards model was used to determine hazard ratios (HRs) for PLWH who initiated ART after HIV diagnosis. ART initiation was treated as a time-dependent variable. Results: We enrolled 34581 PLWH with CD4 >500 cells/µL; 1838 (5.3%) initiated ART ≤30 days after diagnosis (immediate ART group), and 19 deaths were observed with a mortality rate of 1.04 per 100 person-years (PY). Fifty-eight deaths were documented among the 5640 PLWH in the delayed ART group with a mortality rate of 2.25 per 100 PY. There were 713 deaths among the 27103 PLWH in the no ART group with a mortality rate of 2.39 per 100 PY. After controlling for potential confounding factors, ART initiation at ≤30 days (adjusted HR, 0.37 [95% confidence interval, .23-.58]) was a statistically significant protective factor. Conclusions: We found that immediate ART is associated with a 63% reduction in overall mortality among PLWH with CD4 counts >500 cells/µL in China, supporting the recommendation to initiate ART immediately following HIV diagnosis.

Polyclonal Pulmonary Tuberculosis Infections and Risk for Multidrug Resistance, Lima, Peru.

Because within-host Mycobacterium tuberculosis diversity complicates diagnosis and treatment of tuberculosis (TB), we measured diversity prevalence and associated factors among 3,098 pulmonary TB patients in Lima, Peru. The 161 patients with polyclonal infection were more likely than the 115 with clonal or the 2,822 with simple infections to have multidrug-resistant TB.

Testing and linkage to HIV care in China: a cluster-randomised trial.

BACKGROUND: Multistage, stepwise HIV testing and treatment procedures can result in lost opportunities to provide timely antiretroviral therapy (ART). Incomplete engagement of patients along the care cascade translates into high preventable mortality. We aimed to identify whether a structural intervention to streamline testing and linkage to HIV health care would improve testing completeness, ART initiation, and viral suppression and reduce mortality. METHODS: We did a cluster-randomised, controlled trial in 12 hospitals in Guangxi, China. All hospitals were required to be level 2A county general hospitals and ART delivery sites. We selected the 12 most similar hospitals in terms of structural characteristics, past patient caseloads, and testing procedures. Hospitals were randomly assigned (1:1) to either the One4All intervention or standard of care. Hospitals were randomised in a block design and stratified by the historical rate of testing completeness of the individual hospital during the first 6 months of 2013. We enrolled patients aged 18 years or older who were identified as HIV-reactive during screening in study hospitals, who sought inpatient or outpatient care in a study hospital, and who resided in the study catchment area. The One4All strategy incorporated rapid, point-of-care HIV screening and CD4 counts, and in-parallel viral load testing, to promote fast and complete diagnosis and staging and provide immediate ART to eligible patients. Participants in control hospitals received standard care services. All enrolled patients were assessed for the primary outcome, which was testing completeness within 30 days, defined as completion of three required tests and their post-test counselling. Safety assessments were hospital admissions for the first 90 days and deaths up to 12 months after enrolment. This trial is registered with ClinicalTrials.gov, number NCT02084316. FINDINGS: Between Feb 24 and Nov 25, 2014, we enrolled 478 patients (232 in One4All, 246 in standard of care). In the One4All group, 177 (76%) of 232 achieved testing completeness within 30 days versus 63 (26%) of 246 in the standard-of-care group (odds ratio 19·94, 95% CI 3·86-103·04, p=0·0004). Although no difference was observed between study groups in the number of hospital admissions at 90 days, by 12 months there were 65 deaths (28%) in the in the One4All group compared with 115 (47%) in the standard-of-care group (Cox proportional hazard ratio 0·44, 0·19-1·01, p=0·0531). INTERPRETATION: Our study provides strong evidence for the benefits of a patient-centred approach to streamlined HIV testing and treatment that could help China change the trajectory of its HIV epidemic, and help to achieve the goal of an end to AIDS. FUNDING: US National Institute on Drug Abuse Clinical Trials Network and China's National Health and Family Planning Commission.

Mortality and virological failure among HIV-infected people who inject drugs on antiretroviral treatment in China: An observational cohort study.

OBJECTIVE: HIV-infected people who inject drugs (PWID) have a disproportionally low rate of access to antiretroviral therapy (ART). We aimed to assess the impact of ART on 12-month mortality and virological failure of HIV-infected PWID in China, stratified by methadone maintenance treatment (MMT) and active drug use status. METHODS: HIV-infected PWID who initiated ART at 29 clinics in 2011 were enrolled and followed in this prospective cohort study. Kaplan-Meier curves and log-rank tests were used to compare the survival probability. Risk factors for mortality and virological failure were evaluated by Cox proportional hazards models and logistic regression analyses. RESULTS: A total of 1,633 participants initiated ART. At the time of initiation, 324 were on MMT, 625 were engaged in active drug use, and 684 had discontinued drug use but were not on MMT. At the 12-month follow-up, 80.3% remained on ART, 13.5% had discontinued ART, and 6.2% had died. Among the MMT group, active drug use group, and drug abstinent group, we observed all-cause mortality of 4.9%, 12.0%, and 1.5% and virological suppression of 51.9%, 41.1%, and 68.7%, respectively. Factors associated with both mortality and virological failure were drug use status, unemployment, and treatment facility type. CONCLUSION: For HIV-infected PWID receiving ART, engagement in MMT and discontinuation of drug use were more likely to be associated with lower mortality and virological failure compared with active drug use. In order to maximize the clinical impact of ART, HIV treatment programs in China should be further integrated with MMT and social services.

HIV seroconversion and risk factors among drug users receiving methadone maintenance treatment in China: A qualitative study.

OBJECTIVE: We sought to explore the experiences of drug users in China who were recently diagnosed with HIV infection while engaged in methadone maintenance treatment (MMT) and to better understand their perceptions of MMT, HIV risk, and HIV prevention. METHODS: We recruited clients of MMT clinics in Chongqing and Kunming who had a baseline HIV-negative test result upon entry to MMT and had been diagnosed with HIV within the past 12 months. We conducted semi-structured qualitative interviews and thematic data analysis to identify situations and factors that increased HIV risk. RESULTS: Among the 27 participants who were interviewed, 15 believed their infection was due to injection drug use, 7 attributed their infection to sexual contact, and 5 were unsure as to how they became infected. High risk behaviors were common; 18 participants continued to use drugs during treatment, and 10 engaged in unprotected sex. Common themes were the difficulty of drug abstinence despite receiving MMT, social pressure to continue using drugs, and low knowledge of effective HIV prevention measures. CONCLUSION: While MMT is effective in reducing drug usage and needle sharing, many clients remain at risk of HIV infection due to continued injection drug use and unprotected sex. Clients may benefit from additional counseling on HIV prevention methods as well as structural interventions to increase the availability of clean injection equipment.

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

INTRODUCTION: 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. METHODS: Serial cross-sectional surveys were conducted among KAPs from 2010 to 2014. Trends in HIV prevalence were assessed by the Cochran-Armitage test, adjusted by risk group. HIV incidence was estimated from a mathematical model that describes the relationship between changes in HIV incidence with HIV prevalence and mortality. RESULTS: The crude HIV prevalence for the survey samples remained stable at 1.1 to 1.2% from 2010 to 2014. Among drug users (DUs), HIV prevalence declined from 4.48 to 3.29% (p<0.0001), and among men who have sex with men (MSM), HIV prevalence increased from 5.73 to 7.75% (p<0.0001). Changes in HIV prevalence among female sex workers (FSWs) and male patients of sexually transmitted disease clinics were more modest but remained statistically significant (all p<0.0001). The MSM population had the highest incidence estimates at 0.74% in 2011, 0.59% in 2012, 0.57% in 2013 and 0.53% in 2014. Estimates of the annual incidence for DUs and FSWs were very low and may not be reliable. CONCLUSIONS: Serial cross-sectional prevalence data from representative samples may be another approach to construct approximate estimates of national HIV incidence among key populations. We observed that the MSM population had the highest incidence for HIV among high-risk groups in China, and we suggest that interventions targeting MSM are urgently needed to curb the growing HIV epidemic.

Baseline HCV Antibody Prevalence and Risk Factors among Drug Users in China's National Methadone Maintenance Treatment Program.

BACKGROUND: Hepatitis C virus (HCV) is the most common viral infection among injecting drug users worldwide. We aimed to assess HCV antibody prevalence and associated risk factors among clients in the Chinese national methadone maintenance treatment (MMT) program. METHODS: Data from 296,209 clients who enrolled in the national MMT program between March 2004 and December 2012 were analyzed to assess HCV antibody prevalence, associated risk factors, and geographical distribution. RESULTS: Anti-HCV screening was positive for 54.6% of clients upon MMT entry between 2004 and 2012. HCV antibody prevalence at entry declined from 66.8% in 2005 to 45.9% in 2012. The most significant predictors of HCV seropositivity were injecting drug use (adjusted odds ratio [AOR]: 8.34, 95% confidence interval [CI]: 8.17-8.52, p<0.0001) and a history of drug use ≥9 years (AOR: 2.01, 95% CI: 1.96-2.06, p<0.0001). Being female, of Uyghur or Zhuang ethnicity, and unmarried were identified as demographic risk factors (all p-values<0.0001). Of the 28 provincial-level divisions included in the study, we found that 5 divisions had HCV antibody prevalence above 70% and 20 divisions above 50%. The HCV screening rate within 6 months after MMT entry greatly increased from 30.4% in 2004 to 93.1% in 2012. CONCLUSIONS: The current HCV antibody prevalence remains alarmingly high among MMT clients throughout most provincial-level divisions in China, particularly among injecting drug users and females. A comprehensive prevention strategy is needed to control the HCV epidemic among MMT clients in China.

Simplified HIV Testing and Treatment in China: Analysis of Mortality Rates Before and After a Structural Intervention.

BACKGROUND: Multistage stepwise HIV testing and treatment initiation procedures can result in lost opportunities to provide timely antiretroviral therapy (ART). Incomplete patient engagement along the continuum of HIV care translates into high levels of preventable mortality. We aimed to evaluate the ability of a simplified test and treat structural intervention to reduce mortality. METHODS AND FINDINGS: In the "pre-intervention 2010" (from January 2010 to December 2010) and "pre-intervention 2011" (from January 2011 to December 2011) phases, patients who screened HIV-positive at health care facilities in Zhongshan and Pubei counties in Guangxi, China, followed the standard-of-care process. In the "post-intervention 2012" (from July 2012 to June 2013) and "post-intervention 2013" (from July 2013 to June 2014) phases, patients who screened HIV-positive at the same facilities were offered a simplified test and treat intervention, i.e., concurrent HIV confirmatory and CD4 testing and immediate initiation of ART, irrespective of CD4 count. Participants were followed for 6-18 mo until the end of their study phase period. Mortality rates in the pre-intervention and post-intervention phases were compared for all HIV cases and for treatment-eligible HIV cases. A total of 1,034 HIV-positive participants (281 and 339 in the two pre-intervention phases respectively, and 215 and 199 in the two post-intervention phases respectively) were enrolled. Following the structural intervention, receipt of baseline CD4 testing within 30 d of HIV confirmation increased from 67%/61% (pre-intervention 2010/pre-intervention 2011) to 98%/97% (post-intervention 2012/post-intervention 2013) (all p < 0.001 [i.e., for all comparisons between a pre- and post-intervention phase]), and the time from HIV confirmation to ART initiation decreased from 53 d (interquartile range [IQR] 27-141)/43 d (IQR 15-113) to 5 d (IQR 2-12)/5 d (IQR 2-13) (all p < 0.001). Initiation of ART increased from 27%/49% to 91%/89% among all cases (all p < 0.001) and from 39%/62% to 94%/90% among individuals with CD4 count ≤ 350 cells/mm3 or AIDS (all p < 0.001). Mortality decreased from 27%/27% to 10%/10% for all cases (all p < 0.001) and from 40%/35% to 13%/13% for cases with CD4 count ≤ 350 cells/mm3 or AIDS (all p < 0.001). The simplified test and treat intervention was significantly associated with decreased mortality rates compared to pre-intervention 2011 (adjusted hazard ratio [aHR] 0.385 [95% CI 0.239-0.620] and 0.380 [95% CI 0.233-0.618] for the two post-intervention phases, respectively, for all newly diagnosed HIV cases [both p < 0.001], and aHR 0.369 [95% CI 0.226-0.603] and 0.361 [95% CI 0.221-0.590] for newly diagnosed treatment-eligible HIV cases [both p < 0.001]). The unit cost of an additional patient receiving ART attributable to the intervention was US$83.80. The unit cost of a death prevented because of the intervention was US$234.52. CONCLUSIONS: Our results demonstrate that the simplified HIV test and treat intervention promoted successful engagement in care and was associated with a 62% reduction in mortality. Our findings support the implementation of integrated HIV testing and immediate access to ART irrespective of CD4 count, in order to optimize the impact of ART.

Renal Function in Chinese HIV-Positive Individuals following Initiation of Antiretroviral Therapy.

AIM: To identify the prevalence and predictors of abnormal renal function among HIV-positive Chinese patients prior to antiretroviral therapy (ART) initiation and to evaluate subsequent changes in renal function after ART exposure. METHODS: We conducted a nationwide cohort study of subjects who enrolled in the national Chinese ART program from January 1, 2012 to December 31, 2012. We estimated the glomerular filtration rate (eGFR) of subjects prior to and after initiating ART. Risk factors for abnormal renal function, as defined by eGFR <60 ml/min/1.73m2, at baseline and follow-up were assessed by logistic regression and Cox proportional hazards regression models, respectively. RESULTS: Among 41,862 subjects, at ART baseline, 3.3% had a baseline eGFR <60 ml/min/1.73m2 and 24.2% had eGFR = 60-90 ml/min/1.73m2. Adjusted baseline risk factors for baseline eGFR <60 ml/min/1.73m2 were older age (Adjusted odds ratio [AOR] = 5.19, 95% confidence interval [CI]: 4.52-5.67), female (AOR = 1.68, 95% CI: 1.47-1.93), hemoglobin <120g/L (AOR = 1.68, 95% CI: 1.47-1.93), blood glucose >6.1 mmol/L (AOR = 1.46, 95% CI: 1.25-1.72), and hepatitis C co-infection (AOR = 1.36, 95% CI: 1.06-1.73). Among subjects with baseline eGFR >90 ml/min/1.73m2, the incidence of the eGFR falling to <60 ml/min/1.73m2 was 0.92/100 person-years after a median of 15.0 months of ART. Being on a tenofovir with lopinavir/ritonavir regimen (Adjusted hazard ratio [AHR] = 3.02, 95% CI: 1.96-4.66) and having an unsuppressed viral load (AHR = 2.70, 95% CI: 1.80-4.03) were independent predictors for eGFR <60 ml/min/1.73m2 after ART initiation as well as older age, female, and hemoglobin <120 g/L. CONCLUSION: A high proportion of HIV-positive subjects in China presented with abnormal renal function prior to ART initiation. But the incidence of the eGFR decrease after ART was low. Patient renal function should be regularly monitored by eGFR before initiating and during ART.

Effects of a Quasi-Randomized Web-Based Intervention on Risk Behaviors and Treatment Seeking Among HIV-Positive Men Who Have Sex With Men in Chengdu, China.

The men who have sex with men (MSM) population in China has experienced a recent increase in HIV incidence. Due to the dual stigma and discrimination towards homosexuality and HIV infection, most MSM living with HIV/AIDS are hard to reach by offline intervention initiatives. We recruited HIV-positive MSM participants in Chengdu, China and assessed whether they disclosed their HIV status to partners, motivated a partner to receive testing, used condoms consistently, or initiated antiretroviral therapy. Participants were quasi-randomized to either the intervention or control arm. The intervention group was given instructions for an online program with four modules: an information exchange website, a bulletin board system, individualized online counseling with trained peer educators, and an animation game. All participants were re-assessed at 6 months. The study enrolled 202 HIV-positive MSM. The intervention group had significant increases in disclosing their HIV status to their partners (76.0% vs 61.2%, P=0.0388) and motivating partners to accept HIV testing (42.3% vs 25.5%, P=0.0156) compared with the control group, but there were no between-group differences in receiving early treatment or using condoms consistently. We found that a web-based intervention targeting HIV-positive MSM was an effective tool in increasing the uptake of HIV testing within this high-risk population.

Predictors of accessing antiretroviral therapy among HIV-positive drug users in China's National Methadone Maintenance Treatment Programme.

AIMS: The objective of this study was to examine factors that predict antiretroviral therapy (ART) access among eligible, HIV-positive methadone maintenance treatment (MMT) clients. We also tested the hypothesis that sustained MMT participation increases the likelihood of accessing ART. DESIGN: A nation-wide cohort study conducted from 1 March 2004 to 31 December 2011. SETTING: MMT clients were followed from the time of their enrolment in China's national MMT programme until their death or the study end date. PARTICIPANTS: Our cohort comprised 7111 ART-eligible, HIV-positive MMT clients, 49.2% of whom remained ART-naive and 50.8% of whom received ART. MEASUREMENTS: Demographic variables, drug use history, MMT programme participation and HIV-related clinical characteristics of study participants who remained naive to ART and those who accessed ART were compared by univariate and multivariable analysis. FINDINGS: Predictors of accessing ART among this cohort included being retained in MMT at the time of first meeting ART eligibility [adjusted odds ratio (AOR)=1.84, confidence interval (CI)=1.54-2.21, P<0.001] compared to meeting ART eligibility before entering MMT (AOR=0.98, CI=0.80-1.21, P=0.849) or previously entering MMT and dropping out before meeting ART eligibility. Additional predictors were CD4≤200 cells/µl when ART-eligibility requirement was first met (AOR=1.81, CI=1.61-2.05, P<0.001 compared to CD4=201-350 cells/µl), and being in a stable partner relationship (married/cohabitating: AOR=1.14, CI=1.01-1.28, P=0.030). CONCLUSIONS: Retained participation in methadone maintenance treatment increases the likelihood that eligible clients will access antiretroviral therapy. These results highlight the potential benefit of colocalization of methadone maintenance treatment and antiretroviral therapy services in a 'one-stop-shop' model.

Aphrodisiac use associated with HIV infection in elderly male clients of low-cost commercial sex venues in Guangxi, China: a matched case-control study.

BACKGROUND: Rising HIV infection rates have been observed among elderly people in Guangxi, China. Inexpensive aphrodisiacs are available for purchase in suburban and rural areas. This study aims to investigate the association between aphrodisiac use and increased HIV risk for middle-aged and elderly men in Guangxi. METHODS: A matched case-control study of aphrodisiac use-associated HIV infection was performed among male subjects over 50 years old who were clients of low-cost commercial sex venues in Guangxi. The cases were defined as clients who were HIV-positive and two controls were selected for each case. The cases and the controls were matched on the visited sex venue, age (±3 years), number of years of purchasing sex (±3 years), and educational attainment. Subjects were interviewed and tested for HIV. Paired t-test or McNemar Chi-squared test were used to compare the characteristics between the cases and controls. A stepwise conditional logistic regression was used to identify risk factors associated with HIV infection. FINDINGS: This study enrolled 103 cases and 206 controls. Aphrodisiac use (P = 0.02, odds ratio (OR) = 1.81, 95% CI = 1.08-3.04), never using condom during commercial sex encounter (P = 0.03, odds ratio (OR) = 1.82, 95% CI = 1.08-3.07), and lacking a stable partner (P = 0.03, odds ratio (OR) = 1.76, 95% CI = 1.05-2.98) were found to be risk factors for HIV infection among the study groups. For subjects reporting aphrodisiac use, the frequency of purchasing sex was positively correlated with the frequency of aphrodisiac use (r = 0.3; p = 0.02). CONCLUSIONS: Aphrodisiac use was significantly associated with increased HIV infection risk in men over 50 years old who purchased commercial sex in the suburban and rural areas of Guangxi. Further research and interventions should address the links between aphrodisiac use, commercial sex work, condom use, and increased HIV transmission.

Baseline CD4 cell counts of newly diagnosed HIV cases in China: 2006-2012.

BACKGROUND: Late diagnosis of HIV infection is common. We aim to assess the proportion of newly diagnosed HIV cases receiving timely baseline CD4 count testing and the associated factors in China. METHODS: Data were extracted from the Chinese HIV/AIDS Comprehensive Response Information Management System. Adult patients over 15 years old who had been newly diagnosed with HIV infection in China between 2006 and 2012 were identified. The study cohort comprised individuals who had a measured baseline CD4 count. RESULTS: Among 388,496 newly identified HIV cases, the median baseline CD4 count was 294 cells/µl (IQR: 130-454), and over half (N = 130,442, 58.8%) were less than 350 cells/µl. The median baseline CD4 count increased from 221 (IQR: 63-410) in 2006 to 314 (IQR: 159-460) in 2012. A slight majority of patients (N = 221,980, 57.1%) received baseline CD4 count testing within 6 months of diagnosis. The proportion of individuals who received timely baseline CD4 count testing increased significantly from 20.0% in 2006 to 76.9% in 2012. Factors associated with failing to receiving timely CD4 count testing were: being male (OR: 1.17, 95% CI: 1.15-1.19), age 55 years or older (OR:1.03, 95% CI: 1.00-1.06), educational attainment of primary school education or below (OR: 1.30, 95% CI: 1.28-1.32), infection with HIV through injection drug use (OR: 2.07, 95% CI: 2.02-2.12) or sexual contact and injection drug use (OR: 1.87, 95% CI: 1.76-1.99), diagnosis in a hospital (OR: 1.91, 95% CI: 1.88-1.95) or in a detention center (OR: 1.75, 95% CI: 1.70-1.80), and employment as a migrant worker (OR:1.55, 95% CI:1.53-1.58). CONCLUSION: The proportion of newly identified HIV patients receiving timely baseline CD4 testing has increased significantly in China from 2006-2012. Continued effort is needed for further promotion of early HIV diagnosis and timely baseline CD4 cell count testing.

Sexual dysfunction improved in heroin-dependent men after methadone maintenance treatment in Tianjin, China.

OBJECTIVE: To investigate whether methadone maintenance treatment (MMT) is correlated with sexual dysfunction in heroin-dependent men and to determine the prevalence and risk factors of sexual dysfunction among men on MMT. METHODS: The study included a retrospective survey and a cross-sectional survey which contained interviews of 293 men who are currently engaged in MMT. The results of the two surveys were compared. For a subset of 43 participants, radioimmunoassay was additionally conducted using retrospective and prospective blood samples to test the levels of plasma testosterone and luteinizing hormone. Other study evaluations were the International Index of Erectile Function (IIEF-15), and Self-rating Depression Scale. RESULTS: Sexual dysfunction in all five IIEF-15 domains (erectile function, orgasmic function, sexual desire, intercourse satisfaction, and overall satisfaction) was strongly associated with long-term use of heroin. A decrease in the severity of sexual dysfunction was associated with MMT initiation. Erectile dysfunction, lack of sexual desire, inability to orgasm, and lack of intercourse satisfaction were significantly correlated with increasing age of the participants. Methadone dose and duration of methadone treatment were not found to be associated with sexual dysfunction. The level of plasma testosterone significantly declined during methadone treatment, but results from multivariate analysis indicated low levels of testosterone were not the main cause of sexual dysfunction. No correlation between reported depression status and sexual function was found. CONCLUSIONS: While high levels of sexual dysfunction were reported by heroin-dependent men in our study before and after MMT initiation, MMT appears to be correlated with improved sexual function in the population of the study.

Methadone maintenance treatment and mortality in HIV-positive people who inject opioids in China.

OBJECTIVE: To examine the effect of methadone maintenance treatment (MMT) on mortality in people injecting opioids who receive antiretroviral therapy (ART) for the treatment of human immunodeficiency virus (HIV) infection in China. METHODS: The study involved a nationwide cohort of 23 813 HIV-positive (HIV+) people injecting opioids who received ART between 31 December 2002 and 31 December 2011. Mortality rates and demographic, disease and treatment characteristics were compared in patients who received either ART and MMT or ART only. Factors associated with mortality were identified by univariate and multivariate analysis. FINDINGS: Overall, 3057 deaths occurred during 41 959 person-years of follow-up (mortality: 7.3 per 100 person-years; 95% confidence interval, CI: 7.0-7.5). Mortality 6 months after starting ART was significantly lower with ART and MMT than with ART only (6.6 versus 16.9 per 100 person-years, respectively; P < 0.001). After 12 months, mortality was 3.7 and 7.4 per 100 person-years in the two groups, respectively (P < 0.001). Not having received MMT was an independent predictor of death (adjusted hazard ratio: 1.4; 95% CI: 1.3-1.6). Other predictors were a low haemoglobin level and a low CD4+ T-lymphocyte count at ART initiation and treatment at facilities other than infectious disease hospitals. CONCLUSION: Patients would benefit more from both MMT and HIV treatment programmes and would face fewer barriers to care if cross-referrals between programmes were promoted and ART and MMT services were located together.

Addressing injecting drug use in Asia and Eastern Europe.

While the global HIV incidence dropped about 20% in the past 10 years, HIV incidences among people who inject drugs (PWID) in Asia and Europe continue to increase and to account for high proportions of new HIV infections among PWID globally. Great changes have been observed in this region, such as progressing from rejection to acceptance of harm reduction strategies in Asian countries, but no such change has occurred in Eastern European countries. China has quickly scaled up harm reduction activities nationwide, resulting in the decline of HIV incidence and HIV prevalence among PWID since 2006. However, insufficient scaling up of harm reduction programs in other countries has failed to slow down their HIV epidemics. In Eastern European countries where the spread of HIV among PWID is the most severe, only about 15% of funding for harm reduction programs are from domestic sources. Strong political and financial commitment from countries in this region is urgently needed to quickly scale up evidence-based harm reduction strategies in order to prevent the HIV epidemic from spreading rapidly from PWID to the heterosexual general population.