HIV-1 Treatment-as-Prevention: A Cohort Study Analysis of Serodiscordant Couples in Rural Southwest China

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Excess mortality and associated factors among people living with HIV initiating highly active antiretroviral therapy in Luzhou, China 2006-2020

BACKGROUND

To estimate crude mortality, excess mortality, and standardized mortality rates (SMR) among people living with HIV (PLHIV) initiating highly active antiretroviral therapy (HAART) in Luzhou, China 2006-2020, and assess associated factors.

METHODS

PLHIV initiating HAART in the HIV/AIDS Comprehensive Response Information Management System (CRIMS) in Luzhou, China 2006-2020 were included in the retrospective cohort study. The crude mortality, excess mortality, and SMR were estimated. Multivariable Poisson regression model was used for analyzing risk factors associated with excess mortality rates.

RESULTS

The median age among 11,468 PLHIV initiating HAART was 54.5 years (IQR:43.1-65.2). The excess mortality rate decreased from 1.8 deaths/100 person-years (95% confidence interval [CI]:1.4-2.4) in 2006-2011 to 0.8 deaths/100 person-years (95%CI:0.7-0.9) in 2016-2020. SMR decreased from 5.4 deaths/100 person-years (95%CI:4.3-6.8) to 1.7 deaths/100 person-years (95%CI:1.5-1.8). Males had greater excess mortality with the eHR of 1.6 (95%CI:1.2-2.1) than females. PLHIV with CD4 counts ≥ 500 cells/μL had the eHR of 0.3 (95%CI:0.2-0.5) in comparison to those with CD4 counts < 200 cells/μL. PLHIV with WHO clinical stages III/IV had greater excess mortality with the eHR of 1.4 (95%CI:1.1-1.8). PLHIV with time from diagnosis to HAART initiation ≤ 3 months had the eHR of 0.7 (95%CI:0.5-0.9) compared to those with time ≥ 12 months. PLHIV with initial HAART regimens unchanged and viral suppression had the eHR of 1.9 (95%CI:1.4-2.6) and 0.1 (95%CI:0.0-0.1), respectively.

CONCLUSIONS

The excess mortality and SMR among PLHIV initiating HAART in Luzhou, China decreased substantially from 2006 to 2020, but the mortality rate among PLHIV was still higher than general population. PLHIV who were male, with baseline CD4 counts less than 200 cells/μL, WHO clinical stages III/IV, time from diagnosis to HAART initiation ≥ 12 months, initial HAART regimens unchanged, and virological failure had a greater risk of excess deaths. Early and efficient HAART would be significant in reducing excess mortality among PLHIV.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Rapidly Spreading Human Immunodeficiency Virus Epidemic Among Older Males and Associated Factors: A Large-scale Prospective Cohort Study in Rural Southwest China

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Human immunodeficiency virus incidence was associated with males, older age, less than secondary schooling and not currently being married.

Background

Increasing risk of human immunodeficiency virus (HIV) heterosexual transmission can raise the potential for a more diffuse and generalized epidemic. In response to the paucity of data on HIV incidence among heterosexuals in China, we conducted a large-scale, population-based cohort study located in rural southwest China.

Methods

Baseline enrollment for the study was conducted from 2013 to 2014 and follow-up at 12 months was from 2014 to 2015 among adults 20 years or older in 3 rural counties of Southwest China. Study participants were informed of the study by brochures and leaflets distributed in outreach activities. Interviews and blood collection were conducted in private rooms. Blood samples were tested for HIV infection.

Results

The HIV prevalence of the sample was 0.29% (95% confidence interval [CI], 0.27–0.30) (2063 of 722,795) among the total adult population of 1,090,296 potential participants 20 years or older at baseline. Of the 720,732 individuals who tested HIV-negative at baseline, 493,990 (69%) completed the follow-up. Overall HIV incidence was 2.73 (95% CI, 2.38–3.08) per 10,000 person-years (PY) (235 of 860,627 PY). Human immunodeficiency virus incidence was associated with males, older age, less than secondary schooling and not currently being married. Human immunodeficiency virus incidence was 71.28 (95% CI, 35.21–107.35) per 10,000 PY among males aged 50 to 69 years who had less than secondary schooling and were divorced or widowed. Heterosexual sex was the dominant transmission mode for HIV seroconversions (99.0%).

Conclusions

Older heterosexual males were at disproportionate risk of HIV infection. Health authorities in China need to develop and implement innovative interventions suitable for the broader population of older heterosexuals.

Treatment effects of the differential first-line antiretroviral regimens among HIV/HBV coinfected patients in southwest China: an observational study

HIV with HBV co-infection can result in greater HIV-related immunosuppression, morbidity and mortality. Currently, there are few studies to evaluate direct treatment effects on mortality and attrition rates between first-line antiretroviral therapy (ART) based-on tenofovir (TDF) and/or lamivudine (3TC) in a real-world setting. We used Cox proportional hazard models to evaluate direct treatment effects of the first-line ART containing stavudine (d4T), azidothymidine (AZT) and TDF on death and attrition among HIV patients with HBV coinfection. A total of 3912 patients met study eligibility criteria. The overall mortality rate and attrition rate was 2.85 (95% CI: 2.55-3.16) and 8.87 (95% CI: 8.32-9.41) per 100 person-years, respectively. The ART containing TDF had a significantly lower risk of death [adjusted hazard ratio (AHR) = 0.58, 95% CI: 0.44-0.77] when compared to the ART containing d4T, but the risk of death was not significantly different when compared to the ART containing AZT (AHR = 0.91, 95% CI: 0.69-1.20). Patients with HIV/HBV coinfection receiving the ART containing TDF had significantly lower risk rates of attrition compared to those receiving the ART containing d4T (AHR = 0.72, 95% CI: 0.60-0.86) or AZT (AHR = 0.67, 95% CI: 0.58-0.77). Compared with the ART containing d4T, the ART containing AZT was significant and not significant associated with a lower risk of death and attrition, respectively. The ART containing TDF had significant effects on both of death and attrition among HIV patients with HBV coinfection.

Incidence and clinical outcomes of diabetes mellitus in HIV-infected adults in Thailand: a retrospective cohort study

BACKGROUND

Since 2005, Thailand has scaled up one of the largest antiretroviral treatment (ART) programs in South East Asia. Although diabetes mellitus (DM) incidence is increasing in low and middle-income countries, its burden and contributing factors in the HIV infected population are not well known.

METHODS

Using the Thai National AIDS Program data over a period of 8-years, we identified patients diagnosed with DM based on the following records: 1) fasting plasma glucose equal to or greater than 126 mg/dl following the 2013 American Diabetes Association criteria or 2) diagnosis codes E11-E14 of the 2010 WHO International Classification of Diseases, or 3) anti-diabetic drugs. Incidence was the number of new cases divided by that of person-years of follow-up (PYFU). Competing risks survival regression, treating death without DM as a competing event, was used to identify factors associated with DM. The risk of death in patients diagnosed with DM was estimated using Cox regression models.

RESULTS

Data of 763,666 PYFU from 199,707 patients (54.2% male; median age 36.2 years at registration with the program) were available and 8383 cases were diagnosed with DM, resulting in an incidence rate of 11.0 per 1000 PYFU. New DM diagnosis was more likely in men (adjusted sub-distribution hazard ratio 1.2), older patients (compared to patients 18 to 34 years old: 1.8 for 35 to 44; 3.0 for 45 to 59; 3.8 for ≥60), and if ART was initiated (1.3). In 2014, 1313 (16.6%) of 7905 diabetic patients had DM complications (11.5% microvascular complications and 6.9% macrovascular complications). Patients diagnosed with DM were at higher risk of death compared to the others.

CONCLUSIONS

DM incidence was higher in this Thailand cohort of HIV infected adults than in the general population. Risk factors were similar to those in the general population, in addition to starting ART.

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

Objectives:

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

Design:

Regression discontinuity study arising from a population-based cohort.

Methods:

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

Results:

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

Conclusion:

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

Effects of high CD4 cell counts on death and attrition among HIV patients receiving antiretroviral treatment: an observational cohort study

Current WHO guidelines recommend initiating ART regardless of CD4+ cell count. In response, we conducted an observational cohort study to assess the effects of pre-ART CD4+ cell count levels on death, attrition, and death or attrition in HIV treated patients. This large HIV treatment cohort study (n = 49,155) from 2010 to 2015 was conducted in Guangxi, China. We used a Cox regression model to analyze associations between pre-ART CD4+ cell counts and death, attrition, and death or attrition. The average mortality and ART attrition rates among all treated patients were 2.63 deaths and 5.32 attritions per 100 person-years, respectively. Compared to HIV patients with <350 CD4+ cells/mm³ at ART initiation, HIV patients with >500 CD4+ cells/mm³ at ART initiation had a significantly lower mortality rate (Adjusted hazard ratio: 0.56, 95% CI: 0.40–0.79), but significantly higher ART attrition rate (AHR: 1.17, 95% CI: 1.03–1.33). Results from this study suggest that HIV patients with high CD4+ cell counts at the time of ART initiation may be at greater risk of treatment attrition. To further reduce ART attrition, it is imperative that patient education and healthcare provider training on ART adherence be enhanced and account for CD4 levels at ART initiation.

Risk factors associated with sexually transmitted infections among HIV infected men who have sex with men

To investigate the factors associated with sexually transmitted infection and Human Immunodeficiency Virus (STI-HIV) co-infection among men who have sex with men (MSM). A total of 357 HIV-infected participants (84 STI-HIV co-infection and 273 HIV infections only) were recruited from Jiangsu, China. Logistic regression analyses were used to estimate the related factors associated with STI-HIV co-infection. Marginal structural models were adopted to estimate the effect of transmission drug resistance (TDR) on STI-HIV co-infection. For all participants, logistic regression analyses revealed that those who diagnosed with HIV-1 for longer duration (≥1.8 years) were significantly associated with reduced STI-HIV co-infection risk (OR = 0.55, 95%CI: 0.32–0.96, P = 0.036). In further stratification analysis by antiretroviral therapy (ART), individuals with longer duration showed consistent significant associations with STI-HIV co-infection risk (OR = 0.46, 95%CI: 0.26–0.83, P = 0.010) among MSM with ART-naïve status. In addition, significant reduced risk for STI-HIV co-infection (OR = 0.98, 95%CI: 0.96–0.99, P = 0.010) were observed in younger (under the average age of 31.03) MSM of the same group. Interestingly, we also found TDR was significantly associated with an increased risk of STI-HIV co-infection risk (OR = 3.84, 95%CI: 1.05–14.03, P = 0.042) in ART-naïve group. Our study highlights a pattern of STI-HIV co-infection among MSM in China and indicates that targeted interventions aimed at encouraging TDR monitoring in MSM with early HIV infection are warranted.

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

Background

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

Methods

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

Results

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

Conclusion

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

Electronic supplementary material

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

Effects of CD4 Cell Counts and Viral Load Testing on Mortality Rates in Patients With HIV Infection Receiving Antiretroviral Treatment: An Observational Cohort Study in Rural Southwest China

BACKGROUND

Recent studies have suggested that CD4 cell count monitoring has little added value in patients who are virologically suppressed and immunologically stable if viral load (VL) testing is routinely available. These conclusions have not been directly assessed using mortality rate as a study end point in a real-world setting.

METHODS

This human immunodeficiency virus (HIV) treatment cohort study from 2008 to 2014 was conducted in Guangxi, China. We used a Cox regression model to analyze associations between the frequency of CD4 cell counts and VL testing and death.

RESULTS

Compared with monitoring CD4 cell counts ≥3 times during the first year of antiretroviral therapy (ART) initiation, as currently suggested by the Chinese National Free Antiretroviral Treatment Program, monitoring them less than twice during the first year of ART was significantly associated with death; however, monitoring them twice in that year did not significantly increase mortality rates. Compared with testing VL at least once during the first year of ART, as currently suggested by the National Free Antiretroviral Treatment Program, performing no VL tests in the first year after ART initiation was significantly associated with higher mortality rates. Routine CD4 cell count monitoring did not have an impact on mortality rates among HIV-infected patients with VLs <1000 copies/mL or CD4 cell counts ≥350/μL beyond 12 months after ART initiation.

CONCLUSIONS

Our study suggests that CD4 cell counts can be reduced to twice during the first year of ART and be reduced or stopped for patients who have achieved virologic suppression or immunologic stability after 12 months of treatment.