Quality assurance in the HIV/AIDS laboratory network of China

Anonymous Linkage Between College Students and Human Immunodeficiency Virus (HIV) Facilities: Systematic Evaluation of Urine Self-Collection for HIV Testing Initiative in China

BACKGROUND

Identifying young individuals living with human immunodeficiency virus (HIV) who are unaware of their status is a major challenge for HIV control in China. To address this, an innovative, anonymous vending machine-based urine self-collection for HIV testing (USCT) program was implemented in 2016 in colleges across China.

METHODS

From June 2016 to December 2019, 146 vending machines stocked with urine self-collection kits were distributed on 73 college campuses across 11 provinces of China. Urine samples were collected, delivered, and tested in an anonymous manner. We analyzed the returned rate, reactive rate (likelihood of HIV screening positive), testing effectiveness (the annual number of college students living with HIV screened by USCT or other testing methods), and the spatiotemporal relationship between USCT usage and student activity per college generated from the usage of a social networking application.

RESULTS

Among the 5178 kits sold, 3109 (60%) samples were returned; of these, 2933 (94%) were eligible for testing. The HIV reactive rate was 2.3% (66 of 2933). The average effectiveness ratio among the 34 participating Beijing colleges was 0.39 (12:31) between USCT and conventional testing methods. A strong spatiotemporal correlation between USCT numbers and online student activity was observed during school semesters in Beijing.

CONCLUSIONS

USCT is a powerful complement to current interventions that target at-risk students and promote HIV testing. The social networking-based evaluation framework can be a guide in prioritizing at-risk target populations.

Shift in HIV/AIDS Epidemic and Factors Associated with False Positives for HIV Testing: A Retrospective Study from 2013 to 2018 in Xi'an, China

BACKGROUND

In China, although quite a few bold programmes have been made for HIV/AIDS, the epidemic has still shown an increasing trend.

OBJECTIVES

The study was aimed to investigate the characteristics of new HIV/AIDS and the major factors of false positives (FP) for HIV testing.

METHODS

A retrospective review was performed in a teaching hospital in Xi'an between 2013 and 2018. The overall characteristics and trends of new HIV/AIDS were described. Moreover, the major factors of FP were determined by the Pareto analysis.

RESULTS

A total of 469 new HIV/AIDS were diagnosed, with an increasing prevalence of the new HIV/AIDS from 0.0626% (41/65503) in 2013 to 0.0827% (115/139046) in 2018. Of them, the majority occurred in the males (88.50%), people aged 21-50 years (76.97%), migrants (60.98%), and sexual contact route (88.70%). There was a rapid increase in the annual number of new HIV/AIDS and increasing trends in groups of young individuals, students, and homosexual mode; however, a downward trend in the percentage of injecting drug use was also observed. Over 50 years old and patients from oncology, obstetrics, hepatobiliary surgery, nephrology, cardiology, and infectious disease constituted the major factors of FP.

CONCLUSION

The HIV/AIDS epidemic in Xi'an is still evolving, therefore, effective strategies, appropriate education and scaling up HIV testing should be developed. In addition, old adults and specific departments were associated with FP.

Performance of HIV detection in Zhejiang province in China: The Pareto principle at work

Background

Timely detection of HIV infection is critical for curbing the AIDS epidemic, and building an extensive and effective HIV laboratory network is of great importance. Therefore, improving quality management of the laboratory network and optimizing detection strategies are desirable research issues.

Methods

We assessed the applicability of the Pareto principle to HIV detection performance. We conducted a retrospective review of basic information and numbers of screening tests among an HIV laboratory network (1,452 laboratories) in Zhejiang province in 2014 and statistically analyzed HIV testing data for different population categories.

Results

Approximately, 80% of the cumulative HIV screening tests and positive screening tests originated from 17.3% (251/1,452) and 11.7% (170/1,452) of the laboratories in the whole province, respectively, and similar patterns were observed at the prefectural level. We found that the top five population screening categories (25%, 5/20) had the highest contribution (approximately 80%) to not only the number of screening tests (77.2%) but also the numbers of positive (76.4%) and confirmed positive tests (81.5%).

Conclusions

The Pareto principle provides a method for identifying noteworthy laboratories to deliver prior quality supervision and developing highly efficient screening strategies that best suit local needs.

External Quality Assessment on CD4+ T-Cell Count Using in-House Proficiency Testing Panels for CD4 Count Laboratories in Addis Ababa, Ethiopia

Background

CD4+ T-cell count External Quality Assessment program is important for the evaluation of performance of CD4 count laboratories. The aim of this study was to assess the quality of CD4count laboratory performance using in-house Proficiency testing panels that perform routine CD4 counts in Addis Ababa, Ethiopia, 2013/14.

Methods

Participating laboratories were 20, 23 and 25 in trials 1, 2 and 3, respectively. In-house prepared fresh whole blood samples both with “normal” and “low” CD4 values were sent to participating laboratories. Percentage and absolute counts of CD4+ T-lymphocytes were done using their routine procedures. Data were analyzed for each trial including trimmed mean, standard deviation (SD), percent coefficient of variation (%CV), residual, and standard deviation index (SDI) values for both absolute counts and percentages of CD4+ lymphocytes (%CD4).

Results

Most participating laboratories produced results that were within 2SD of the mean. Average inter-laboratory precision (trimmed %CV) was 10.87% and 5.14% for CD4 absolute counts and %CD4, respectively. For normal material, the trimmed mean %CV was 9.59% and3.23% for CD4 absolute counts and %CD4, respectively. For low material, the trimmed mean % CV was 12.15% and 7.05% for CD4 absolute counts and %CD4 respectively. BDFACSCount™ users showed the best accuracy and precision as evidenced by longitudinal analysis.

Conclusion

This study was found to help facilities in early identifying their gaps with regard to their CD4 count performance and in avoiding the challenges encountered during participation in external EQA providers like the high cost, transportation problem, feedback delay and CD4laboratory coverage.

The US CDC Global AIDS Program in China

The China-US Cooperation-Global AIDS Program (GAP) was a strategic technical collaboration program jointly implemented by the US Centers for Disease Control and Prevention and the Chinese Center for Disease Control and Prevention. This program developed, piloted, launched, and evaluated a broad range of projects supporting national and local HIV prevention and control programs; evidence-based decision-making; strengthening systems and capacity at national, provincial, and local levels; prioritizing high-risk geographic areas and populations; developing innovative approaches for scale-up; answering important scientific questions that can be most effectively answered in China but also with global implications for the HIV response; and increasing China’s engagement with the global public health community and sharing critical lessons learned. A productive working relationship with well-conceived models, a results-based activity implementation plan, and proper linkage to the domestic policy process has made a significant contribution to HIV control and prevention in China.

Interventions to improve the HIV continuum of care in China

PURPOSE OF REVIEW

To describe HIV epidemic and interventions for improving HIV continuum of care in China.

RECENT FINDINGS

The reported HIV epidemic has been continuously increasing, partially due to the expansion of active HIV testing campaign. Public health intervention programs have been effective in containing HIV spread among former plasma donors and people who inject drugs (PWID), but more infections occur among heterosexual men and women and young men who have sex with men. Of 1.25 million Chinese people are living with HIV, one-third do not know their status. About two-thirds of diagnosed individuals have used antiretroviral therapy (ART) and two-thirds of those on ART have achieved viral suppression, but some risk groups such as PWID have lower rates. The national free ART program has reduced adult and pediatric mortality and reduced heterosexual transmission. China faces great challenges to reduce HIV sexual transmission, improve the HIV continuum of care, and close the gaps to the UNAIDS Three "90" Targets.

"Late for testing, early for antiretroviral therapy, less likely to die": results from a large HIV cohort study in China, 2006-2014

BACKGROUND

Timely HIV testing and initiation of antiretroviral therapy are two major determinants of survival for HIV-infected individuals. Our study aimed to explore the trend of late HIV/AIDS diagnoses and to assess the factors associated with these late diagnoses in China between 2006 and 2014.

METHODS

We used data from the Chinese Comprehensive Response Information Management System of HIV/AIDS (CRIMS). All individuals who tested positive for HIV between 2006 and 2014 in China and were at least 15 years of age were included. A late diagnosis was defined as an instance in which an individual was diagnosed as having AIDS or WHO stage 3 or 4 HIV/AIDS, or had a CD4 cell count less than 200 cells/mm³ at the time of diagnosis.

RESULTS

Among the 528,234 individuals (≥15 years old) newly diagnosed with HIV between 2006 and 2014, 179,700 (34.0%) people were considered to have received late diagnoses. The late diagnosis rate decreased from 33.9% in 2006 to 29.7% in 2014 (P < 0.01). Late diagnoses were more likely to be found among those who were 45-54 years old (adjusted odds ratio [aOR]: 3.25, 95% confidence interval [CI]: 3.17-3.34) or 55+ years old (OR: 2.94, 95% CI: 2.86-3.02), male (aOR: 1.15, 95% CI: 1.13,1.17), employed as a farmer or rural laborer (aOR: 1.13, 95% CI: 1.11-1.14), infected through blood or plasma transfusion (aOR: 4.18, 95% CI: 4.02, 4.35), diagnosed at hospitals (OR: 1.17, 95% CI: 1.15, 1.19), of Han ethnicity (aOR: 1.30, 95% CI: 1.28, 1.32), and married (OR: 1.12, 95% CI: 1.11,1.13). Of those people living with HIV (PLHIV) who received late diagnoses, 7.4%(8637) and 46.1%(28,462) ultimately died with or without receiving antiretroviral therapy within a year of diagnosis, respectively.

CONCLUSION

A large proportion of individuals with HIV/AIDS receive late diagnoses, and this proportion has witnessed a slight decline in recent years. Expanded testing is needed to increase early HIV diagnosis and antiretroviral therapy should be recommended to all diagnosed individuals as early as possible to reduce AIDS-related death.

An innovative HIV testing service using the internet: Anonymous urine delivery testing service at drugstores in Beijing, China

Innovative human immunodeficiency virus (HIV) testing services will be needed to achieve the first 90 (90% of HIV-positive persons aware of their infection status) of the 90-90-90 target in China. Here, we describe an internet-based urine delivery testing service delivered through three pilot drugstores in Beijing that send specimens to a designated laboratory for HIV. From May 2016 to January 2017, we provided 500 HIV urine-testing service packs for display at the drugstores, and a total of 430 (86.0%) urine specimens were mailed back. All of the 430 urine specimens were of good quality and were tested. 70 urine specimens were HIV positive, showing a 16.3% (70/430) positivity rate. A total of 94.3% (66/70) of the HIV-positive participants obtained their test results through the internet, and 69.7% (46/66) of these participants received follow-up care. A total of 40 out of 46 (87.0%) participants agreed to have their results confirmed by a blood test, and 39 out of 40 (97.5%) participants were confirmed as HIV-1 positive, including two individuals that were previously diagnosed. Lastly, 28 out of 37 (75.7%) of the study participants were referred to the hospital and provided free antiviral treatment. Our data indicate that this innovative HIV testing service is effective and play an important role in HIV testing and surveillance.

Predictors of HIV virological failure and drug resistance in Chinese patients after 48 months of antiretroviral treatment, 2008-2012: a prospective cohort study

OBJECTIVE

To explore factors associated with HIV virological failure (VF) and HIV drug resistance (HIVDR) among HIV-positive Chinese individuals 4 years after initiating first-line lamivudine-based antiretroviral treatment (ART) in 2008 at five sentinel sites.

DESIGN

First-line ART initiators who were previously treatment naïve were selected using consecutive ID numbers from the 2008 National Surveillance Database into a prospective cohort study. Questionnaires and blood samples were collected in 2011 and 2012 to assess the outcomes of interest: VF (defined as viral load ≥1000 copies/mL) and HIVDR (defined as VF with genetic drug-resistant mutations). Questionnaires and data from National Surveillance Database assessed demographics and drug adherence data.

RESULTS

536 individuals with HIV were analysed; the 4-year risk of VF was 63 (11.8%) and HIVDR was 27 (5.0%). Female participants initiating stavudine (D4T)-based regimens were more susceptible to both VF (adjusted OR (aOR)=2.5, 95% CI 1 to 6.1, p=0.04) and HIVDR (aOR=3.6, 95% CI 1 to 12.6, p=0.05) versus zidovudine-based regimens. Male participants missing doses in past month were more susceptible to both VF (aOR=2.8, 95% CI 1.1 to 7, p=0.03) and HIVDR (aOR=9.7, 95% CI 2.1 to 44.1, p<0.01). Participants of non-Han nationality were of increased risk for HIVDR (aOR from 4.8 to 12.2, p<0.05) and non-Han men were at increased risk for VF (aOR=2.9, 95% CI 1.1 to 7.3, p=0.02). All 27 participants detected with HIVDR had non-nucleoside reverse-transcriptase inhibitor mutations, 21 (77.8%) also had nucleoside reverse-transcriptase inhibitor mutations, and no protease inhibitor mutations were detected.

CONCLUSIONS

Our findings suggest successful treatment outcomes at 4 years for roughly 90% of patients. We suggest conducting further study on whether and when to change ART regimen for women initiated with D4T-based regimen, and reinforcing adherence counselling for men. Increased VF and HIVDR risk among non-Han minorities warrants further exploration, and ethnic minorities may be an important group to tailor adherence-focused interventions.

Dynamic changes in biomarkers in acute human immunodeficiency virus infections: a case report

Background

The highest incidence of human immunodeficiency virus infection in China is among men who have sex with men. This case report aims to describe the dynamic changes in biomarkers in an acute human immunodeficiency virus infection of a Han Chinese man who has sex with men, and to illustrate the possibility of using these biomarkers for the early detection of human immunodeficiency virus infection in Chinese hospital settings.

Case presentation

The 25-year-old Han Chinese male patient presented himself with an 8-day history of symptoms and signs of upper respiratory viral infections to a sexually transmitted infection clinic of a hospital setting in Shanghai. The viral load of human immunodeficiency virus, p24 antigen–antibody complex, and lymphocyte subsets of blood samples were repeatedly measured over the next 39 days. The human immunodeficiency virus from serum was genotyped. This patient was diagnosed as a human immunodeficiency virus infection, and the viral genotype was CRF 01_AE. The onset of the symptoms and signs was 12 days after his last reported unprotected intercourse with a human immunodeficiency virus -infected man. The patient had detectable levels of p24 antigen at his first visit, 20 days after infection, and the HIV viral load was at the highest point (8 × 10⁶ copies/ml). A low concentration of antibody to HIV was observed in the patient’s serum 10 days after his 1st visit (30 days after infection). The confirmation of human immunodeficiency virus infection by Western blot assays was made at day 20 after his 1st visit (40 days after infection).

Conclusions

Symptoms of acute human immunodeficiency virus infection are non-specific. Specific laboratory markers appear shortly after HIV infections. The first biomarker detected from serum is the viral RNA and p24 antigen, followed by HIV-specific antibody. The results suggest that there are urgent needs for both human immunodeficiency virus antigen and antibody testing in routine medical practice, and that human immunodeficiency virus RNA testing should be recommended to detect early infection. Ethics approval was obtained from the Ethics Board of the Shanghai Dermatology Hospital.

Accuracy in HIV Rapid Testing among Laboratory and Non-laboratory Personnel in Zambia: Observations from the National HIV Proficiency Testing System

Background

Despite rapid task-shifting and scale-up of HIV testing services in high HIV prevalence countries, studies evaluating accuracy remain limited. This study aimed to assess overall accuracy level and factors associated with accuracy in HIV rapid testing in Zambia.

Methods

Accuracy was investigated among rural and urban HIV testing sites participating in two annual national HIV proficiency testing (PT) exercises conducted in 2009 (n = 282 sites) and 2010 (n = 488 sites). Testers included lay counselors, nurses, laboratory personnel and others. PT panels of five dry tube specimens (DTS) were issued to testing sites by the national reference laboratory (NRL). Site accuracy level was assessed by comparison of reported results to the expected results. Non-parametric rank tests and multiple linear regression models were used to assess variation in accuracy between PT cycles and between tester groups, and to examine factors associated with accuracy respectively.

Results

Overall accuracy level was 93.1% (95% CI: 91.2–94.9) in 2009 and 96.9% (95% CI: 96.1–97.8) in 2010. Differences in accuracy were seen between the tester groups in 2009 with laboratory personnel being more accurate than non-laboratory personnel, while in 2010 no differences were seen. In both PT exercises, lay counselors and nurses had more difficulties interpreting results, with more occurrences of false-negative, false-positive and indeterminate results. Having received the standard HIV rapid testing training and adherence to the national HIV testing algorithm were positively associated with accuracy.

Conclusion

The study showed an improvement in tester group and overall accuracy from the first PT exercise to the next. Average number of incorrect test results per 1000 tests performed was reduced from 69 to 31. Further improvement is needed, however, and the national HIV proficiency testing system seems to be an important tool in this regard, which should be continued and needs to be urgently strengthened.

Building political will for HIV response: an operational model and strategy options

As global programs for HIV response look to transfer responsibility and financing increasingly to country governments, the political will to take on these responsibilities becomes increasingly prominent. However, defining and assessing political will are problematic; it involves intent and motivation, and thus is inherently difficult to observe. It is intimately connected to capacity and is contextually embedded. This article describes an operational model of political will comprised of seven components that are observable and measurable. Two case studies illustrate the application of the model and shed light on the interconnections among commitment, capacity and context: South Africa and China. Strategy options to build political will for HIV response identify possible actions for both government and civil society. Political will as a concept is most usefully viewed as integrated within larger political and bureaucratic processes, as a product of the complex array of incentives and disincentives that those processes create. However, this conclusion is not a recipe for discouragement or inaction. Agent-based conceptualizations of policy change offer a solid grounding for building political will that supports HIV policy and programs. Copyright © 2015 John Wiley & Sons, Ltd.

A retrospective cohort study on the mortality of AIDS patients in Guangxi, China (2001-2011)

The purpose of this article is to describe mortality trends in different highly active antiretroviral therapy (HAART) periods and associated factors among AIDS patients in Guangxi, China. We prospectively analyzed AIDS patients in Guangxi between 2001 and 2011; demographic characteristics were compared among AIDS patients diagnosed in three treatment periods (pre-HAART: 2001-2004, early-HAART: 2005-2008, and late-HAART: 2009-2011). AIDS mortality was calculated by person-years, and treatment coverage was defined as the proportion of time that patients who were eligible for treatment received treatment. Factors of AIDS mortality were determined by a Cox proportional hazard regression. Of 19,020 AIDS patients, overall mortality declined from 41.1 per 100 person-years in 2001 to 13.3 per 100 person-years in 2011 with treatment coverage increasing from zero to 72.1%. The overall median survival figure was 5.6 years (95% CI: 4.4-6.8) with 60.3% for 5-year survival rate. After AIDS diagnosis, the mortality rate peaked in the first year, and 37.4% patients were still active in the ninth year. Protective factors for mortality were AIDS patients diagnosed from 2009 to 2011 (AHR=0.75, 95% CI: 0.58-0.89), having received HAART (AHR=0.71, 95% CI: 0.50-0.87), and having a CD4 count of higher than 350 cells/μl at AIDS diagnosis (AHR=0.79, 95% CI: 0.60-0.92). Risk factors for mortality included being male (AHR=1.28, 95% CI: 1.07-1.43), living in a rural area (AHR=1.40, 95% CI: 1.18-1.94), and being aged ≥60 years at AIDS diagnosis (AHR=1.36, 95% CI: 1.18-1.73). A decline in AIDS mortality was observed in Guangxi with a concomitant increase in treatment coverage. Some subpopulations of AIDS patients, such as males, rural residents, and the old, require more medical care.

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.

Development of a proficiency testing program for the HIV-1 BED incidence assay in China

The HIV-1 BED incidence assay was adopted in China in 2005 for HIV-1 incidence surveillance. A proficiency testing (PT) program was established in 2006 to provide quality assurance services. The BED PT program consisted of two components, an international program provided by the U.S. Centers for Disease Control and Prevention from 2006 and a domestic program started by the National HIV/HCV Reference Laboratory in 2011. Each PT panel consisted of eight coded specimens distributed to participating laboratories semi-annually, and testing results were collected and analyzed. The number of participating laboratories increased progressively from 2006 to 2012. The Chinese HIV-1 incidence laboratory network performed satisfactorily both in international and domestic PT programs. We also demonstrated that the BED assay was highly reproducible among participating laboratories. Our success and lessons learned can be readily replicated in other countries or regions contemplating the establishment of a PT program for assay-based HIV incidence estimation.

Describing the Chinese HIV surveillance system and the influences of political structures and social stigma

China’s public health surveillance system for HIV was established in late 1980s and has evolved significantly during the past three decades. With the gradually changing mode of HIV transmission from sharing of intravenous injecting equipment to sexual exposure and the rapid spread of HIV infection among Chinese homosexual men in recent years, an efficient and comprehensive population-level surveillance system for describing epidemics trends and risk behaviours associated with HIV acquisition are essential for effective public health interventions for HIV. The current review describes the overall strength of the Chinese HIV surveillance system and its structural weaknesses from a political and social perspective. The HIV surveillance system in China has undergone substantial revamping leading to a comprehensive, timely and efficient reporting system. However, large data gaps and lack of quality control and sharing of information obstruct the full performance of the system. This is largely due to fragmented authoritarianism brought about by the underlying political structure. Social stigma and discrimination in health institutes are also key barriers for further improvements of HIV diagnosis and surveillance in China.

Predictors of HIV and syphilis among men who have sex with men in a Chinese metropolitan city: comparison of risks among students and non-students

Background

Men who have sex with men (MSM) are at a substantial risk of HIV, given rising HIV prevalence in urban China. Adolescent and adult students often take HIV-related risk as part of sexual exploration. We compared the risks of HIV and syphilis infections and risky sexual behaviors between student and non-student among urban MSM.

Methods

Respondent driven sampling approach was used to recruit men who were self-identified as MSM in Chongqing Metropolitan City in southwestern China in 2009. Each participant completed a computer-assisted self-interview which collected demographic and behavioral data, and provided blood specimens for HIV and syphilis testing. Multivariable logistic regression analyses identified predictors for HIV and syphilis infections while comparing student and non-student MSM.

Results

Among 503 MSM participants, 36.4% were students, of whom 84.2% were in college. The adjusted prevalence of HIV infection was 5.5% (95% confidence interval [CI]: 2.1%–10.2%) in students and 20.9% (95% CI: 13.7%–27.5%) in non-students; the adjusted prevalence of syphilis was 4.4% (95% CI: 0.7%–9.0%) in students and 7.9% (95% CI: 3.6%–12.9%) in non-students (P = 0.12). Two groups had similar risky sexual behaviors such as number of sexual partners and exchanging sex for money. Multivariate analysis showed that students had lower HIV prevalence than non-students (adjusted odds ratio [AOR]: 0.3; 95% CI: 0.1–0.8) adjusting for age, ethnicity and other variables.

Conclusion

Student MSM have lower HIV and similar syphilis prevalence compared with non-student MSM. However, due to a shorter duration of sexual experience and high prevalence of at-risk sexual behaviors among student MSM, HIV risk might be quite high in students as in non-students.

The integration of multiple HIV/AIDS projects into a coordinated national programme in China

External financial support from developed countries is a major resource for any developing country's national AIDS programme. The influence of donors on the content and implementation of these programmes is thus inevitable. China is a large developing country that has received considerable international support for its HIV/AIDS programme. In the early stage of the response, each large HIV/AIDS project independently implemented their activities according to their project framework. When internationally funded projects were few and the quantity of domestic support was minimal, their independent implementation did not pose a problem. When many HIV/AIDS projects were simultaneously implemented in the same locations, problems emerged such as inconsistency and overlap in data collection. China has thus coordinated and integrated all large international and domestic HIV/AIDS projects into one national programme. The process of integration began slowly and initially consisted of unified data collection. Integration is now complete and encompasses the processes of project planning, budgeting, implementation, monitoring and evaluation. The process was facilitated by having a single coordinating body, cooperation from international agencies and financial commitment from the government. Some problems were encountered during this process, such as initial reluctance from health-care staff to allocate additional time to coordinate projects. This paper describes that process of integrating domestic and foreign HIV/AIDS projects and may serve as a useful example for other developing countries for management of scarce resources.