Care of HIV-infected patients in China

Prevalence of transmitted HIV-1 drug resistance among treatment-naive individuals in China, 2000-2016

Human immunodeficiency virus (HIV) with transmitted drug-resistance (TDR) limits the therapeutic options available for treatment-naive HIV patients. This study aimed to further our understanding of the prevalence and transmission characteristics of HIV with TDR for the application of first-line antiretroviral regimens. A total of 6578 HIV-1 protease/reverse-transcriptase sequences from treatment-naive individuals in China between 2000 and 2016 were obtained from the Los Alamos HIV Sequence Database and were analyzed for TDR. Transmission networks were constructed to determine genetic relationships. The spreading routes of large TDR clusters were identified using a Bayesian phylogeographic framework. TDR mutations were detected in 274 (4.51%) individuals, with 1.40% associated with resistance to nucleoside reverse transcriptase inhibitors, 1.52% to non-nucleoside reverse transcriptase inhibitors, and 1.87% to protease inhibitors. The most frequent mutation was M46L (58, 0.89%), followed by K103N (36, 0.55%), M46I (36, 0.55%), and M184V (26, 0.40%). The prevalence of total TDR initially decreased between 2000 and 2010 (OR = 0.83, 95% CI 0.73-0.95) and then increased thereafter (OR = 1.50, 95% CI 1.13-1.97). The proportion of sequences in a cluster (clustering rate) among HIV isolates with TDR sequences was lower than that of sequences without TDR (40.5% vs. 48.8%, P = 0.023) and increased from 27.3% in 2005-2006 to 63.6% in 2015-2016 (P < 0.001). While most TDR mutations were associated with reduced relative transmission fitness, mutation M46I was associated with higher relative transmission fitness than the wild-type strain. This study identified a low-level prevalence of TDR HIV in China during the last two decades. However, the increasing TDR HIV rate since 2010, the persistent circulation of drug resistance mutations, and the expansion of self-sustaining drug resistance reservoirs may compromise the efficacy of antiretroviral therapy programs.

Rapid and Simultaneous Detection of Major Drug Resistance Mutations in Reverse Transcriptase Gene for HIV-1 CRF01_AE, CRF07_BC and Subtype B in China Using Sequenom MassARRAY® System

The development of a rapid, high-throughput and cost-effective HIV-1 drug resistance (HIV-DR) testing system is a challenge for areas consisting different HIV-1 strains. In this study, we established a broadly reactive multiplex assay that could simultaneously detect major drug resistance mutations at 8 loci, which are associated with resistance to commonly used nucleoside reverse transcriptase inhibitors (NRTIs) and Non-nucleoside reverse transcriptase inhibitors (NNRTIs), in specimens of HIV-1 CRF01_AE, CRF07_BC and subtype B, the three major circulating strains in China, using the matrix-assisted laser desorption ionization-time of flight mass spectrometry (MALDI-TOF MS) provided by Sequenom MassARRAY® system. To establish the assay, pol gene fragments were prepared from the plasma viral RNA of 159 patients by nested PCR and the presence of wild type and mutant alleles at the 8 loci were analyzed by MALDI-TOF MS. In terms of loci, the detection rate of the alleles was greater than 97% for M41L, K65R, M184V and G190A, 91.2% for K101E/Q/P, 91.2% for T215F/Y, 89.9% for K103N/S and 80.5% for L210W. In terms of individuals, 80% of the alleles were detected in 95.4% CRF01_AE patients, 100% CRF07_BC patients and 83.3% subtype B patients. Importantly, the MALDI-TOF MS results were concordant to the drug resistance profiles of patients obtained from conventional sequencing analysis after excluded the failed detections. Using plasmid templates, the assay was estimated to be sensitive to detect drug resistant variants at level about 20% of the circulating viral population. The capability of this assay to detect mixed viral populations was further verified by two different patient specimens. In conclusion, this study evaluated the use of Sequenom MassARRAY® system for high-throughput detection of HIV-DR mutations towards the commonly used reverse transcriptase inhibitors in China.

Antiretroviral Therapy (ART) Side Effect Impacted on Quality of Life, and Depressive Symptomatology: A Mixed-Method Study

Antiretroviral therapy (ART) is known for its side effects. In this paper, we describe ART side effects as experienced by Chinese HIV+ individuals. This study presents two stages of a research project, combining qualitative in-depth interviews (29 HIV+ participants) with quantitative statistical data analysis (N = 120). All data was collected between July 2005 to March 2008 at Beijing's Ditan Hospital. Consent was obtained from each participant for the qualitative interview and again for the quantitative survey. During in-depth interviews, Chinese HIV+ patients reported experiencing digestive discomfort, skin rashes, numbness, memory loss, nightmares, and dizziness, which not only brought them physical discomfort, but also interrupted different dimensions of their social lives. Furthermore, multiple regression analyses revealed that those who reported more severe side effects also experienced greater depressive mood after controlling for other clinical and psychosocial factors. ART side effects are one of the primary reasons causing HIV+ individuals to delay or stop taking life-saving medication; therefore, clinical interventions are critically needed to assist HIV+ individuals in managing ART side effects. ART side effects reinforced existing negative attitudes toward ART and lead to lower ART adherence. Future research should focus on developing culturally sensitive interventions to enhance HIV+ self-management, to alleviate physical and psychological burden from ART and HIV.

F18, a novel small-molecule nonnucleoside reverse transcriptase inhibitor, inhibits HIV-1 replication using distinct binding motifs as demonstrated by resistance selection and docking analysis

Nonnucleoside reverse transcriptase inhibitors (NNRTIs) are one of the key components of antiretroviral therapy drug regimen against human immunodeficiency virus type 1 (HIV-1) replication. We previously described a newly synthesized small molecule, 10-chloromethyl-11-demethyl-12-oxo-calanolide A (F18), a (+)-calanolide A analog, as a novel anti-HIV-1 NNRTI (H. Xue et al., J. Med. Chem. 53:1397-1401, 2010). Here, we further investigated its antiviral range, drug resistance profile, and underlying mechanism of action. F18 consistently displayed potent activity against primary HIV-1 isolates, including various subtypes of group M, circulating recombinant form (CRF) 01_AE, and laboratory-adapted drug-resistant viruses. Moreover, F18 displayed distinct profiles against 17 NNRTI-resistant pseudoviruses, with an excellent potency especially against one of the most prevalent strains with the Y181C mutation (50% effective concentration, 1.0 nM), which was in stark contrast to the extensively used NNRTIs nevirapine and efavirenz. Moreover, we induced F18-resistant viruses by in vitro serial passages and found that the mutation L100I appeared to be the dominant contributor to F18 resistance, further suggesting a binding motif different from that of nevirapine and efavirenz. F18 was nonantagonistic when used in combination with other antiretrovirals against both wild-type and drug-resistant viruses in infected peripheral blood mononuclear cells. Interestingly, F18 displayed a highly synergistic antiviral effect with nevirapine against nevirapine-resistant virus (Y181C). Furthermore, in silico docking analysis suggested that F18 may bind to the HIV-1 reverse transcriptase differently from other NNRTIs. This study presents F18 as a new potential drug for clinical use and also presents a new mechanism-based design for future NNRTI.

Decentralization of the provision of health services to people living with HIV/AIDS in rural China: the case of three counties

This study is based on a large-scale household survey and in-depth interviews of key informants that was conducted in villages in three counties of two provinces in China. We assess the new decentralized service provision system for people living with HIV/AIDS in rural populations in China. Since 2003, new social assistance schemes, and, more importantly, decentralization of routine treatment and care to community health stations, were progressively implemented in rural areas most affected by the HIV/AIDS epidemic. Though some problems remain, such as persistent discrimination towards infected patients and the lack of sufficient training of medical staff, the new decentralized pattern of service provision has lowered barriers to health access and alleviated economic pressure on affected households.

Design and implementation of a China comprehensive AIDS response programme (China CARES), 2003-08

BACKGROUND

Prior to 2003, there was limited capacity for an HIV/AIDS response in China. In early 2003, China launched a 5-year China Comprehensive AIDS Response Programme (China CARES) to contain the spread of HIV infection and reduce its impact. This article describes the China CARES' practices and experiences.

METHODS

China CARES covered 83.3 million people in 127 programme sites chosen from 28 provinces based on HIV prevalence. Each China CARES site was required to carry out surveillance and surveys to understand the local HIV/AIDS epidemic, to deliver primary interventions to reduce new HIV infections among and from high-risk groups, to prevent mother-to-child transmission, to treat AIDS patients with antiretroviral medicines and to provide support services to families affected by HIV/AIDS. Data were collected to monitor and evaluate implementation.

RESULTS

HIV/AIDS prevention knowledge and awareness improved significantly in China CARES sites from <30% in 2004 to 86% in 2008. The number of persons tested for HIV increased by 67% between 2005 and 2007 from 1.5 to 2.5 million. China CARES enrolled 23 000 patients in anti-retroviral treatment and supported 6007 AIDS orphans. Among pregnant women, 81.8% received counselling and 75.8% received HIV testing during antenatal care, while 92.9% of HIV-infected pregnant women and 85.5% of their newborns received anti-retroviral prophylaxis. During the project period, no known HIV transmissions occurred through blood transfusions.

CONCLUSION

China CARES has facilitated AIDS prevention, treatment and care in resource-poor, rural and ethnic minority areas of China.

Technology Development Through Pooling ARV Drug Patents: A Vision from China

Unaffordable prices still bar the end-users in China from accessing ARV drugs. Patent protection of ARV drugs has dramatically limited the availability of these lifesaving drugs to AIDS patients in China.

The way Chinese government can go to breakthrough the ARV drug patents are suggested as:

Make more generic drugs available through compulsory licensing, impartment from other countries or building ARVs plants by partnerships between governments or generic drug companies.

Do a thorough and detailed research on the patent application of ARV drugs to find out the loophole.

Try patent pool to make AIDS medicines more affordable and appropriate for patients.

Consistent ART adherence is associated with improved quality of Life, CD4 counts, and reduced hospital costs in central China

This study aimed to assess levels of ART adherence and to examine the relationship between adherence and treatment outcomes. A longitudinal study in Hunan and Hubei provinces used the CPCRA Antiretroviral Medication Self-Report and a 7-day Visual Analogue Scale to assess levels of adherence, while quality of life was evaluated using SF-36. CD4 cell count and the number, duration, and cost of hospitalizations were collected from participant medical records. Measurements were obtained at baseline, month 3, and month 6. A total of 113 participants enrolled and 98 completed the study. The mean level of adherence was 91%, 89%, and 88% at baseline and at 3 and 6 months, respectively. Of participants, 54/98 (58%) reported taking all doses at all three interviews and were classified as consistent adherers (CA). CAs had better physical function (p = 0.001), general health (p = 0.009), vitality (p = 0.016), social functioning (p = 0.001), and mental health (p = 0.023), and presented a higher CD4 cell count (p = 0.028). CAs also had fewer hospital admissions and readmissions (p = 0.005), shorter hospital stays (p = 0.005), and lower hospital expenses (p = 0.006). Consistent adherence is associated with better outcomes including improved quality of life, higher CD4 counts, and lower health care costs.

Sibling separation and psychological problems of double AIDS orphans in rural China - a comparison analysis

OBJECTIVE

We investigated the psychological impact of sibling separation among children who lost both of their parents to AIDS and were placed in group care or kinship care settings in rural China.

METHODS

Comparative analysis of cross-sectional survey data among 155 children among whom 96 experienced sibling separation. Trauma symptoms (Anxiety, Depression, Anger, Post-traumatic stress, Dissociation, Sexual concerns) were compared between the AIDS orphans who experienced sibling separation and those who did not using analysis of variance and multivariate analysis of covariance.

RESULTS

Among the participants (47.7% girls) with an average age of 12.4 years, univariate and multivariate analyses showed that separation from siblings was associated with significantly higher scores in anxiety, depression, anger and dissociation before or after controlling for gender, age, care arrangement, number of household replacement, trusting relationship with the current caregivers and perceived quality of current living condition. Sibling separation among orphans was not associated with level of post-traumatic stress and sexual concerns.

CONCLUSION

AIDS orphans separated from their siblings suffered from increased psychological distress compared with those who remained with their siblings. The data in the current study suggest that care arrangement for AIDS orphan should include accommodating the siblings together or providing them with opportunities for frequent contact and/or communication with each other. Appropriate psychological counselling should be given to those orphans experiencing sibling separation.

Macrophage delivery of nanoformulated antiretroviral drug to the brain in a murine model of neuroAIDS

Antiretroviral therapy (ART) shows variable blood-brain barrier penetration. This may affect the development of neurological complications of HIV infection. In attempts to attenuate viral growth for the nervous system, cell-based nanoformulations were developed with the focus on improving drug pharmacokinetics. We reasoned that ART carriage could be facilitated within blood-borne macrophages traveling across the blood-brain barrier. To test this idea, an HIV-1 encephalitis (HIVE) rodent model was used where HIV-1-infected human monocyte-derived macrophages were stereotactically injected into the subcortex of severe combined immunodeficient mice. ART was prepared using indinavir (IDV) nanoparticles (NP, nanoART) loaded into murine bone marrow macrophages (BMM, IDV-NP-BMM) after ex vivo cultivation. IDV-NP-BMM was administered i.v. to mice resulting in continuous IDV release for 14 days. Rhodamine-labeled IDV-NP was readily observed in areas of HIVE and specifically in brain subregions with active astrogliosis, microgliosis, and neuronal loss. IDV-NP-BMM treatment led to robust IDV levels and reduced HIV-1 replication in HIVE brain regions. We conclude that nanoART targeting to diseased brain through macrophage carriage is possible and can be considered in developmental therapeutics for HIV-associated neurological disease.

Prevalence of drug-resistant HIV-1 in rural areas of Hubei province in the People's Republic of China

OBJECTIVE

To determine the prevalence of drug-resistant HIV-1 and the efficacy of first-line highly active antiretroviral therapy (HAART) regimens consisted of generic nucleoside reverse transcriptase inhibitor and nonnucleoside reverse transcriptase inhibitor among 339 study subjects in rural areas of Hubei province, China.

METHODS

Two cross-sectional studies were conducted to investigate 150 HAART-naive (99 received subsequent therapy) between 2003 and 2005 and 288 HAART-experienced patients mainly between 2005 and 2006. Patients' CD4+ T-cell count and viral load were determined. HIV-1 pol gene fragments were amplified from patients' plasma by reverse transcriptase-polymerase chain reaction, subsequently sequenced and analyzed.

RESULTS

About 83.5% of the patients were from rural villages. They were dominantly infected with subtype B' HIV-1 (96.7%) through paid blood donation (64.6%) and related blood transfusion (28.3%). We found that there was a steady increase of CD4 count over time among treated patients without detectable viral load (186/288, 64.6%). There was, however, an increasing prevalence of nucleoside reverse transcriptase inhibitor- and nonnucleoside reverse transcriptase inhibitor-resistant mutations among patients with detected viremia (102/288, 35.4%) after treatment for 3-6 (24.3%), 9-12 (57.1%), and 20-24 (63.3%) months, respectively. The increasing rates were associated with significant CD4 count drop and viral load increase. Some patients also developed multidrug-resistant mutants.

CONCLUSIONS

: We report the first HIV-1 drug resistance study after 2 years on HAART among Chinese patients living in rural villages. Our data suggest that a significant portion of patients are failing first-line regimens with a trend of AIDS progression. It is therefore necessary to maximize the drug adherence and to make affordable second-line HAART regimens available immediately. Our results have implications for implementing HAART in underresourced developing country settings.

Self-Reported adherence to antiretroviral treatment among HIV-infected people in Central China

Although the number of patients receiving antiretroviral (ARV) therapy in Central China is expanding, little is known about their medication adherence. The purpose of this study was to: (1) describe adherence prevalence among patients receiving free ARV in south central China; (2) identify factors associated with adherence; (3) compare 3 self-report measures of adherence in this population. A cross-sectional survey was conducted at seven free treatment sites in Hunan, Hubei, and Anhui Provinces. Adherence measures included direct questioning regarding the number of doses taken in the 7 days prior to interview, the Community Programs for Clinical Research on AIDS (CPCRA) Adherence Self-Report questionnaire, and a 7-day visual analogue scale. Subjects comprised all patients returning for monthly ARV follow-up at each site between April and July 2006. Among the 308 subjects, 244 (79%) lived in the countryside. One hundred seventy (55%) had been on ARV over 1 year. No regimen included a protease inhibitor. Two hundred forty-four (80%) reported taking more than 90% of prescribed doses in the previous 7 days. Sixty-four (20%) subjects reported missing at least 1 dose in that period. The three measures of self-reported adherence were highly correlated. On multivariate analysis, current heroin use (odds ratio [OR] = 2.5; 95% confidence interval [CI] 1,6, p = 0.05) and nonuse of reminders such as cell phone alarms, wall charts, or TV programs (OR 6; 95% CI 3, 11; p = 0.001) were associated with 90% or less adherence. Adherence to ARV in Central China is similar to elsewhere in the world. The 20% of subjects who reported taking 90% or fewer doses are of concern in view of the potential for non-nucleoside reverse transcriptase inhibitor resistance and lack of protease inhibitor back-up regimens. Substance abuse treatment will be an essential element of successful AIDS treatment in China. Prospective studies are needed to evaluate the efficacy of reminder devices to improve adherence in this population and to describe the prevalence and incidence of ARV resistance.