Injecting drug use and HIV infection in southwest China

The Prevalence of HIV Infection in Minority Indigenous Populations of the South-East Asia and Western Pacific Regions: A Systematic Review and Meta-analysis

A random effects meta-analysis was used to estimate the pooled prevalence of HIV infection within minority indigenous populations of the South-East Asia (SEAR) and Western Pacific Regions (WPR). Sub-group analyses were conducted, and the sources of heterogeneity explored through meta-regression. The majority of studies were undertaken in high HIV risk subpopulations. There was a paucity of data for many countries with data from China representing 70% of the comparative studies. Within minority indigenous populations the pooled prevalence of HIV infection was 13.7% (95% CI 8.9, 19) and 8.4% (95% CI 6.3, 10.7) among other populations. The prevalence differential between populations was significant in the WPR (adjusted odds ratio 1.1, 95% CI 1.0, 1.2). Across both regions, in contrast to other populations, minority indigenous did not experience any significant reduction in HIV prevalence over the years of data collection. There was large heterogeneity in the prevalence of HIV across studies.

Spatiotemporal Patterns of CRF07_BC in China: A Population-Based Study of the HIV Strain With the Highest Infection Rates

The prevalence of CRF07_BC is 39.7% and has become the most infectious HIV strain in China. To study the transmission and diffusion trajectory of CRF07_BC in China and to prevent further expansion of its transmission. A total of 16,635 sequences of the CRF07_BC pol gene were collected from 1997-2020. We characterized the gene subtypes according to a phylogenetic tree analysis. A 0.50% molecular network was constructed to analyze the transmission relationship among different provinces for CRF07_BC and its two epidemic clusters. Spatial and temporal propagation characteristics were analyzed according to phylogeographic analysis. Finally, we evaluated the differences in transmission of CRF07_BC-O, and CRF07_BC-N. Our dataset included 8,816 sequences of CRF07_BC-N and 7,819 sequences of CRF07_BC-O. There were 7,132 CRF07_BC sequences in the molecular network, and the rate of clustered was 42.9%. Compared to CRF07_BC-O, CRF07_BC-N showed significantly (P<0.001) higher transmission-specific rates. CRF07_BC originated among injecting drug users (IDUs), and spread to men who have sex with men (MSMs) and heterosexual individuals (HETs), while MSMs also transmitted directly to HETs. CRF07_BC-O and CRF07_BC-N were prevalent in Xinjiang and Sichuan, respectively, before spreading interprovincially. In modern China, CRF07_BC-N occurs in five of the major economic zones. The CRF07_BC strain, which has contributed to the highest number of HIV infections in China, is divided into two epidemic clusters. Compared with CRF07_BC-O, risk of transmission is much greater in CRF07_BC-N, which is predominantly prevalent in economically developed provinces, and both MSMs and IDUs have transmitted this epidemic cluster to HETs. High-resolution, large-scale monitoring is a useful tool in assessing the trend and spread of the HIV epidemic. The rapidly developing economy of China requires an equally rapid response to the prevention and control of infectious diseases.

Using molecular transmission networks to understand the epidemic characteristics of HIV-1 CRF08_BC across China

HIV-1 CRF08_BC has become a major epidemic in heterosexuals and intravenous drug users (IDUs) in southern China. In order to evaluate the trends of its epidemic and facilitate targeted HIV prevention, we constructed the genetic transmission networks based on its pol sequences, derived from the National HIV Molecular Epidemiology Survey. Through retrospective network analysis, to study the epidemiological and demographic correlations with the transmission network. Of the 1,829 study subjects, 639 (34.9%) were clustered in 151 transmission networks. Factors associated with increased clustering include IDUs, heterosexual men, young adults and people with lower education (P < 0.05 for all). The IDUs, MSM, young adult and person with low education had more potential transmission links as well (P < 0.05 for all). The most crossover links were found between heterosexual women and IDUs, with 30.9% heterosexual women linked to IDUs. The crossover links heterosexual women were mainly those with middle age and single (P < 0.001). This study indicated that the HIV-1 CRF08_BC epidemic was still on going in China with more than one third of the infected people clustered in the transmission networks. Meanwhile, the study could help identify the active CRF08_BC spreader in the local community and greatly facilitate précising AIDS prevention with targeted intervention.

Consistency of spatial dynamics of HIV-1 and HCV among HIV-1/HCV coinfected drug users in China

BACKGROUND

As the transmission routes of human immunodeficiency virus type 1 (HIV-1) and hepatitis C virus (HCV) are similar, previous studies based on separate research on HIV-1 and HCV assumed a similar transmission pattern. However, few studies have focused on the possible correlation of the spatial dynamics of HIV-1 and HCV among HIV-1/HCV coinfected patients.

METHODS

A total of 310 HIV-1/HCV coinfected drug users were recruited in Yingjiang and Kaiyuan prefectures, Yunnan Province, China. HIV-1 env, p17, pol and HCV C/E2, NS5B fragments were amplified and sequenced from serum samples. The genetic characteristics and spatial dynamics of HIV-1 and HCV were explored by phylogenetic, bootscanning, and phylogeographic analyses.

RESULTS

Among HIV-1/HCV coinfected drug users, eight HCV subtypes (1a, 1b, 3a, 3b, 6a, 6n, 6v, and 6u) and two HIV-1 subtypes (subtype B and subtype C), three HIV-1 circulating recombinant forms (CRF01_AE, CRF07_BC and CRF08_BC), and four unique recombinant forms (URF_BC, URF_01B, URF_01C and URF_01BC) were identified. HCV subtype 3b was the most predominant subtype in both Yingjiang and Kaiyuan prefectures. The dominant circulating HIV-1 subtypes for drug users among the two areas were CRF08_BC and URF_BC. Maximum clade credibility trees revealed that both HIV-1 and HCV were transmitted from Yingjiang to Kaiyuan.

CONCLUSIONS

The spatial dynamics of HIV-1 and HCV among HIV-1/HCV coinfected drug users seem to have high consistency, providing theoretical evidence for the prevention of HIV-1 and HCV simultaneously.

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.

Prevalence of Different Genotypes of HIV-1 in Injection Drug Users in China: A Systematic Review and Meta-Analysis

BACKGROUND

Since 1981, an increasing trend in HIV has been observed for transmission via injection drug users (IDUs), sexual transmission and mother-to-child transmission. The IDUs are blamed for early increases in HIV-positive cases in China.

OBJECTIVE

HIV genotypes of IDUs were comprehensively analysed to trace the source and relationships of the AIDS epidemic in China.

METHODS

Relevant databases written in English and Chinese were searched. Overall, 7,149 publications were identified in six databases. After screening 7,104 articles according to the inclusion and exclusion criteria, 45 studies consisting of 2,765 cases were finally identified. A meta-analysis was conducted using R MATLAB software, RevMan and SPSS. Subgroup analyses focused on time frame, region, and location of different genotypes of IDUs in China.

RESULTS

There were five dominant HIV-1 genotypes among the 2,765 IDU cases. The proportions of CRF07_BC, CRF01_AE, CRF08_BC, subtype B/B', and subtype C were 45.18% (95% CI: 33.55-57.08%), 16.00% (95% CI: 9.39-23.82%), 13.43% (95% CI: 7.32-20.84%), 3.58% (95% CI: 1.52-6.24%), and 0.90% (95% CI: 0.04-2.43%), respectively. HIV genotypes transmitted among IDUs in China are primarily CRF07-BC, followed by CRF01-AE and CRF08-BC. Across the different time frames and regions, CRF07_BC was the most prevalent HIV-1 genotype among IDUs, while CRF08_BC was the most prevalent genotype in the southwest region.

CONCLUSION

Our study reveals that CRF07-BC was the dominant prevalent strain among IDUs from 1991 to 2015 in China, while CRF08-BC was the dominant prevalent strain among IDUs in southwestern China. This systematic review and meta-analysis shows evidence of the comprehensive prevalence of different genotypes, data and characteristics of HIV among IDUs in China.

Trend of HIV-1 drug resistance in China: A systematic review and meta-analysis of data accumulated over 17 years (2001-2017)

BACKGROUND

The emergence and spread of HIV-1 drug resistance may compromise HIV control globally. In response to HIV/AIDS epidemic, China launched national HIV/AIDS treatment program in 2003, and started to accumulate drug resistance data since 2001. In this study we aimed to assess the level, trend and distribution of HIV-1 drug resistance during a period of 17 years from 2001 to 2017, and to characterize crucial drug resistance mutations.

METHODS

We systematically reviewed 4737 studies published between January 1, 2001 and March 31, 2019 in PubMed, Embase, China National Knowledge Infrastructure (CNKI), WanFang Database, Web of Science, conference abstracts from the Chinese Medical Association and the Chinese AIDS Academic Conferences, and selected 170 studies that met our study criteria. To assess the prevalence of drug resistance in whole country or a local region, we performed pooled analyses of raw data. The transformed proportions were pooled using the inverse variance fixed effects methods or the DerSimonian-Laired random effects methods. The temporal trend of transmitted drug resistance (TDR) was determined using generalized additive model implemented in the Mgcv version 1.8 package. HIV-1 genotypic resistance was analyzed using the Stanford HIVdb algorithm.

FINDINGS

We assembled 218 datasets from 170 selected studies (129 in Chinese and 41 in English), covering 21,451 ART-naïve and 30,475 ART-treated individuals with HIV-1 infection. The pooled prevalence of TDR was 3.0% (95%CI: 2.8-3.2), including 0.7% (95%CI: 0.4-1.0), 1.4% (95%CI: 1.3-1.6) and 0.5% (95%CI: 0.4-0.6) for nucleoside reverse transcriptase inhibitor (NRTI), non-NRTI (NNRTI) and protease inhibitor (PI) resistance, respectively. The acquired drug resistance (ADR) prevalence was 44.7% (95%CI: 39.3-50.2), including 31.4% (95%CI: 28.2-34.6), 39.5% (95%CI: 35.6-43.5) and 1.0% (95%CI: 0.8-1.2) for NRTI, NNRTI and PI resistance, respectively. TDR and ADR prevalence had characteristic regional patterns. The worst prevalence of drug resistance occurred in Central China, and higher ADR prevalence occurred in South China than North China. TDR in whole country has risen since 2012, and this rise was driven mainly by NNRTI resistance. One NRTI-associated (M184V/I) and three NNRTI-associated (K103N/S, Y181C/I and G190A/S) mutations had high percentages in ART-naïve and ART-treated individuals, and these mutations conferred high-level resistance to 3TC, EFV and/or NVP.

INTERPRETATION

These findings suggest that the current available first-line ART regimens containing 3TC and/or EFV or NVP need to be revised. In addition, scale-up of multiple viral load measurements per year and drug resistance testing prior to ART initiation are recommended. Furthermore, implementation of pre-treatment education and counseling to improve patient adherence to ART is encouraged.

FUNDING

This work was supported by grants from the National Natural Science Foundation of China (81672033, U1302224, and 81271888) and Open Research Fund Program of the State Key Laboratory of Virology of China (2019IOV002).

Genomic Characterization of a Novel HIV-1 Second-Generation Recombinant Form (CRF01_AE/B) from Men Who Have Sex with Men in Guangxi Zhuang Autonomous Region, China

We report here a novel HIV-1 recombinant form (18GXD4705) composed of CRF01_AE and subtype B, acquired from an unmarried HIV-positive young man subject infected through homosexual contact in Guangxi Province of eastern China. The phylogenetic analysis of the near full-length genome of 18GXD4705 indicated that one subtype B segment was inserted into the CRF01_AE backbone, with one recombinant breakpoint demonstrated in the pol region. The CRF01_AE region (I and III) of recombinant correlated with a previously reported subcluster 4 lineage. The B subregions (II) are greatly clustered together, with B strain references. The continued generation of this novel recombinant increases the genetic complexity and diversity of the HIV epidemic in Guangxi. In addition, further molecular epidemiological investigations should be conducted to continuously monitor the dynamic transmission of HIV-1 in the region.

Multiple HIV-1 Subtypes Were Found Circulating in Suqian District of Jiangsu Province, China

Jiangsu province has severe HIV-1 epidemic in China. Suqian which is located in north of the province has limited HIV epidemic information. Therefore, this study aimed to characterize the epidemic details in the area. A total of 196 plasma samples were collected from treated HIV-1-positive cases and viral RNA was extracted. Then HIV partial pol genes (nucleotide 2147-3462 by using HXB2 as calibrator) were amplified and sequenced. Finally, 84 partial pol genes were successfully obtained. The subtyping results indicate that multiple HIV-1 subtypes are circulating in Suqian district. Thereinto, CRF01_AE has been the dominant stains here and belonged to multiple lineages of CRF01_AE identified in China previously. Moreover, there is a high level of HIV drug resistance. All these results suggest HIV-1 epidemic in Suqian is rather complex and more measures must be performed for prevention and intervention in the area.

Multiple HIV-1 Subtypes Were Found Circulating in Shijingshan District of Beijing, China

High level of HIV prevalence was found in some specific areas or populations in China. Shijingshan district was one of the areas with rapid increase of newly reported HIV cases in Beijing, China. Comprehensive investigation on HIV genetic characteristics is necessary in the district. In this study, we enrolled 223 newly identified HIV-1 sero-positive drug-naive patients from Shijingshan district. The full-length gag, pol, and partial env gene sequences were amplified and sequenced. Genetic characterization and transmission of drug resistance of HIV-1 were further investigated. Many stains, including CRF01_AE (48.25%), CRF07_BC (31.47%), subtype B (4.9%), 55_01B (1.40%), 59_01B (0.70%), 65_cpx (2.10%), 79_0107 (0.70%), and A (0.70%) and unique recombinant forms (URF) of 0107 (6.29%), 01B (1.40%), and 01BC (2.10%), were identified. Among 106 strains that harbor full-length PR gene, 10 (9.43%) strains contain mutations associated with drug resistance to protease inhibitors. Among 59 strains that harbor full-length reverse transcriptase (RT) gene, no strains contained mutations conferred to nucleoside reverse transcriptase inhibitors resistance and 4 strains (6.78%) contained drug-resistant mutations to non-nucleoside reverse transcriptase inhibitors. Among 58 sequences harboring full-length IN gene, 1 stain (1.72%) contained a mutation causing drug resistance to integrase strand transfer inhibitors. Our results provided detailed genetic data on HIV prevalent in Shijingshan district of Beijing, which would be helpful for understanding HIV-1 transmission among local populations.

Causes and Consequences of Drug Abuse: A Comparison Between Synthetic Drug and Heroin Users in Urban China

This article examined the differences in causes and health consequences between synthetic drug and heroin abuse in urban China. Two-group comparisons were conducted to quantify differences in individual characteristics, causes of drug use, and HIV/STI risky sexual behavior between synthetic drug and heroin users; logistic regressions were employed to assess the net effect of synthetic drug use on risky sexual behavior. Results revealed that causes of synthetic drug use differed from those of heroin use; a combination of the knowledge gap concerning the harmful impact of synthetic drugs and the lesser punishment for their use appeared a main reason behind the shift from heroin to synthetic drugs; and synthetic drug use was a significant and powerful risk factor for HIV/STI risky sexual behavior. Educational and behavioral interventions are urgently needed to prevent the initiation of synthetic drug use among users to reduce their HIV/STI risky sexual behavior.

Effect of community-based extension clinics of methadone maintenance therapy for opiate-dependent clients: A prospective cohort study in Dehong Prefecture, Yunnan Province of China

Methadone maintenance therapy (MMT) is effective in treatment of opiate dependents. However, there is a gap between the coverage of standard MMT clinics and the need of opiate dependents. Establishment of extension clinics of methadone maintenance therapy (EMMT) will increase the coverage and improve MMT accessibility. We implemented a prospective cohort study to understand the effects of establishment of community-based EMMT clinics comparing with MMT clinics in Yunnan Province.A total of 462 opiate-dependent clients were interviewed from the community-based EMMT clinics and standard MMT clinics located in 5 counties of Mangshi, Ruili, Longchuan, Yingjiang, and Lianghe in Yunnan Province. The information on the demographic characteristics, drug risk behaviors, quality of life (QOL), and urine testing results for morphine of the clients was collected and compared between the EMMT and MMT clinics. A survival analysis method was utilized to know the retention situation of the newly enrolled clients with Kaplan-Meier method during 9 months treatment.Among the EMMT clients, 96.9% were male; 31.4% were Han; 61.4% were married; 39.0% had primary school education; 95.5% lived with their family or relatives; 96.9% who arrived the clinic less than 15 min; 52.9% had used drugs for more than 10 years; and 16.7% injected drug. After 9 months therapy, there was no difference in the changes of life quality such as physical and psychological features, social relationships, environmental function, and total QOL and well-being between those of EMMT and MMT clinics. The positive detection rate of urine-morphine testing among newly enrolled clients of EMMT clinics decreased as the period of treatment lengthened. The average time of retention for newly enrolled EMMT clients who are still receiving the treatment was 175 days. And the average time from initiations to drop-out of treatment for newly enrolled EMMT clients was 122 days. The 9-month retention rates of the clients were 52.1% and 60.9% at EMMT and MMT clinics, respectively.The effect on EMMT retention was the same as that of MMT. Establishment of EMMT clinics was an effective strategy to expand the coverage of MMT and increase the retention of opiate dependents in the rural areas of the counties.

Treatment for HIV prevention study in southwestern areas of China

Background

China has ambitious to achieve significant reductions in HIV transmission and HIV-related mortality by adopting the World Health Organization's “Treat All” approach. Such a prevention strategy is needed future study on regional scale.

Methods

An observational cohort study of HIV epidemiology and treatment databases was used to study the effectiveness of antiretroviral therapy on the transmission of HIV in serodiscordant couples in Guangxi of China.

Results

A total of 7713 couples were entered into the cohort study analysis which included 1885 couples in the treatment-naive cohort and 5828 couples in the treated cohort. During the follow-up of 18985.29 person-years from 2003 to 2014, the average incidence of HIV was 2.4 per 100 person-years (95% CI 2.1–2.6). HIV seroincidence rate was significantly higher among the treatment naive group (4.2 per 100 person-years, 3.7–4.8) compared with the on treatment group (1.6 per 100 person-years, 1.3–1.8). An overall 45% reduction in risk of HIV transmission among serodiscordant couple was associated with ART treatment (adjusted Hazard Ratio [HR] 0.55, 95% Confidence Interval [CI] 0.44–0.69). Treatment prevention had significantly effectiveness for most baseline characteristics of index partners, such as for male, female, age above 25 years, education below high school, farmer, infected by heterosexual intercourse.

Conclusion

Treatment-as-prevention can be implemented in the real-world on a national or regional scale, but ART adherence and comprehensive harm reduction while implementing this strategy require further study.

High prevalence of HIV-1 transmitted drug resistance among therapy-naïve Burmese entering travelers at Dehong ports in Yunnan, China

BACKGROUND

The overall success of Human immunodeficiency virus type 1 (HIV-1) antiretroviral therapy (ART) was heavily challenged upon the occurrence of drug resistance. Dehong Prefecture witnessed not only the first report of HIV-1 infection but also the experimental adoption of antiviral treatment in China. The transmission and epidemic of HIV-1 in Dehong is impacted by cross-border activities. The characteristics of HIV-1 drug resistance among therapy-naïve Burmese entering travelers in Yunnan and their speculated origin are still not clarified.

METHODS

Two hundred ninety-eight HIV-1 infected Burmese entering travelers at Dehong ports were recruited between 2003 and 2012. The partial HIV-1 pol gene fragments were amplified and sequenced for the analysis of drug-resistance mutations (DRMs). Phylogenetic analysis on gag-pol gene was conducted to elucidate phylogenetic and evolutionary characteristics of these drug resistant strains.

RESULTS

It was figured out that the occurrence ratio of HIV-1 drug resistance among HIV-1 infected entering travelers from Myanmar was up to 12.8%. The resistant mutations covered several types, including one type of PI mutations (L33F), six types of NRTI mutations and seven types of NNRTI. Close genetic relationship was observed in the phylogenetic analysis on gag-pol gene among the drug resistant strains respectively from Dehong, other Yunnan areas, neighboring provinces (Guangxi) and neighboring countries (Thailand and Myanmar).

CONCLUSIONS

The findings in this study revealed that HIV drug resistant locus is spreading from the population who is receiving drug-resistance treatment to the new infectors, which indicates the urgency of surveillance work on drug resistance among the migrant population with high risks of HIV infection.

Methadone maintenance-lessons from two systems in China

In Hong Kong, methadone maintenance treatment (MMT) was launched in the 1970s, almost 30 years before the counterpart programme’s inauguration in Mainland China. Both were established in response to perceived public crises—addiction-related crime and HIV outbreak, respectively—and both are now regular services under two systems in the same country. Effectiveness of MMT in achieving the stated goals was evident in each case and provides useful lessons on strategies for dealing with the varied concerns related to illicit drug use. Today, with changing patterns of drug addiction, increasing competition for resources, and changing attitudes towards addiction and its treatment, the two MMT systems are confronted with similar challenges to achieve sustainability.

Phylodynamics of major CRF01_AE epidemic clusters circulating in mainland of China

As the most dominant HIV-1 strain in China, CRF01_AE needs to have its evolutionary and demographic history documented. In this study, we provide phylogenetic analysis of all CRF01_AE pol sequences identified in mainland China. CRF01_AE sequences were collected from the Los Alamos HIV Sequence Database and the local Chinese provincial centers of disease control and prevention. Phylogenetic trees were constructed to identify major epidemic clusters. Bayesian coalescent-based method was used to reconstruct the time scale and demographic history. There were 2965 CRF01_AE sequences from 24 Chinese provinces that were collected, and 5 major epidemic clusters containing 85% of the total CRF01_AE sequences were identified. Every cluster contains sequences from more than 10 provinces with 1 or 2 dominant transmission routes. One cluster arose in the 1990s and 4 clusters arose in the 2000s. Cluster I is in the decline stage, while the other clusters are in the stable stage. Obvious lineage can be observed among sequences from the same transmission route but not the same area. Two large clusters in high-level prevalence were found in MSM (Men who have sex with men), which highlighted that more emphasis should be placed on MSM for HIV control in mainland China.

High HIV incidence epidemic among men who have sex with men in china: results from a multi-site cross-sectional study

BACKGROUND

Recent upsurge of new HIV infections among men who have sex with men (MSM) is a major concern in China. Paucity of national-level information regarding the burden and predictors of this progressive epidemic of new infections called for a multi-centric, timely and comprehensive investigation.

METHODS

Mixed methods were used to recruit MSM from seven cities in China between 2012 and 2013. Recent and established HIV infections were estimated by Western Blot and BED HIV-1 capture enzyme immunoassay. Syphilis and herpes simplex virus-2 (HSV-2) were also tested.

RESULTS

A total of 4496 eligible MSM were recruited. The majority was aged ≤35 years (77.5 %), migrants (60.3 %), never married (69.8 %), and played receptive role in anal sex (70.5 %). The HIV prevalence was 9.9 %, and 41.9 % were recently infected, with sensitivity/specificity adjusted HIV incidence of 8.9 (95 % CI: 7.6-10.2)/100 Person-Years. The prevalence of history HSV-2 and syphilis were 12.5 % and 8.5 %, respectively. Recent HIV infection was associated with having multiple male partners (aOR = 1.4, 95 % CI 1.1-1.9), recreational drug use (aOR = 2.2, 95 % CI 1.6-3.0), anal bleeding (aOR = 2.1, 95 % CI 1.4-3.0), syphilis infection (aOR = 2.8, 95 % CI 1.9-4.3) and history HSV-2 infection (aOR = 2.3, 95 % CI 1.5-3.3).

CONCLUSION

High rate of recent HIV infection is potentially resulting in progressive deterioration of the overall HIV epidemic among MSM in China. Targeted interventions to address high-risk MSM including those having multiple partners, history of recreational drug use and syphilis or HSV-2 infection seemed to be the need of the hour.

Extensive Genetic Diversity of HIV-1 in Incident and Prevalent Infections among Malaysian Blood Donors: Multiple Introductions of HIV-1 Genotypes from Highly Prevalent Countries

Transfusion-transmissible infections including HIV-1 continue to pose major risks for unsafe blood transfusions due to both window phase infections and divergent viruses that may not be detected by donor screening assays. Given the recent emergence of several HIV-1 circulating recombinant forms (CRFs) in high-risk populations in the Southeast Asia region, we investigated the genetic diversity of HIV-1 among the blood donors in Kuala Lumpur, Malaysia. A total of 211 HIV-positive plasma samples detected among 730,188 donations to the National Blood Centre between 2013 and 2014 were provided (90.5% male, median age: 27.0 years old). Recent or long-term infection status at the time of donation was determined using a limiting antigen avidity enzyme immunoassay (LAg-Avidity EIA). HIV-1 gag-pol genes were amplified and sequenced from residual plasma for 149 cases followed by genotype determination using phylogenetic and recombination analyses. Transmitted antiretroviral resistance mutations were not observed among the blood donors, among which 22.7% were classified as recent or incident infections. Major circulating HIV-1 genotypes determined by neighbour-joining phylogenetic inference included CRF01_AE at 40.9% (61/149), CRF33_01B at 21.5% (32/149), and subtype B at 10.1% (15/149). Newly-described CRFs including CRF54_01B circulated at 4.0%, CRF74_01B at 2.0%, and CRF53_01B and CRF48_01B at 0.7% each. Interestingly, unique HIV-1 genotypes including African subtype G (8.7%), CRF45_cpx (1.3%), CRF02_AG (0.7%) and CRF07_BC (0.7%) from China were detected for the first time in the country. A cluster of subtype G sequences formed a distinct founder sub-lineage within the African strains. In addition, 8.7% (13/149) of HIV-infected donors had unique recombinant forms (URFs) including CRF01_AE/B' (4.7%), B'/C (2.7%) and B'/G (1.3%) recombinants. Detailed analysis identified similar recombinant structures with shared parental strains among the B'/C and B'/G URFs, some of which were sequenced from recently infected individuals, indicating the possible emergence and on-going spread of foreign clades of CRF candidates among the local population. The findings demonstrate extensive molecular complexity of HIV-1 among the infected blood donors in Malaysia, driven in part by the increased spread of recently described CRFs and multiple introductions of previously unreported genotypes from highly prevalent countries.

Overview of HIV molecular epidemiology among people who inject drugs in Europe and Asia

HIV strains continuously evolve, tend to recombine, and new circulating variants are being discovered. Novel strains complicate efforts to develop a vaccine against HIV and may exhibit higher transmission efficiency and virulence, and elevated resistance to antiretroviral agents. The United Nations Joint Programme on HIV/AIDS (UNAIDS) set an ambitious goal to end HIV as a public health threat by 2030 through comprehensive strategies that include epidemiological input as the first step of the process. In this context, molecular epidemiology becomes invaluable as it captures trends in HIV evolution rates that shape epidemiological pictures across several geographical areas. This review briefly summarizes the molecular epidemiology of HIV among people who inject drugs (PWID) in Europe and Asia. Following high transmission rates of subtype G and CRF14_BG among PWID in Portugal and Spain, two European countries, Greece and Romania, experienced recent HIV outbreaks in PWID that consisted of multiple transmission clusters including subtypes B, A, F1, and recombinants CRF14_BG and CRF35_AD. The latter was first identified in Afghanistan. Russia, Ukraine, and other Former Soviet Union (FSU) states are still facing the devastating effects of epidemics in PWID produced by A_FSU (also known as IDU-A), B_FSU (known as IDU-B), and CRF03_AB. In Asia, CRF01_AE and subtype B (Western B and Thai B) travelled from PWID in Thailand to neighboring countries. Recombination hotspots in South China, Northern Myanmar, and Malaysia have been generating several intersubtype and inter-CRF recombinants (e.g. CRF07_BC, CRF08_BC, CRF33_01B etc.), increasing the complexity of HIV molecular patterns.

Genomic Characterization of a Novel HIV-1 Second-Generation Recombinant Form Originated from CRF01_AE and CRF08_BC in Dali Prefecture of Yunnan Province, China

Yunnan seems to be a "hot spot" region of HIV-1 recombination. CRF01_AE and subtype CRF08_BC are two main HIV-1 clades circulating in Yunnan. We report here a novel HIV-1 second-generation recombinant form originated from CRF01_AE and CRF08_BC. The strain (12YN10551) was isolated from a HIV-positive male infected through heterosexual contact in Dali prefecture of Yunnan province, China. This is the first report of HIV-1 near full-length genomic sequence in Dali. Recombinant analysis shows that 12YN10551 was composed of two well-established circulating recombinant forms (CRF01_AE and CRF08_BC). Two CRF01_AE recombinant fragments were inserted into the CRF08_BC backbone genome in the pol/vif/vpr/tat/rev and nef gene regions, respectively. The discovery and characterization of this new recombinant indicate that intersubtype recombination is continuously generating new forms of HIV-1. More work is needed to better monitor the genetic diversity of HIV-1 in this region.

The Identification of a Novel HIV-1 CRF01_AE/B Recombinant Based on Near Full-Length Genomic Analysis in Yunnan Province, China

Recombination contributes substantially to the genetic diversity of HIV-1. Recently, many kinds of circulating recombinant forms (CRFs) and unique recombinant forms (URFs) were identified in China, especially in areas with multiple subtypes of HIV-1 circulating. Yunnan, which borders the "Golden triangle" region of South China, is an epicenter of HIV-1 infections in China. Multiple subtypes, including subtypes B, CRF01_AE, CRF07_BC, and CRF08_BC, were found epidemic in the area. Many URFs composed of subtypes B and C genomes were identified in Yunnan; however, CRF01_AE/B recombinant form is relatively rare. In this study, we identified a novel recombinant form of CRF01_AE/B, which was isolated from a heterosexual transmitted individual. The genomic structure of the strain is distinctly different from any previously reported URFs. Three CRF01_AE segments were inserted into the subtype B backbone genome. In the past few years, many kinds of URFs and CRFs have emerged and spread quickly in China, which implies that coinfection or super infection of more than one HIV-1 subtype might be common in China, especially in Yunnan. Therefore, more work is needed to monitor the appearance of URFs and survey the epidemiologic significance of the new recombination.

Prevalence of different HIV-1 subtypes in sexual transmission in China: a systematic review and meta-analysis

Sexual transmission has become the primary route of HIV transmission in China. Therefore, a comprehensive overview of HIV-1 subtype distribution is necessary for the prevention and control of the HIV epidemic. The present study aimed to provide a comprehensive prevalence estimate of different HIV-1 subtypes in sexual transmission in China. We conducted a systematic literature review for studies of HIV-1 subtypes in English and Chinese through several databases. Eligible articles were screened and selected by two authors independently. Random-effects model were applied to calculate the pooled prevalence of different HIV-1 subtypes, and subgroup analyses examined prevalence estimates across time, locations, and populations. A total of 130 eligible studies were identified, including 18 752 successfully genotyped samples. The pooled prevalence of CRF01_AE, subtype B, CRF07_BC, CRF08_BC, and subtype C were 44·54% (95% CI 40·81-48·30), 18·31% (95% CI 14·71-22·17), 16·45% (95% CI 13·82-19·25), 2·55% (95% CI 1·56-3·73), 0·37% (95% CI 0·11-0·72), respectively. The prevalence of subtype B in sexual transmission decreased, while the prevalence of CRF01_AE and CRF07_BC in sexual transmission, and CRF08_BC in heterosexual transmission increased. There is significant variation in HIV-1 subtype distribution between regions. The distribution of HIV-1 subtypes and circulating recombinant forms have changed significantly. The high genetic variability of HIV-1 poses a significant challenge for disease control and surveillance in China.

Geographic origin and evolutionary history of China's two predominant HIV-1 circulating recombinant forms, CRF07_BC and CRF08_BC

To determine the origin and evolutionary history of two predominant and closely-related circulating recombinant forms (CRF07_BC and CRF08_BC), recombinant structures and phylogenies of 7 unique recombinant forms comprised of subtypes of B’ (Thai B linage) and C (designated URFs_BC) from archival specimens of injection drug users (IDUs) collected in 1996 to 1998 from western Yunnan and 4 circulating recombinant forms with B’/C recombinants recently identified (designated nCRFs_BC) in China were compared with those of CRF07_BC and CRF08_BC. The results showed that 5 of 7 URFs_BC and all the nCRFs_BC shared recombination breakpoints with CRF07_BC and/or CRF08_BC. Yunnan URFs_BC consistently occupied the basal branch positions compared with CRF07_BC, CRF08_BC, and nCRFs_BC in phylogenetic trees. The estimated most recent common ancestors (tMRCA) for Yunnan URFs_BC were from ~1987, approximately half a decade earlier than those for CRF07_BC (~1994) and CRF08_BC (~1992). Discrete phylogeographic and spatial diffusion analysis revealed that both CRF07_BC and CRF08 BC came from western Yunnan in the early 1990s. Our results provide compelling evidence for western Yunnan as the geographic origin of CRF07_BC and CRF08_BC, which emerged from a swarm of URFs_BC by a series of recombination events in western Yunnan in the early 1990s.

Prevalence of HIV-1 subtypes among men who have sex with men in China: a systematic review

The distribution of prevalent HIV-1 strains are still complex in China. Men who have sex with men (MSM) play an important bridging role in spreading HIV. The aim of our study was to quantitatively evaluate the prevalence of HIV-1 subtypes among the MSM population in China from published studies. Relevant studies were searched by selection criteria from CNKI, CBM, Pubmed, etc. We computed the estimates of the pooled proportion of HIV-1 subtypes. Heterogeneity between studies was investigated and measured using Cochran's Q statistic and the I (2) statistic. All analyses were conducted by the R statistical package version 2.13.1. A meta-analysis was performed, which included 19 articles. For comprehensive analysis of env, gag and pol genes, the pooled estimates for the prevalence of subtype B was 28.25% (95% CI: 18.10-39.66%), CRF01_AE was 53.46% (95% CI: 46.11-60.74%), CRF07_BC was 18.66% (95% CI: 13.06-25.01%) and CRF08_BC was 5.85% (95% CI: 2.73-10.07%), respectively. In subgroup analysis, the proportion of subtype B decreased, while the proportion of CRF01_AE and CRF07_BC showed an increasing tendency. Beijing, Guangdong and Henan provinces had high proportions of subtype CRF01_AE while Guangdong and Hebei provinces had the highest proportions of subtype B and CRF07_BC, respectively. A high genetic variability of HIV-1 presents a serious challenge for HIV prevention and treatment strategies among MSM in China.

Identification of a novel HIV Type 1 circulating recombinant form (CRF65_cpx) composed of CRF01_AE and subtypes B and C in Western Yunnan, China

A novel HIV-1 circulating recombinant form (CRF) designated CRF65_cpx was recently characterized from three epidemiologically unlinked individuals infected through heterosexual contact in western Yunnan province of China. This is the first complex mosaic HIV-1 CRF, consisting of contributions from three or more different subtypes, identified in China. An additional full-length genome sequence with identical recombinant breakpoints was found among a previously reported recombinant strain from a man who had sex with a man in Anhui province of East Central China. The breakpoint analysis of the recombinants showed a complex genome organization composed of parental subtypes B' (Thailand variant of subtype B), C, and CRF01_AE, with 13 recombination breakpoints observed in almost all structure genes of HIV-1. The generation of complex recombinant forms is likely due to cocirculation of multiple lineages of HIV-1 strains in high-risk populations in western Yunnan.

High prevalence of HIV, HCV and tuberculosis and associated risk behaviours among new entrants of methadone maintenance treatment clinics in Guangdong Province, China

Background

Methadone maintenance treatment (MMT) has been available in Guangdong province, China since 2006. This study aims to estimate the prevalence levels of HIV, Hepatitis C (HCV), Tuberculosis (TB) and their co-infections and associated demographic and risk behaviours among MMT entrants.

Method

A total of 2296 drug users at the time of their MMT enrolment were recruited from four clinics during 2006-2011. Participants’ demographic characteristics, infection status and self-reported high-risk drug-use and sexual behaviours were surveyed. Log-linear contingency analysis was employed to investigate the demographic and behavioural differences between gender and drug-user type, while multivariate regression analysis was used to identify the associated factors of HIV, HCV and TB infections.

Results

Female drug users demonstrate significantly higher frequency of daily drug consumption (Log-linear contingency analysis, G²=10.86, p=0.013) and higher proportion of having had sex in the past three months (G²=30.22, p<0.001) than their male counterparts. Among injecting drug users, females also inject (χ²=16.15, p=0.001) and share syringes (χ²=13.24, p=0.004) more frequently than males. Prevalence of HIV, HCV and TB among MMT entrants are 6.3%, 78.7% and 4.4% respectively. Co-infections of HIV/HCV, HIV/TB, HCV/TB and HIV/HCV/TB reportedly infect 5.6%, 0.5%, 3.8% and 0.3% of study participants. Infection risks of HIV, HCV and TB are consistently associated with increasing length of drug use, injecting drugs, financial dependence and reduced sexual activities.

Conclusion

Injecting drug use is the major contributing factor in prevalence levels of HIV, HCV and TB among MMT entrants. Female drug users are more disadvantaged in their social status and risk-taking in their drug use behaviours than males.

Human immunodeficiency virus prevalence is increasing among men who have sex with men in China: findings from a review and meta-analysis

BACKGROUND AND METHOD

Multiple studies reported a fast-spreading human immunodeficiency virus (HIV) epidemic among men who have sex with men (MSM) in China. This study aimed to estimate the magnitude and time trends of HIV prevalence among MSM in different geographical regions of China through a systemic review and meta-analysis.

RESULTS

A total of 94 articles were identified (25 in English and 69 in Chinese) and analyzed. National HIV prevalence among Chinese MSM has increased over this period, from 1.4% (95% confidence interval [CI]: 0.8%-2.4%) in 2001 to 5.3% (95% CI: 4.8%-5.8%) in 2009. MSM in Southwest China have the highest HIV prevalence, of 11.4% (95% CI: 9.6%-13.5%) in comparison with other regions, which range 3.5% to 4.8%.

CONCLUSION

Significant increases in HIV prevalence among MSM were consistently observed across all Chinese regions. There is an urgent need for implementation of effective public health interventions to curb the spread of HIV infection among MSM across China, especially in the Southwest.

HIV and associated risk factors among male clients of female sex workers in a Chinese border region

BACKGROUND

Male clients of female sex workers (FSWs) serve as a potential bridge of human immunodeficiency virus (HIV) to the general population. Little is known about the characteristics and risk factors for HIV infection among male clients patronizing FSWs in Hekou County, Yunnan Province in southern China bordering with Vietnam.

METHODS

Male clients were recruited through outreach of study staff, referrals by Vietnamese FSWs and their bosses, and snowball sampling. Each participant completed a questionnaire survey and donated a blood specimen to test for HIV, herpes simplex virus type 2 (HSV-2), and syphilis. Logistic regression models were fitted to identify factors associated with HIV infection.

RESULTS

Among 306 participants, 28 (9.2%) were HIV positive, 81 (26.5%) were HSV-2 positive, and none was infected with syphilis. Approximately half (n = 149, 49.2%) reported always using condoms with sex workers in the past year; 36 (11.8%) reported a history of injection drug use (IDU). Compared with HIV-negative men, HIV-positive men were more likely to have a history of IDU (64.3% vs. 6.5%) and be coinfected with HSV-2 (50.0% vs. 24.1%).

CONCLUSIONS

IDU was the most salient risk factor for HIV infection in this study, which suggests that male clients may acquire HIV from routes other than commercial sex, but the significance of HSV-2 infection indicates that sexual transmission is also of concern. HIV prevention intervention programs for this often ignored and hard-to-reach risk group should be two-pronged, addressing both drug use and commercial sex.

Prospective cohort study of HIV incidence and molecular characteristics of HIV among men who have sex with men(MSM) in Yunnan Province, China

Background

Yunnan has the largest number of reported HIV/AIDS cases among all Chinese provinces, the reported prevalence of HIV among Yunnan men who have sex with men (MSM) passed 10%, while HIV incidence epidemic and molecular characteristics of new infected Yunnan MSM were not evaluated before.

Methods

An 18 months prospective followed up with a frequency of 3 month per visit were conducted among HIV seronegative MSM in Kunming cityduring 2009–2011. Interviewer-administrated questionnaires were carried out. Blood specimens were obtained to test for syphilis and HIV, in which HIV were evaluated by standard HIV enzyme immunoassay (EIA) and HIV nucleic acid amplification testing (NAAT). Near full-length regions of the HIV-1 were evaluated for subtyping, primary drug resistance mutations.

Results

During the follow-up 70.1% of the recruited 378 MSM retained in the cohort. Eleven MSM seroconverted to HIV and fifteen MSM seroconverted to syphilis. The HIV incidence and syphilis incidence was 3.5 (95% CI 1.8-6.2) cases /100 person year(PY) and 5.3 (95% CI 3.0-8.7) cases/100 PY, respectively. Multivariate analysis showed that baseline syphilis infection (aHR, 17.7), occupation (students vs. others [aHR, 5.7], retirees vs. others [aHR, 4.1]), bleeding experience after receptive anal intercourse (aHR,7.6), and minority ethnic(vs. Han) [aHR, 5.7] were independent risk factors for HIV seroconversion(each P<0.05). Among the 7/11 successfully amplified near full-length sequences, 71.4% (5/7) were CRF01_AE, and 28.6% (2/7) were CRF07_BC. Two HIV transmission pairs were detected among seroconverted minority ethnic MSM.

Conclusions

HIV incidence was moderately high among Yunnan MSM. Yunnan province need to strengthen both HIV and syphilis screening among MSM population. Some subpopulations of MSM, such as students, retirees and minority ethnic groups require more HIV epidemic surveillance and strengthened behavior interventions. HIV subtypes and primary drug resistance should be continually monitored to track cross-group transmission of HIV strains.

Genetic diversity and drug resistance among newly diagnosed and antiretroviral treatment-naive HIV-infected individuals in western Yunnan: a hot area of viral recombination in China

Background

The emergence of an HIV-1 epidemic in China was first recognized in Dehong, western Yunnan. Due to its geographic location, Dehong contributed greatly in bridging HIV-1 epidemics in Southeast Asia and China through drug trafficking and injection drug use; and also extensively to the HIV genetic diversity in Yunnan and China. We attempt to monitor HIV-1 in this area by studying the HIV-1 genetic distribution and transmitted drug resistance (TDR) in various at-risk populations.

Methods

Blood samples from a total of 320 newly HIV-1 diagnosed individuals, who were antiretroviral therapy (ART)-naive, were collected from January 2009 to December 2010 in 2 counties in Dehong. HIV-1 subtypes and pol gene drug resistance (DR) mutations were genotyped.

Results

Among 299 pol sequences successfully genotyped (93.4%), subtype C accounted for 43.1% (n=129), unique recombinant forms (URFs) for 18.4% (n=55), CRF01_AE for 17.7% (n=54), B for 10.7% (n=32), CRF08_BC for 8.4% (n=25) and CRF07_BC for 1.7% (n=5). Subtype distribution in patients infected by different transmission routes varied. In contract to the previous finding of CRF01_AE predominance in 2002-2006, subtype C predominated in both injecting drug users (IDUs) and heterosexually transmitted populations in this study. Furthermore, we found a high level of BC, CRF01_AE/C and CRF01_AE/B/C recombinants suggesting the presence of active viral recombination in the area. TDR associated mutations were identified in 4.3% (n=13) individuals. A total of 1.3% of DR were related to protease inhibitors (PIs), including I85IV, M46I and L90M; 0.3% to nucleoside reverse transcriptase inhibitors (NRTIs), including M184I; and 2.7% to non-nucleoside reverse transcriptase inhibitors (NNRTIs), including K103N/S, Y181C, K101E and G190A.

Conclusion

Our work revealed diverse HIV-1 subtype distributions and intersubtype recombinations. We also identified a low but significant TDR mutation rate among ART-naive patients. These findings enhance our understanding of HIV-1 evolution and are valuable for the development and implementation of a comprehensive public health approach to HIV-1 DR prevention and treatment in the region.

Recombination form and epidemiology of HIV-1 unique recombinant strains identified in Yunnan, China

Several studies identified HIV-1 recombination in some distinct areas in Yunnan, China. However, no comprehensive studies had been fulfilled in the whole province up to now. To illustrate the epidemiology and recombination form of Unique Recombinant Forms (URFs) circulating in Yunnan, 788 HIV-1 positive individuals residing in 15 prefectures of Yunnan were randomly enrolled into the study. Full-length gag and pol genes were amplified and sequenced. Maximum likelihood tree was constructed for phylogenetic analysis. Recombinant breakpoints and genomic schematics were identified with online software jpHMM. 63 (10.2%) unique recombinant strains were identified from 617 strains with subtypes. The URFs distributed significantly differently among prefectures (Pearson chi-square test, P<0.05). IDUs contained more URFs than sexual transmitted population (Pearson chi-square test, P<0.05). Two main recombinant forms were identified by considering the presence of CRF01_AE segments in full length gag-pol genes, which were B′/C and B′/C/CRF01-AE recombinants. Three clusters were identified in the ML tree which contained more than three sequences and supported by high bootstrap values. One CRF was identified. Many of URFs contained identical breakpoints. The results will contribute to our understanding on HIV recombination and provide clues to the identification of potential CRFs in China.

Rising epidemic of HIV-1 infections among general populations in Fujian, China

BACKGROUND

HIV-1 infections have increased significantly with a doubled number of cases identified between 2006-2007 and 2008-2009 in Fujian, a southeastern province of China. No study has investigated the cause and the evolving epidemic there.

METHODS

In a province-wide study of recently identified infections from 2006 to 2009, we sought to investigate the rising epidemic of HIV-1 infections among general populations and conducted a molecular epidemiology study to determine the new trends of HIV-1 evolution there.

RESULTS

About 915,830 and 2,152,658 specimens collected in 2006-2007 and 2008-2009 were tested for HIV-1 infection. We found that the overall prevalence of infections elevated from 0.064% in 2006-2007 to 0.074% in 2008-2009 (P = 0.003). A high frequency of HIV-1 infections was consistently related to unprotected heterosexual transmissions compared with other risk groups such as intravenous drug users. Critically, the prevalence rate had significantly increased in recent years among general populations such as voluntary blood donors (P < 0.001), recipients of blood transfusion (P < 0.001) and people during presurgery screening (P < 0.001). Besides CRF01_AE as the major circulating subtype (61/86, 70.9%), 25 non-CRF01_AE strains were found contributing to increased HIV-1 genetic diversity including C/CRF07_BC/CRF08_BC (5.8%), B/B' (15.1%), unique recombinant forms (8.1%), and some minor drug-resistant variants.

CONCLUSIONS

Increased prevalence of HIV-1 infections among general populations likely accounts for the rising epidemic in recent years in Fujian. The epidemic was no longer dictated by CRF01_AE but rather by multisubtype viruses. Our findings call for an enhanced surveillance system and have implications to strategic prevention programs among general populations.

Reconstituting the epidemic history of HIV strain CRF01_AE among men who have sex with men (MSM) in Liaoning, northeastern China: implications for the expanding epidemic among MSM in China

HIV CRF01_AE accounted for 84% of the recent infections among men who have sex with men (MSM) in Liaoning Province of northeastern China. CRF01_AE strains were grouped into two distinct clusters (designated clusters 1 and 2) that were also detected in other regions in China. Phylodynamics study revealed that these two CRF01_AE strains were independently introduced into the population of MSM in China in the early and mid-1990s. Our study elucidated unique features of dynamics and interrelationships of MSM epidemics in China.

HPV prevalence and cervical intraepithelial neoplasia among HIV-infected women in Yunnan Province, China: a pilot study

OBJECTIVES

To determine the prevalence of HPV and cervical neoplasia among HIV-infected women in southwestern China.

METHODS

Cervical cytology, HPV detection by Hybrid Capture-2™ assay, and diagnostic colposcopy were followed by cervical biopsy if indicated. Logistic regression analysis was used to analyze associations between HPV co-infection and cervical intraepithelial neoplasia (CIN), and HIV-related clinical and laboratory parameters.

RESULTS

Colposcopic-histopathologically proven CIN2+ lesions were present in 7/83 (8.4%) HIV-infected women. Nearly half (41/83, 43%) were co-infected with carcinogenic HPV genotypes. HPV co-infection was higher in women with colposcopic-histopathologically proven CIN2+ lesions than women with <CIN1 after adjusting for age (OR: 8.3, 95% CI: 0.9, 73.4). Women with CD4+ cell counts less than 350 cells/μL had higher CIN2+ prevalence after adjusting for current ART status and age (adjusted OR: 6.3, 95% CI: 1.1, 36.5).

CONCLUSIONS

HIV/AIDS care and treatment programs should integrate effective cervical cancer prevention services to mitigate the risk of invasive cervical cancer among HIV-infected women in China.

Are females who inject drugs at higher risk for HIV infection than males who inject drugs: an international systematic review of high seroprevalence areas

OBJECTIVE

There are multiple reasons why females who inject drugs may be more likely to become infected with HIV than males who inject drugs. Where this is the case, special HIV prevention programs for females would be needed.

DESIGN

International systematic review and meta-analysis of studies across 14 countries.

METHODS

Countries with high seroprevalence (>20%) HIV epidemics among persons who inject drugs (PWID) were identified from the Reference Group to the UN on HIV and Injecting Drug Use. Systematic literature reviews collected data on HIV prevalence by gender for these countries. Non-parametric and parametric tests along with meta-analytic techniques examined heterogeneity and differences in odds ratios (OR) across studies.

RESULTS

Data were abstracted from 117 studies in 14 countries; total sample size N = 128,745. The mean weighted OR for HIV prevalence among females to males was 1.18 [95% CI 1.10-1.26], with high heterogeneity among studies (I(2)= 70.7%). There was a Gaussian distribution of the log ORs across studies in the sample.

CONCLUSION

There was a significantly higher HIV prevalence among females compared to males who inject drugs in high seroprevalence settings, but the effect size is extremely modest. The high level of heterogeneity and the Gaussian distribution suggest multiple causes of differences in HIV prevalence between females and males, with a specific difference determined by local factors. Greater understanding of factors that may protect females from HIV infection may provide insights into more effective HIV prevention for both females and males who inject drugs.

HIV and HCV prevalence among entrants to methadone maintenance treatment clinics in China: a systematic review and meta-analysis

BACKGROUND

Methadone maintenance treatment (MMT) was implemented in China since 2004. It was initiated in 8 pilot clinics and subsequently expanded to 738 clinics by the end of 2011. Numerous individual research studies have been conducted to estimate HIV and HCV prevalence among MMT clients but an overview of the epidemics in relations to MMT remains unclear. The aim of this study is to estimate the magnitude and changing trends of HIV, HCV and HIV-HCV co-infections among entry clients to MMT clinics in China during 2004-2010.

METHODS

Chinese and English databases of literature were searched for studies reporting HIV, HCV and co-infection prevalence among MMT clients in China from 2004 to 2010. The prevalence estimates were summarized through a systematic review and meta-analysis of published literatures.

RESULTS

Ninety eligible articles were selected in this review (2 in English and 88 in Chinese). Nationally, pooled prevalence of HIV-HCV and HIV-HCV co-infection among MMT clients was 6.0% (95%CI: 4.7%-7.7%), 60.1% (95%CI: 52.8%-67.0%) and 4.6% (95%CI: 2.9%-7.2%), respectively. No significant temporal trend was found in pooled prevalence estimates. Study location is the major contributor of heterogeneities of both HIV and HCV prevalence among drug users in MMT.

CONCLUSIONS

There was no significant temporal trend in HIV and HCV prevalence among clients in MMT during 2004-2010. Prevalence of HCV is markedly higher than prevalence of HIV among MMT clients. It is recommended that health educational programs in China promote the earlier initiation and wider coverage of MMT among injecting drug users (IDUs), especially HIV-infected IDUs.

Extensive and complex HIV-1 recombination between B', C and CRF01_AE among IDUs in south-east Asia

OBJECTIVE

To investigate the subtype characterization of HIV-1 among IDUs in northern Myanmar.

DESIGN

A molecular epidemiological investigation was conducted among IDUs in Laza and Maizayang cities of northern Myanmar.

METHODS

A total of 83 HIV-1-positive serums were collected from consenting IDUs during June to August 2009. HIV-1 p17, pol, vif-env, C2V3 fragments were amplified and sequenced. Phylogenetic and bootscanning analyses were performed.

RESULTS

A very high proportion (86.1%) of HIV-1 intersubtype recombinants and very low proportion of subtypes B' (3.8%), C (7.6%) and CRF01_AE (1.3%) were found in this HIV-infected IDUs cohort. These recombinants cover all four kinds of recombination forms formed among CRF01_AE, B and C. The B/C and CRF01_AE/B/C recombinants are the two most dominant recombinants, accounting for 54.4 and 42.6% of all cases, respectively, and indicating the ongoing generation of extensive and complex HIV-1 recombination among CRF01_AE, B' and C in northern Myanmar. Intriguingly, most recombinants have different chimeric patterns from each other, forming 64 unique recombination forms (URFs) that are quite distinct from any previously identified circulating recombinant forms (CRFs) and URFs in Asia.

CONCLUSION

The extremely high proportion of intersubtype recombinants, especially CRF01_AE/B'/C recombinants (42.6%), strongly suggests that northern Myanmar is a big forge for HIV-1 recombination among CRF01_AE, B' and C.

Phylodynamic inference of infectious diseases caused by HIV, enterovirus 71 and the 2009 swine-origin human influenza virus

The rapidly evolving nature of viruses, particularly RNA viruses, exhibit complex phylodynamic behaviors, accumulating mutations across the genome on a timescale observable by humans. Phylodynamic investigations provide unique and quantitative evolutionary data on the origin, progression in terms of time and space, and epidemic and transmission history of pathogens. This review describes recent phylodynamic conjectures on three distinct categories of human viruses, including HIV, enterovirus 71 and the swine-origin pandemic influenza virus H1N1, which are of enormous importance to public health.

Parental LTRs are important in a construct of a stable and efficient replication-competent infectious molecular clone of HIV-1 CRF08_BC

Circulating recombinant forms (CRFs) of HIV-1 have been identified in southern China in recent years. CRF08_BC is one of the most predominant subtypes circulating in China. In order to study HIV subtype biology and to provide a tool for biotechnological applications, the first full-length replication-competent infectious molecular clone harboring CRF08_BC is reported. The construction of this clone pBRGX indicates that a moderate-copy number vector is required for its amplification in E. coli. In addition, it is shown that the parental CRF08_BC LTRs are important for generating this efficient replication-competent infectious clone. These observations may aid in the construction of infectious clones from other subtypes. Both the pBRGX-derived virus and its parental isolate contain CCR5 tropism. Their full-length genomes were also sequenced, analyzed, compared and deposited in GenBank (JF719819 and JF719818, respectively). The availability of pBRGX as the first replication-competent molecular clone of CRF08_BC provides a useful tool for a wide range of studies of this newly emergent HIV subtype, including the development of HIV vaccine candidates, antiviral drug screening and drug resistance analysis.

Phylogeographic analyses reveal a crucial role of Xinjiang in HIV-1 CRF07_BC and HCV 3a transmissions in Asia

Background

China faces an increasing prevalence of two HIV-1 circulating recombinant forms (CRFs) 07_BC and 08_BC. Both CRFs_BC were previously demonstrated to originate in Yunnan and spread to Liaoning from Yunnan via injection drug use (IDU) in China. Supposing it is true, we are unable to answer why only CRF07_BC, rather than both CRFs_BC together, was transmitted to Xinjiang.

Methodology/Principal Findings

We investigated the phylogeography of CRF07_BC and CRF08_BC using multiple HIV-1 genomic regions with Bayesian phylogeography method. Phylogenetic reconstructions showed that all CRF07_BC sequences were divided into two clades, Yunnan and Xinjiang, and all strains from other regions of mainland China clustered within the Xinjiang clade. Significant geographic diffusion links of Xinjiang with other regions (including Liaoning, Beijing, Jiangsu and Guangdong) were supported by Bayes factor tests. The temporal dynamics analyses showed that CRF07_BC spread from Xinjiang to Liaoning in 1996.10, and to Jiangsu in 2000.9. The analyses of CRF08_BC not only confirmed the previous conclusion on temporal and spatial dynamics of CRF08_BC, but also indicated that the CRF08_BC strains from Guangdong and Shanghai originated from Yunnan. The analyses of HCV 3a showed that it was introduced into Xinjiang in the early 1980s, and spread from Xinjiang to Yunnan in 1990.10 and to Jiangsu in 1999.2, and further from Yunnan to Guangxi in 1995.3. The temporal and spatial dynamics of HCV 3a were similar to some extent to that of HIV-1 CRF07_BC and/or CRF08_BC, suggesting a possible association in migration patterns between HCV and HIV-1 through IDU. In addition, HCV 3a spread from Xinjiang to Pakistan, implying a drug trafficking route linking them.

Conclusions/Significance

Xinjiang, as the most important transfer station for drug trafficking from Golden Crescent to other regions of China, plays a very crucial role in the transmission of viruses (e.g., HIV-1 and HCV) through IDU in Asia.

Crossing over: drug network characteristics and injection risk along the China-Myanmar border

Border areas are important locations for understanding HIV transmission. This study examines individual and network correlates of border crossing and equipment sharing among methadone maintenance clients in Ruili City, a Chinese city on the Myanmar border. Data are from 298 clients enrolled in the Ruili Methadone Treatment Center. Clients were interviewed about drug use, HIV/AIDS knowledge, treatment motivation, and their social networks. Multinomial and logistic regression analysis were performed. Thirty percent of clients reported injecting in Myanmar. Compared to drug networks that usually inject in China, networks that inject equally in both places (border crossing) are more likely to share equipment. The association between HIV positive status and border-crossing was marginally significant and robust. Results indicate some added degree of risk among clients and drug networks who border-cross to use drugs. More research is needed to understand this phenomenon.

Near full-length genomic characterization of a novel HIV type 1 CRF07_ BC/CRF08_ BC recombinant strain from Yunnan, China

Yunnan province was considered the HIV-1 epicenter of China, where many subtypes and CRFs of HIV-1 were circulating. CRF07_BC and CRF08_BC were two of the main circulating subtypes that caused more than 90% of the HIV-1 infections in intravenous drug users (IDUs) in this district. The cocirculation of these two CRFs in the same area and population predicted the emergence of new second-generation recombinants. This study presented a near full-length genomic analysis of a novel HIV-1 recombination (09YN072) involving CRF07_BC and CRF08_BC. The analyses of the sequence of 09YN072 showed that two CRF07_BC segments were inserted into the CRF08_BC backbone. The discovery of the novel recombinant strain complicates the HIV-1 epidemic in Yunnan, China, as well as the development of effective vaccines to limit the spread of HIV-1 in China.

The characteristics and risk factors for HIV infection among Beijing drug users in different settings

BACKGROUND

Treatment for drug addiction in China can take place in mandatory detoxification centers (MDC), voluntary detoxification centers (VDC), or at outreach programs located in the community. To date little is known about HIV prevalence or associated risk factors among the current and past drug users (DU) in each setting.

METHODS

Cross-sectional surveys were conducted at three different settings in Beijing, China; 795 subjects were enrolled at MDC, 824 at VDC, and 520 within the community. Subjects who provided informed consent took part in face-to-face interviews and provided blood samples for HIV and syphilis testing.

RESULTS

Significant differences were found across enrollment sites in terms of demographic, drug use and sexual behavior characteristics. Overall HIV sero-prevalence was 2.9%, and was particularly high in MDC (5.2% versus 1.0% in VDC and 2.3% among community drug users). Adjusted odds ratios (OR) for HIV infection were 50.5 (95% CI: 19.07-133.85) for being of Yi ethnicity, 29.4 (95% CI: 15.10-57.24) for Uyghur ethnicity, 3.4 (95% CI: 1.57-7.52) for injection drug users who did not share equipment, and 18.8 (95% CI: 8.31-42.75) among injection drug users who shared injection equipment.

CONCLUSIONS

The vast differences among DU in various enrollment sites in terms of demographic characteristics, socioeconomic status, and HIV related risk profiles underscore the importance of familiarity with population characteristics and drug user environment to better inform targeted prevention programs. Prevention programs targeting DU in Chinese settings must also consider differences in ethnicities, culture, and residential status.

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.

Near full-length sequence analysis of a novel HIV-1 C/CRF01_AE recombinant variant from Yunnan, China

Recombination contributes substantially to the overall genetic complexity of HIV-1, especially in populations in which multiple subtypes circulate. Yunnan is a province in China with most severely HIV epidemic where many subtypes and CRFs of HIV-1 are circulating. In this study, we report a novel HIV-1 recombination involving C and CRF01_AE. The near full-length genome was reverse transcripted and amplified in two halves with the 1 kb overlap regions. The PCR products were sequenced directly after purification. Sequence analysis showed that the majority of the genome was CRF01_AE, three fragments of C subtype were inserted along the genome in gag and pol region. This is the first report of a novel recombination involving subtype C and CRF01_AE in Yunnan, China. More work is needed to check the epidemiologic significance of the new recombination.

Needle sharing and sex-related risk behaviours among drug users in Shenzhen, a city in Guangdong, southern China

Intravenous drug users (IDUs) are at high risk of contracting HIV, but there is a geographic bias in such research efforts in China. The aim was to study the pattern of needle sharing and sex-related risk behaviours among drug users in southern China. About 260 drug users in a detoxification centre completed an anonymous questionnaire (response rate=87.3%). The results show that needle sharing among IDUs was prevalent (60.6% and 45.3% for male and female IDUs, respectively); the sharers were often friends, spouses, and acquaintances. Few IDUs sterilized the used needles properly. Commercial sex behaviours (males: 44%; females: 60%) as well as multiple partnership (males: 60%; females: 53%) were also prevalent among all male and female drug users studied. Inconsistent condom use with commercial sex partners, spouses, and regular sex partners was also very common. Yet, few of all drug users studied perceived the susceptibility of contracting HIV (11%) or sexually transmitted diseases (24%) in the future. A better HIV-related knowledge level was associated with lower levels of risk behaviours. It is concluded that harm reduction programmes are urgently warranted in China.

Reconstructing the epidemic history of HIV-1 circulating recombinant forms CRF07_BC and CRF08_BC in East Asia: the relevance of genetic diversity and phylodynamics for vaccine strategies

HIV-1 CRF07_BC and CRF08_BC are closely related circulating recombinant forms (CRFs) with serious public health consequences in China. The temporal and spatial dynamics of these CRFs were determined by estimating their times of divergence, using phylogenetic and Bayesian coalescent methods. Studies of the timelines of CRF07_BC and CRF08_BC trace the expansion of these strains back their origins to Yunnan province. The present study highlights the relevance of incorporating evolutionary and molecular epidemiological analyses into an in-depth understanding of the genesis of HIV epidemic, providing information for determining regional and global public health policies, including future vaccine strategies.

APOE epsilon4 and MBL-2 O/O genotypes are associated with neurocognitive impairment in HIV-infected plasma donors

BACKGROUND

Host genetic factors are important determinants for risk of HIV-1 infection and disease progression. This study examined associations of host genetic variants and neurocognitive impairment in Chinese individuals infected through contaminated blood products.

METHODS

Two hundred and one HIV-infected patients from Anhui, China, had neuropsychological tests at baseline and 12 months. DNA was genotyped for APOE epsilon2, epsilon3 and epsilon4 alleles; MBL2-A/O; CCR5-wt/Delta32; CCR5-59029-G/A; CCR2-180-G/A; SDF-1-G/A; IL4-589-C/T; MCP-1-2518-A/G; CX3CR1-745-G/A; -849-C/T polymorphisms and CCL3L1 copy number variants using real-time PCR. Univariate and multivariate analyses were performed.

RESULTS

The cohort included 61% men, with mean education 5.5 years, AIDS diagnosis 113 (55%), on antiretrovirals 114 (56%), mean baseline CD4(+) cell count 349 cells/microl and mean log10 RNA 4.09. At baseline, 37% had global neuropsychological impairment increasing to 44% after 12 months. Of 43 patients with the APOE epsilon4 allele, 58% were cognitively impaired compared with 31% without the epsilon4 allele (P = 0.001, odds ratio 3.09, 95% confidence interval 1.54-6.18). The mean global deficit score (GDS) for epsilon4-positive participants on antiretrovirals for 12 months was 0.88 (0.55) compared with 0.63 (0.54) for epsilon4-negative participants (P = 0.053, 95% confidence interval -0.004 to 0.51). For MBL2, 52% of patients with the O/O genotype declined in cognitive function over 12 months compared with 23% with A/A (odds ratio 3.62, 95% confidence interval 1.46-9.03, P = 0.004). No associations were observed for the other genetic variants.

CONCLUSION

The APOE epsilon4 allele was associated with increased risk for cognitive deficits, whereas the MBL2 O/O genotype was associated with increased risk for progressive cognitive decline in Chinese individuals infected with HIV through contaminated blood products.