The changing face of the HIV epidemic in Taiwan: a new challenge for public health policy strategies

Sex stratification of the trends and risk of mortality among individuals living with HIV under different transmission categories

We retrospectively examined 33,142 persons living with HIV (PLWH) in Taiwan from a nationwide database to assess sex-stratified trends and risk of all-cause mortality under different transmission categories from 1984 to 2016. Overall, 61.25% were men who have sex with men (MSM), 14.37% were men who have sex with women (MSW), 18.32% were male persons who inject drugs (M-PWID), 3.30% were women who have sex with men (WSM), and 2.74% were female PWID (F-PWID). All-cause mortality (per 100 person-years) among heterosexual people and PWID was higher in men (4.04 and 3.39, respectively) than in women (2.93 and 2.18, respectively). In each sex-stratified transmission category, the all-cause mortality reduced substantially from 1984–1996 to 2012–2016, but evolved distinctly from 2007–2011 to 2012–2016. Since 2007–2011, the decline in all-cause mortality has slowed notably in the groups with sexually transmitted HIV, but has increased in PWID, surpassing even that among groups with sexually transmitted HIV in 2012–2016. PLWH with sexually transmitted HIV had lower risks of all-cause mortality than PWID, regardless of sex. Sex and transmission category did not interact significantly on all-cause mortality. Understanding the reasons for the distinct evolving trends of all-cause mortality in each transmission category serves as a reference for developing strategies to reduce mortality in PLWH in Taiwan further.

Impact of immediate initiation of antiretroviral therapy among men who have sex with men infected with HIV in Chengdu, southwest China: trends analysis, 2008-2018

Background

Given the rampant HIV epidemic among men who have sex with men (MSM) in Chengdu, southwest China, Treat All policy, defined as immediate antiretroviral therapy (ART) initiation after HIV diagnosis, was implemented since 2014. Real-world research evaluating impacts of immediate ART on HIV epidemics is needed to optimize policy-making as national and international guidelines have been lowering ART eligibility threshold. The purpose of this study is to: assess temporal trends of the HIV epidemic and impacts of Treat All policy among MSM; and lay foundation for HIV-related policy evaluation using longitudinal routine data from health information systems.

Methods

Data used in this study were HIV sentinel seroprevalence, annual reported HIV cases and ART coverage rate among MSM in Chengdu from 2008 to 2018, derived from national HIV/AIDS information system. Temporal trends of the HIV epidemic were described using Joinpoint Regression Program. Interrupted time-series method was deployed to evaluate Treat All policy.

Results

HIV sentinel seroprevalence rose from 11.20% in 2008 to 17.67% in 2013 and Annual Percent Change (APC) was 8.25% (95% CI − 2.40%, 20.07%), then decreased to 5.17% in 2018 (APC = − 19.63%, 95% CI − 27.54%, − 10.86%). Newly reported HIV cases increased from 168 cases in 2008 to 1232 cases in 2015 (APC = 26.99%, 95% CI 21.32%, 32.93%), and reduced to 1014 cases in 2018 (APC = − 8.80%, 95% CI − 18.45%, 2.01%). ART coverage rate has been climbing from 11.11% in 2008 to 92.29% in 2018 and Average Annual Percent Change was 16.09% (95% CI 11.76%, 20.59%). Results of interrupted time-series models showed that compared to an annual increase of 0.87% during pre-policy period, there was a decline of 3.08% (95% CI − 0.0366%, − 0.0250%) per year of HIV sentinel seroprevalence since 2014; and compared to an annual increase of 116 cases before 2014, there was an annual drop of 158 newly reported HIV cases (95% CI − 194.87%, − 121.69%) during the post-policy period.

Conclusions

Immediate ART after HIV diagnosis could potentially curb HIV transmission at population level among MSM, along with other strategies. Future assessment of HIV prevention and control policy can be carried out using routinely collected longitudinal data from health information systems.

Evolution of hepatitis A virus seroprevalence among HIV-positive adults in Taiwan

OBJECTIVES

The study aimed to describe the seroprevalence of hepatitis A virus (HAV) in HIV-positive adult patients in Taiwan between 2012 and 2016 and to examine the evolution of HAV seroprevalence between 2004-2007 and 2012-2016.

METHODS

Clinical information and data of anti-HAV antibody results were collected from 2,860 antiretroviral-naïve HIV-positive Taiwanese aged 18 years or older who initiated combination antiretroviral therapy at 11 hospitals around Taiwan between 2012 and 2016 (2012-2016 cohort). A multivariate logistic regression model was applied to identify independent variables associated with HAV seropositivity. Comparisons of HAV seroprevalences and associated clinical characteristics were made between this 2012-2016 cohort and a previous cohort of 1580 HIV-positive patients in 2004-2007 (2004-2007 cohort).

RESULTS

Of the 2,860 HIV-positive patients between 2012 and 2016, the overall HAV seropositivity rate was 21.2% (605/2860), which was independently associated with an older age (adjusted odds ratio [AOR], per 1-year increase, 1.13; 95% confidence interval [95% CI], 1.11-1.15) and co-infection with hepatitis B virus (AOR 1.44; 95% CI, 1.08-1.93). Residence in southern Taiwan (AOR 0.49; 95% CI, 0.34-0.72) was inversely associated with HAV seropositivity. The overall HAV seroprevalence in the 2012-2016 cohort was significantly lower than that in the 2004-2007 cohort (21.2% vs 60.9%, p<0.01). The decreases of HAV seropositivity rate were observed in nearly every age-matched group, which suggested the cohort effect on HAV seroepidemiology. However, among individuals aged 25 years or younger, the HAV seropositivity rate increased from 3.8% (2/52) in the 2004-2007 cohort to 8.5% (50/587) in the 2012-2016 cohort, with 95.4% (560/587) being MSM in this age group of the latter cohort.

CONCLUSIONS

HAV seroprevalence has decreased with time among HIV-positive adults in Taiwan. The cohort effect has increased the number of young HIV-positive patients that are susceptible to HAV infection in a country without nationwide childhood vaccination program against HAV.

Reduced community viral load does not coincide with a reduction in the rate of new HIV diagnoses and recent infections: data from a region of southern Italy

OBJECTIVES

We assessed whether changes in community viral load (CVL) over time were associated with the rate of new HIV diagnoses (NDs).

METHODS

HIV-1-positive individuals referred to our institute and permanently residing in our province were considered for inclusion in the study. A total of 861 HIV-infected adults with at least one HIV RNA measurement (12 530 measurements in total) between 2008 and 2014 were included. Viraemia copy-years were calculated from all HIV RNA values for each patient using the trapezoidal rule; multiple CVL indicators were considered. Total NDs and recent infections (< 1 year) were analysed separately. The association between NDs and CVL was tested by means of mixed Poisson models, with CVL as a fixed effect and year as a random effect.

RESULTS

The incidence of NDs was 2.28 per 100 000 residents in 2008 and 2.52 per 100 000 residents in 2014. Total numbers of NDs and recent infections did not vary significantly over time (P for trend 0.879 and 0.39, respectively). Mean HIV RNA decreased from 31 095.8 HIV-1 RNA copies/mL in 2008 to 21 231.5 copies/mL in 2014 (P < 0.001); a downward trend was always observed regardless of the CVL indicator considered. Depending on the indicator, there were some differences in CVL by patient characteristics. The most substantial contributors to CVL appeared to be male individuals, men who have sex with men (MSM), non-Italians, and untreated subjects (all P < 0.05). The relative risk of ND increased among Italians and MSM with an increasing proportion of subjects having an undetectable HIV RNA, and decreased in the same population with increasing levels of CVL.

CONCLUSIONS

In our setting, CVL represented a good marker of access to care and treatment; however, reduced CVL did not coincide with a reduction in the rate of NDs.

Harm reduction policy in Taiwan: toward a comprehensive understanding of its making and effects

BACKGROUND

In response to the spread of HIV caused by needle sharing among injection drug users (IDUs), the Taiwan Centers for Disease Control implemented a pilot harm reduction program in 2005 that expanded nationwide in 2006. The policy led to a significant reduction in the number of HIV-positive cases among IDUs in 4 years.

METHODS

This article aims to provide a critical evaluation of this harm reduction policy in Taiwan. The research leading to this article included a thorough literature review and in-depth interviews with 31 active policy participants, including people working in hospitals, the academia, non-governmental organizations, community pharmacies, the legal system, and health authorities at both the central and local levels. The collected data were analyzed on the basis of situational analysis.

RESULTS

The article examines the policy success by showing how this policy was assembled and by exposing the frictions and adjustments during its formation and implementation. Inter-departmental conflicts within or without the government and the efforts to coordinate them are addressed, and the transnational dimensions of this harm reduction policy are also discussed. The article then reflects on the effects of the policy and asks where the line should be drawn between what is harm reduction and what is not.

CONCLUSIONS

This case illustration reveals the complexity of understanding an assembled health policy that involves multiple participants. The article intends to render an analytic account to enable a comparison with similar policies in other countries.

Risk Factors for Advanced HIV Disease and Late Entry to HIV Care: National 1994-2012 HIV Surveillance Data for Wuhan, China

Few studies in China have focused on advanced human immunodeficiency virus (HIV) disease (AHD) and late entry to HIV care, which are associated with increased morbidity and mortality. A population-based retrospective study was conducted using 980 national HIV surveillance reports from 1994 to February 2012 in Wuhan, China. AHD was defined as presence of a first-reported CD4 count<200 cells/μL or an acquired immune deficiency syndrome (AIDS)-defining event within 1 month of HIV diagnosis. Late entry to HIV care was defined as patients with a first-reported CD4 cell count>6 months after diagnosis. Non-conditional logistic regression analysis was used to identify factors associated with AHD, late entry to HIV care, and AIDS within 1 year of HIV diagnosis. The proportions of AHD, AIDS within 1 year of HIV diagnosis, and late entry to HIV care were 29.49%, 39.39%, and 20.84%, respectively. Most of the deaths (74.27%, 127/171) occurred within 1 year of diagnosis. Short-term mortality, proportion of AHD, and late entry to HIV care showed a similar downward trend from pre-2003 to 2011 (p<0.001). Age, transmission category, sample source, and occupation were associated with AHD, late entry to HIV care, and AIDS within 1 year of HIV diagnosis in the multivariate logistic regression analysis. These findings indicate that AHD and late entry to HIV care were associated with an increased incidence of AIDS or death, particularly within 1 year of diagnosis. More effort should be made to assure early diagnosis and timely entry to care.

Gender differences in heroin users receiving methadone maintenance therapy in Taiwan

This study examined gender differences in heroin users who first received MMT. Compared with men, female heroin users were younger and more likely to be unemployed, to have family members using illicit substances, to initiate heroin use at a younger age, to begin MMT earlier after starting heroin use, to have methamphetamine use, to initiate methamphetamine use at a younger age, and to report a child-raising burden and a prior history of traumatic experiences. Men were more likely to have use of betel quid, and to initiate alcohol, nicotine and betel quid use at a younger age than women.

Factors affecting occupational exposure to needlestick and sharps injuries among dentists in Taiwan: a nationwide survey

Background

Although the risks of needlestick and sharps injuries (NSIs) for dentists are well recognized, most papers published only described the frequency of occupational exposure to NSIs. Less has been reported assessing factors contributing to exposure to NSIs. The purpose of this study was to update the epidemiology of NSIs among dentists in Taiwan and identify factors affecting NSIs in order to find preventive strategies.

Methodology/Principal Findings

A nationwide survey was conducted in dentists at 60 hospitals and 340 clinics in Taiwan. The survey included questions about factors supposedly affecting exposure to NSIs, such as dentist and facility characteristics, knowledge and attitudes about infectious diseases, and practices related to infection control. Univariate and multivariate logistic regression analyses were conducted to determine the association between risk factors and exposure to NSIs. In total, 434 (74.8%) of 580 dentists returned the survey questionnaires, and 100 (23.0%) reported that they had experienced more than one NSI per week. Our data showed that the risk of occupational NSIs is similarly heightened by an older age (odds ratio [OR], 3.18; 95% confidence interval [CI], 1.62–6.25), more years in practice (OR, 2.57; 95% CI, 1.41–4.69), working in clinics (OR, 1.73; 95% CI, 1.08–2.77), exhibiting less compliance with infection-control procedures (OR, 1.82; 95% CI, 1.04–3.18), having insufficient knowledge of blood-borne pathogens (OR, 1.67; 95% CI, 1.04–2.67), and being more worried about being infected by blood-borne pathogens (OR, 1.82; 95% CI, 1.05–3.13).

Conclusions/Significance

High rates of NSIs and low compliance with infection-control procedures highly contribute to the chance of acquiring a blood-borne pathogen infection and threaten occupational safety. This study reveals the possible affecting factors and helps in designing prevention strategies for occupational exposure to NSIs.

Educational and structural interventions and their impact on condom use and STI/HIV prevention for Filipina women and male customers

Nearly 30 million people have died of AIDS during the past 27 years. More than 90% of people with HIV live in the developing world. The virus does not discriminate by age, race, gender, ethnicity, sexual orientation, or socioeconomic status-anyone is susceptible. HIV/AIDS has been particularly devastating on women and girls who now comprise more than 50% of people aged 15 years and older living with HIV. Successful strategies with significant impact on new HIV infections include strong governmental support, voluntary counseling and treatment, harm-reduction, community outreach, and universal access to treatment. This study presents the results of educational and social structural/environmental behavioral interventions among young women and their male partners. A 10-year study among high-risk populations (female bar workers and their male customers) in the Philippines identifies major components of a model HIV prevention program.

Decreases in community viral load are accompanied by reductions in new HIV infections in San Francisco

Background

At the individual level, higher HIV viral load predicts sexual transmission risk. We evaluated San Francisco's community viral load (CVL) as a population level marker of HIV transmission risk. We hypothesized that the decrease in CVL in San Francisco from 2004–2008, corresponding with increased rates of HIV testing, antiretroviral therapy (ART) coverage and effectiveness, and population-level virologic suppression, would be associated with a reduction in new HIV infections.

Methodology/Principal Findings

We used San Francisco's HIV/AIDS surveillance system to examine the trends in CVL. Mean CVL was calculated as the mean of the most recent viral load of all reported HIV-positive individuals in a particular community. Total CVL was defined as the sum of the most recent viral loads of all HIV-positive individuals in a particular community. We used Poisson models with robust standard errors to assess the relationships between the mean and total CVL and the primary outcome: annual numbers of newly diagnosed HIV cases. Both mean and total CVL decreased from 2004–2008 and were accompanied by decreases in new HIV diagnoses from 798 (2004) to 434 (2008). The mean (p = 0.003) and total CVL (p = 0.002) were significantly associated with new HIV cases from 2004–2008.

Conclusions/Significance

Reductions in CVL are associated with decreased HIV infections. Results suggest that wide-scale ART could reduce HIV transmission at the population level. Because CVL is temporally upstream of new HIV infections, jurisdictions should consider adding CVL to routine HIV surveillance to track the epidemic, allocate resources, and to evaluate the effectiveness of HIV prevention and treatment efforts.