Treatment to Prevent HIV Transmission in Serodiscordant Couples in Henan, China, 2006 to 2012

HIV transmission and associated factors under the scale-up of HIV antiretroviral therapy: a population-based longitudinal molecular network study

OBJECTIVES

To evaluate the prevention efficacy of scaling up HIV/AIDS antiretroviral therapy (ART) on HIV transmission at the population level and determine associated factors of HIV secondary transmission.

METHODS

We used HIV longitudinal molecular networks to assess the genetic linkage between baseline and newly diagnosed cases. A generalized estimating equation was applied to determine the associations between demographic, clinical characteristics and HIV transmission.

RESULTS

Patients on ART had a 32% lower risk of HIV transmission than those not on ART. A 36% reduction in risk was also seen if ART-patients maintained their HIV viral load lower than 50 copies/mL. A 71% lower risk occurred when patients sustained ART for at least 3 years and kept HIV viral load less than 50 copies/mL. Patients who discontinued ART had a similar HIV transmission risk as those not on ART. Patients who were older, male, non-Han, not single, retired, infected via a heterosexual route of transmission and those who possessed higher CD4 counts had a higher risk of HIV transmission. HIV-1 subtype of CRF01_AE was less transmissible than other subtypes.

CONCLUSIONS

The efficacy of ART in a real-world setting was supported by this longitudinal molecular network study. Promoting adherence to ART is crucial to reduce HIV transmission.

Association of HCV Prior Infection and Unprotected Sex on Subsequent HIV Acquisition Risk in the Era of Treatment as Prevention

Backgrounds

Little was known about the impact of HCV prior infection on HIV transmission and acquisition. We aimed to explore whether HCV prior infection and its interactions with unprotected sex affected HIV acquisition.

Methods

This study was conducted among HIV heterosexual serodiscordant couples whose index cases were receiving treatment during 2008–2014 in Zhumadian. At baseline, we collected information on demographics and medical history of ART use, CD4 count, and HIV viral load for index partners, and also HIV and HCV status for non-index partners. For each year's visit, we followed up on sexual behaviors among couples in the recent year and HIV seroconversion of non-index partners. Analyses of the Cox model and synergistic interaction were performed.

Results

We identified 81 HIV seroconversions over 18,370.39 person-years, with the overall HIV seroconversion rate of 0.44 per 100 person-years. Couples, whose index cases were aged 50 years and above, had a baseline viral load >400 copies per ml and no AIDS-defining illness, and newly-initiated ART in the study period had a higher risk of HIV seroconversion. Unprotected sex and HCV prior infection showed a synergistic association with HIV acquisition risk (RERI = 3.65, SI = 0.48, AP = 2.24).

Conclusion

Unprotected sex and HCV infection were independent risk factors associated with HIV acquisition. The coexistence of them might have a synergistic effect on the risk which needs further research.

Time to Antiretroviral Therapy Initiation and Its Predictors Among Newly Diagnosed HIV-Positive People in Nekemte Town, Western Ethiopia: Claim of Universal Test and Treat

Background

HIV continuum of care demands early ART initiation for all HIV-infected individuals. Early ART initiation reduces onward HIV transmission facilitating rapid viral suppression. Despite this, delayed ART use is a challenge among newly diagnosed HIV-positive individuals, and there is limited evidence on time to ART initiation among this group in Ethiopia. Thus, this study aimed to assess time to ART initiation and its predictors among newly diagnosed HIV-positive individuals in Nekemte town, Western Ethiopia.

Methods

An institution-based retrospective follow-up study was conducted on 518 newly diagnosed HIV-positive people from September 5, 2016 to December 20, 2020 at Nekemte town, Western Ethiopia. Data were collected from ART intake forms, registration log books and patient charts. The collected data were entered into Epi Data version 3.1 and STATA version 14.0 was used for analysis. Survival probability was checked graphically by Kaplan–Meier curve and statistically by Log rank test. Both bivariable and multivariable Cox Proportional hazards regression models were conducted to identify the predictors of ART initiation. Hazard ratio with 95% CI and p-value of <0.05 was used to declare a statistical significance.

Results

By the end of the follow-up, 371 (71.6%) individuals had initiated ART with an overall incidence rate of 51.9 per 1000 [95% CI: 54.07–66.32] person days; median time to ART initiation was 4 [IQR: 1–9] days. Being female (AHR = 1.33, 95% CI: 1.06–1.67), urban dwellers (AHR = 2.02, 95% CI: 1.37–2.97), having baseline OIs (AHR = 1.62, 95% CI: 1.60–4.30); being tested via VCT (AHR = 1.33, 95% CI: 1.02–1.74); linked from OPD (AHR = 0.64, 95% CI: 0.47–0.85); disclosing HIV sero-status (AHR = 2.07, 95% CI: 1.17–3.68); and college and above education level (AHR = 1.43, 95% CI: 1.00–2.0) were identified as significant predictors of early initiation of ART.

Conclusion

The proportion and incidence of ART initiation was high; a short median time to ART initiation was revealed in this study. Strictly screening OIs, encouraging HIV sero-status disclosure and voluntary HIV testing are recommended to increase early ART initiation.

Health economics modeling of antiretroviral interventions amongst HIV serodiscordant couples

Antiretroviral treatment (ART) and pre-exposure prophylaxis (PrEP) for HIV-serodiscordant couples, effectively reduce mortality, transmission events and influence quality of life at the expense of increased costs. We aimed to evaluate health economics of antiretroviral-based strategies for HIV-serodiscordant couples in the China context. A deterministic model of HIV evolution and transmission within a cohort of serodiscordant couples was parameterized using the real-world database of Zhoukou city and published literature. We evaluated the mid-ART (a historical strategy, initiating ART with CD4 < 500 cells/mm³), early-ART (the current strategy, offering ART regardless of CD4 cell counts) and a hypothetical strategy (early-ART combined short-term daily PrEP) versus the late-ART (the baseline strategy, initiating ART with CD4 < 350 cells/mm³) offered by 2008 national guidelines. We estimated the incremental cost-effectiveness ratios (ICER) and incremental cost-utility ratios (ICUR) from a societal perspective, derived by clinical benefits and HIV-caused life quality respectively, and portrayed their changes over a 0-30 year's timeframe. The model projections indicated that the antiretroviral-based interventions were more likely to obtain clinical benefits but difficult to improve quality of life, and cumulative ICER and ICUR were generally decreasing without achieving cost-saving. Scale-up access to ART for the HIV-positive among serodiscordant couples was easily fallen within the range of paying for incremental life-years and quality adjusted life years by the societal willingness. The hypothetical strategy had the potential to prevent most seroconversion events within marriages but required enormous upfront costs, thus it took a long time to reach established thresholds. The current strategy of early-ART is the most cost-effective. Clarifying the obstacles of high cost of PrEP and improving life quality for HIV-serodiscordant couples have emerged as an urgent requisition.

Antiretroviral Therapy Use and HIV Transmission Among Discordant Couples in Nonresearch Settings in Kigali, Rwanda

BACKGROUND

Antiretroviral therapy (ART) efficacy for HIV prevention among discordant couples has been demonstrated in clinical trials. Effectiveness outside of research settings is less well understood.

METHODS

HIV-discordant couples were enrolled in couples' testing and follow-up at 20 government clinics in Kigali from 2010 to 2014. We performed viral linkage analysis on seroconverting couples to determine infection sources (intracouple vs. extracouple). Antiretroviral therapy use in index partners was collected at baseline and during follow-up by self-report with verification of government medical records.

RESULTS

A total of 3777 HIV-discordant couples were identified and followed up at government health clinics. Fifty-four incident HIV infections were identified, of which 36 were confirmed linked to the index partner, 4 were unlinked, and 14 were unknown. Among the 50 linked or unknown transmission pairs, 38% occurred among couples in which the index partner was on ART (HIV incidence rate of 0.63/100 person-years), whereas 62% occurred among couples in which the index partner was not on ART (HIV incidence rate of 5.51/100 person-years; adjusted rate ratio, 6.9). HIV acquisition was higher in women than in men with non-ART using index partners (P < 0.001).

CONCLUSIONS

Couples in a government clinic couples' HIV testing and follow-up program in Rwanda had an 89% reduction in HIV incidence when index partners were using ART, slightly lower than efficacy estimates from randomized trials. Antiretroviral therapy for prevention should be prioritized for key populations including discordant couples identified via couples' voluntary counseling and testing, with increased efforts to improve uptake, adherence, and viral load monitoring.

Using longitudinal genetic-network study to understand HIV treatment-as-prevention

OBJECTIVE

The WHO has recommended that antiretroviral therapy be provided to all HIV patients to reduce future HIV transmission rates. However, few studies have examined this public health strategy at the population level in a real-world setting.

METHODS

In this longitudinal genetic-network study in Guangxi, China, the baseline and follow-up data were collected from HIV patients in 2014 and newly diagnosed HIV patients from 2015 to 2018, respectively. The prevention efficacy was used to estimate the effect of treatment-as-prevention in reducing HIV secondary transmission.

RESULTS

Among 804 newly diagnosed HIV patients during 2015-2018, 399 (49.6%) of them genetically linked to HIV patients at baseline during 2014-2017. The overall proportion of genetic linkage between newly diagnosed HIV patients during 2015-2018 with untreated and treated HIV patients at baseline during 2014-2017 was 6.2 and 2.9%, respectively. The prevention efficacy in HIV transmission for treated HIV patients was 53.6% [95% confidence interval (95% CI): 42.1-65.1]. Subgroup analyses indicated an 80.3% (95% CI: 74.8-85.8) reduction in HIV transmission among HIV patients who were treated for 4 years or more and had viral loads less than 50 copies/ml. There was no significant reduction in HIV transmission among treated HIV patients who dropped out or who had missing viral load measures.

CONCLUSION

Our study results support the feasibility of treating all HIV patients for future reductions in HIV transmission at the population level in real-world settings. Comprehensive intervention prevention programmes are urgently needed.

High Perceived Stigma Among People Living with HIV/AIDS in a Resource Limited Setting in Western Ethiopia: The Effect of Depression and Low Social Support

Background

Antiretroviral therapy (ART) is only one part of a successful range of care among people living with HIV/AIDS (PLWHA). Stigma and low social support are emerging issues worsening the success of ART for PLWHA. This study thus aimed to investigate the level of perceived stigma among PLWHA.

Methods

An institution-based cross-sectional study was conducted in Nekemte, western Ethiopia. A multivariable logistic regression model was used to identify associations between perceived stigma and low social support, depression, and other potential predictor variables using SPSS version 24.0 and adjusted odds ratios (AORs), considering statistical significance at p<0.05.

Results

A total of 418 study participants were included in the study, with a response rate of 100%. About 48.6% of PLWHA had experienced perceived stigma, and more than two-fifths had poor social support. The following factors were associated with perceived stigma among PLWHA: age (18-29 years) (AOR=4.88, 95% CI:1.76-13.5), female sex (AOR=2.10, 95% CI 1.15-3.82), <12 months on ART (AOR=2.63, 95% CI 1.09-6.34), depression (AOR=1.86, 95% CI 1.08-3.19), social support (poor: AOR=3.45, 95% CI 1.65-7.23; medium: AOR=2.22, 95% CI 1.09-4.54), and non-disclosure of HIV status (AOR=2.00, 95% CI 1.11-3.59).

Conclusion and Recommendation

The magnitude of perceived stigma among PLWHA was high, highlighting the importance of integrating social and mental health support within standard ART for PLWHA.

Rate of HIV Seroconversion Among Seronegative Male Partners Living with HIV Positive Women in Addis Ababa, Ethiopia, 2019: A Retrospective Cohort Study

Objective

This study aimed to assess rate of HIV seroconversion and predictors among seronegative male partners living with HIV-positive women in Addis Ababa, Ethiopia, 2019.

Methods

Institutional-based retrospective cohort was used to conduct the study. All eligible 227 sample medical records were used for the study. Kaplan–Meier analysis was used to estimate seroconversion time. Cox proportional-hazard regression was used to identify predictor variables.

Results

In this study, 227 seronegative male partners living with HIV-positive women were followed for 60 months retrospectively and 38 (16.7%) seroconversion was observed. The overall seroconversion rate was 6.4 (95%CI: 4.64–8.76) per 100 person-year observation. Time of antiretroviral therapy (ART) initiation, CD4 level, condom use, and having history of pregnancy after being diagnosed as discordant were identified significant predictors of seroconversion.

Conclusion

The risk of HIV transmission from seropositive partner to seronegative partner in a discordant couple is poorly controlled. Seronegative partners in discordant a couple can be seropositive at any time with influence of predictors unless proper protective measures, counseling, and follow-up are given emphasis.

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.

Secular trends in HIV/AIDS mortality in China from 1990 to 2016: Gender disparities

OBJECTIVES

HIV/AIDS has become the leading cause of death by infectious disease in China since 2009. However, the trend of gender disparities in HIV/AIDS has not been reported in China since 1990. Our study aimed to explore the secular trend of HIV/AIDS mortality in China from 1990 to 2016 and to identify its gender disparities over the past 27 years.

METHOD

The mortality data of HIV/AIDS were obtained from the Global Burden of Disease Study 2016 (GBD 2016). Logistic regression was used to estimate the prevalence odds ratio (POR) of gender for HIV/AIDS mortality in different surveys.

RESULTS

The standardized mortality of HIV/AIDS in China rose dramatically from 0.33 per 100,000 people in 1990 to 2.50 per 100,000 people in 2016. The rate of HIV/AIDS mortality increased more quickly in men than in women, and the sex gap of mortality of HIV/AIDS widened. By 2016, the HIV/AIDS mortality in men was 3 times that in women and was 5.74 times that in women within the 75- to 79-year-old age group.

CONCLUSIONS

The mortality of HIV/AIDS in China is increasing, with a widening gender disparity. It is critical for policymakers to develop policies to eliminate these disparities and to ensure that everyone can live a long life in full health.

Viral Kinetics in Semen With Different Antiretroviral Families in Treatment-Naive Human Immunodeficiency Virus-Infected Patients: A Randomized Trial

Background

There are several regimens for starting antiretroviral treatment, but it remains unknown whether either of them is more advantageous regarding the time course and magnitude of human immunodeficiency virus (HIV) RNA decay in semen.

Objective

To evaluate the differential effect of different antiretroviral drug families on viral kinetics in seminal plasma (SP) of treatment-naive HIV-infected patients.

Methods

Phase II, randomized, open-label study in which participants were randomized 1:1:1 to receive tenofovir-disoproxil fumarate (DF) plus emtricitabine, and either cobicistat-boosted elvitegravir (EVGcobi), rilpivirine (RPV), or ritonavir-boosted darunavir (DRVrtv). The primary endpoint was the proportion of participants with undetectable HIV-RNA in SP at week 12. HIV type 1 (HIV-1) RNA was measured in paired SP and blood plasma (BP) at baseline and after 1, 2, 4, 6, 8, 12, 18, and 24 weeks. Elvitegravir (EVG), RPV, and darunavir (DRV) concentrations were quantified by the liquid chromatography-tandem mass spectrometry method.

Results

In SP, the HIV-RNA decay rate with RPV was as fast as with EVGcobi; by week 12, all participants in the RPV and the EVGcobi groups reached an undetectable viral load but only 58.3% in the DRVrtv arm (P = .003). The highest SP/BP drug concentration ratio was for EVG (0.43), followed-up by RPV (0.19), and DRV (0.10). For both EVG and RPV, the SP concentrations exceeded >2-fold the protein binding-adjusted EC90 for wild-type HIV-1; for DRV, only 33.7% of the SP showed concentrations above the protein binding-adjusted EC90.

Conclusions

In SP, both RPV and EVGcobi, associated to tenofovir-DF and emtricitabine, behave similarly and achieve an undetectable viral load much faster than DRVrtv.

Registration

European Medical Agency (No. EudraCT: 2014-001348-39).

Impact of early antiretroviral therapy eligibility on HIV acquisition: household-level evidence from rural South Africa

Objectives:

We investigate the effect of immediate antiretroviral therapy (ART) eligibility on HIV incidence among HIV-uninfected household members.

Design:

Regression discontinuity study arising from a population-based cohort.

Methods:

Household members of patients seeking care at the Hlabisa HIV Treatment and Care Programme in rural KwaZulu-Natal South Africa between January 2007 and August 2011 with CD4⁺ cell counts up to 350 cells/μl were eligible for inclusion if they had at least two HIV tests and were HIV-uninfected at the time the index patient linked to care (N = 4115). Regression discontinuity was used to assess the intention-to-treat effect of immediate versus delayed ART eligibility on HIV incidence among household members. Exploiting the CD4⁺ cell count-based threshold rule for ART initiation (CD4⁺ < 200 cells/μl until August 2011), we used Cox proportional hazards models to compare outcomes for household members of patients who presented for care with CD4⁺ cell counts just above versus just below the ART initiation threshold.

Results:

Characteristics of household members of index patients initiating HIV care were balanced between those with an index patient immediately eligible for ART (N = 2489) versus delayed for ART (N = 1626). There were 337 incident HIV infections among household members, corresponding to an HIV incidence of 2.4 infections per 100 person-years (95% confidence interval 2.5–3.1). Immediate eligibility for treatment reduced HIV incidence in households by 47% in our optimal estimate (hazard ratio = 0.53, 95% confidence interval 0.30–0.96), and by 32–60% in alternate specifications of the model.

Conclusion:

Immediate eligibility of ART led to substantial reductions in household-level HIV incidence.

Prevention of Sexually Transmitted Diseases in HIV-Infected Individuals

Prevention of sexually transmitted infections (STIs) is an important part of the care of the HIV-infected individual. STIs have been associated with increased risk of transmission and acquisition of HIV. Among HIV-infected persons, treatment failures and high recurrence rates of some STIs are more common. Despite the recognized importance of prevention and discussion of sexual health, rates of screening for STIs are suboptimal. Moreover, rates of STIs such as syphilis continue to increase particularly in men who have sex with men (MSM). This review focuses on the most common STIs seen among HIV-infected individuals and recommendations for screening and prevention.

Effects of patient load and travel distance on HIV transmission in rural China: Implications for treatment as prevention

BACKGROUND

Sustained viral suppression through ART reduces sexual HIV transmission risk, but may require routine access to reliable and effective medical care which may be difficult to obtain in resource constrained areas. We investigated the roles of patient load and travel distance to HIV care clinic on transmission risk in HIV serodiscordant couples in Henan Province, China.

METHODS

Cox proportional hazard models were used to compare HIV transmission events across couples living near, medium, or farther distances from their assigned HIV care clinics, as well as those attending clinics where clinicians bore high versus low patient loads.

RESULTS

Most (84·4%) of the 3695 serodiscordant couples lived within 10 kilometers of their assigned HIV clinic, and most (73·5%) attended clinics with patient-to-provider ratios of at least 100:1. In adjusted Cox models, attending clinics where clinicians bore average patient loads of 100 or more elevated HIV transmission risk (aHR, 1·50, 95% CI, 1·00-4·84), an effect amplified in village tier clinics (aHR = 1·55; 95% CI, 1·23-6·78). Travel distance was associated with HIV transmission only after stratification; traveling medium distances to village clinics (5-10km) increased transmission risk (aHR = 1·83, 95% CI, 1·04-3·21) whereas traveling longer distances to township or county level clinics lowered transmission risk (aHR = 0·10, 95% CI, 0·01-0·75).

CONCLUSION

Higher patient loads at HIV clinics was associated with risk of HIV transmission in our population, particularly at village level clinics. Farther travel distance had divergent effects based on clinic tier, suggesting unique mechanisms operating across levels of resource availability. The resource intensity of long-term HIV treatment may place significant strains on small rural clinics, for which investments in additional support staff or time-saving tools such as point-of-care laboratory testing may bring about impactful change in treatment outcomes.

Outcome of Sentinel Hospital-based and CDC-based ART Service Delivery: A Prospective Open Cohort of People Living with HIV in China

The primary objective of this study was to obtain insights into the outcomes of people living with HIV who accessed services through HIV/AIDS sentinel hospital-based and ART service delivery in China. Post-hoc analyses of an open cohort from an observational database of 22 qualified HIV/AIDS sentinel hospital-based and two CDC-based drug delivery facilities (DDFs) in Guangdong Province was completed. Linkage to care, mortality and survival rates were calculated according to WHO criteria. 12,966 individuals received ART from HIV/AIDS sentinel hospitals and 1,919 from DDFs, with linkage to care rates of 80.7% and 79.9%, respectively (P > 0.05). Retention rates were 94.1% and 84.0% in sentinel hospitals and DDFs, respectively (P < 0.01). Excess mortality was 1.4 deaths/100 person-years (95% CI: 1.1, 1.8) in DDFs compared to 0.4 deaths/100 person-years (95% CI: 0.3, 0.5) in hospitals (P < 0.01). A Cox-regression analysis revealed that mortality was much higher in patients receiving ART from the DDFs than sentinel hospitals, with an adjusted HR of 3.3 (95% CI: 2.3, 4.6). A crude HR of treatment termination in DDFs was 7.5 fold higher (95% CI: 6.3, 9.0) compared to sentinel hospitals. HIV/AIDS sentinel hospital had better retention, and substantially lower mortality compared to DDFs.

Molecular linkage tracing of HIV-1 transmission events in seroconcordant couples in Guangxi Province, Southeastern China

Background

Guangxi Province in Southeastern China has one of the highest HIV-1 infection and transmission rates in stable couples. However, the mode of transmission at the molecular level has seldom been reported amongst this group. It is important to investigate this issue to support the treatment-as-prevention approach and for efficient interventions.

Methods

HIV-1 subgenomic regions (1.2 kb of pol and a 660-bp env C2V5 fragment) were sequenced in 42 couples. A couple linkage assessment was performed by phylogenetic analysis of sequences and Bayesian analysis of genetic distances. A subset of pairs was selected for single-genome amplification.

Results

Thirty-five pairs (83.3 %, 35/42) were identified as linked, 3 pairs (7.1 %, 3/42) were identified as indeterminate, and 4 pairs (9.5 %) were identified as unlinked. The predominant intra-couple-transmitted HIV-1 subtype was CRF01_AE (80 %, 28/35). The median genetic distance of linked couples was 0.5 %.

Conclusion

The majority of HIV-1 transmission events in this study occurred within the partnership, and the predominant HIV-1 subtype was CRF01_AE. Further research on the mode of HIV transmission in other locations is needed.

Electronic supplementary material

The online version of this article (doi:10.1186/s40064-016-3578-2) contains supplementary material, which is available to authorized users.

Clinical challenges in HIV/AIDS: Hints for advancing prevention and patient management strategies

Acquired immune deficiency syndrome has been one of the most devastating epidemics of the last century. The current estimate for people living with the HIV is 36.9 million. Today, despite availability of potent and safe drugs for effective treatment, lifelong therapy is required for preventing HIV re-emergence from a pool of latently infected cells. However, recent evidence show the importance to expand HIV testing, to offer antiretroviral treatment to all infected individuals, and to ensure retention through all the cascade of care. In addition, circumcision, pre-exposure prophylaxis, and other biomedical tools are now available for included in a comprehensive preventive package. Use of all the available tools might allow cutting the HIV transmission in 2030. In this article, we review the status of the epidemic, the latest advances in prevention and treatment, the concept of treatment as prevention and the challenges and opportunities for the HIV cure agenda.