Human immunodeficiency virus-1 genotypic drug resistance among volunteer blood donors in Yunnan, China

Characterization and Recombinant Genotypes of HIV-1 in Gansu Province, China

It is important to monitor the diversity and evolution of HIV-1 genotypes, especially in some remote and undeveloped regions in China where the diversity and distribution of HIV-1 genotypes are not fully clear. To investigate the genotypes and distribution of HIV-1 in far Northwestern Gansu Province of China, we selected 220 HIV-1-positive plasma samples from the Center for Disease Control and Prevention (CDC) in Gansu from January 2016 to December 2018. The viral load of inclusion samples were over 1,000 copies per milliliter. The gag, pol, and env gene of HIV-1 were amplified by nested reverse transcription-polymerase chain reaction kit, sequenced, and then identified genotypes using HIV-BLAST tool and the neighbor-joining method. One hundred fifty of 220 inclusion samples were successfully determined HIV-1 genotypes. Our results show that circulating recombinant forms (CRF) 07_BC and CRF01_AE are predominant and accounted for 46.7% and 28.0%, respectively. Other HIV-1 subtypes and genotypes included B/B' (6.0%), CRF08_BC (4.0%), and C (1.3%). In addition, we reported CRF65_cpx and CRF55_01B subtypes in Gansu for the first time. Phylogenetic tree analysis showed that the sequences of different samples are scattered in different genotype groups, and no obvious aggregation occurs. Our results indicate the genetic variety and complexity of HIV-1 and provide critical information for HIV/AIDS control and prevention in Gansu Province.

The infection staging and profile of genotypic distribution and drug resistance mutation among the human immunodeficiency virus-1 infected blood donors from five Chinese blood centers, 2012-2014

The increasing complexity and diversity of the human immunodeficiency virus-1 (HIV-1) infections challenge the disease control and anti-retrovirus treatment in China. The infection stages and molecular characteristics of HIV-1 from infected Chinese blood donors were examined to shed light on the HIV genotype distribution and the status of drug resistance mutations (DRMs) in the changing HIV epidemic in China. Western blot (WB) confirmed HIV-1 positive plasma samples were collected from blood donors at five Chinese blood centers from April 16, 2012, through June 30, 2014. The HIV infection stages were determined using the Lag-avidity assay. HIV Pol regions including whole protease and partial reverse transcriptase (RT) were amplified and sequenced to establish the profile of genotype distribution and drug resistance mutations (DRMs). Viral loads were determined using the ROCHE COBAS system. Of the 259 HIV-1 positive samples tested by the Lag-avidity assay, 23.6% (61/259) were identified as recent infections. A total of 205 amplified sequences displayed the following genotype distributions: circulating recombinant form (CRF) 07_BC (61.5%), CRF08_BC (8.3%), CRF01_AE (20%), B (6.3%), and 01B (3.9%). There was no significant difference in genotype distribution between recent and long-term infections. 31 DRMs were identified from 27 samples including four protease inhibitors (PIs) accessory DRMs, two PIs major DRMs (M46I), two nucleoside RT inhibitors DRMs (K219R and K70Q), and 23 nonnucleoside RT inhibitors DRMs. 27 samples had DRMs, yielding a drug resistance prevalence of 13.2% (27/205). Our findings provide important information for developing strategies for comprehensive HIV control and improving anti-retroviral treatment in China.

HIV prevalence and phylogenetic characteristics among entry travelers in Xishuangbanna prefecture, Yunnan province, between 2003 and 2012

Xishuangbanna is a popular tourist destination in southern Yunnan Province, bordering with Vietnam and Laos, and Myanmar. There are more than 2 million cross-border travelers annually entering China at two land ports, Daluo and Mohan. To clarify the characteristics of HIV-1 prevalence among entry travelers, a retrospective epidemic investigation was conducted. Between 2003 and 2012, 196 among 91 432 entry travelers were detected to be HIV-1-positive, accounting for infection rate of 0.21%. Eighty-one gag-pol gene sequences were obtained for phylogenetic analyses and subsequent recombination analysis. It was shown that the most prevalent HIV-1 subtype in this population was circulating recombinant form (CRF) 01_AE (42, 51.86%), followed by CRF08_BC (17, 20.99%), CRF07_BC (4, 4.94%), B' (2, 2.47%), C (2, 2.47%), other recombinants (9, 11.11%), and undefined subtype (5, 6.17%). HIV-1 genotype distribution among travelers entering at two land ports is different, CRF01_AE and CRF08_BC accounted for a larger percentage among individuals from Daluo, whereas the proportions of subtype C and undefined URFs were larger among individuals from Mohan. The undefined subtype indicates the occurrence of novel HIV-1 subtype or CRF. This finding is useful for developing of AIDS prevention strategies.

Near-Full-Length Genome Sequences of a Novel HIV-1 Circulating Recombinant Form, CRF01_AE/B'/C (CRF78_cpx), in Yunnan, China

We report a novel HIV circulating recombinant form (CRF78_cpx) composed mainly of CRF01_AE with inserts from subtypes B and C identified from three epidemiologically unlinked individuals in Yunnan province, China. Two of the subjects are heterosexual men and one is a male intravenous drug user. Sequencing and analyzing the near-full-length genome of these three isolates (YNTC88, YNTC19, and YNTC35) revealed identical recombination breakpoints in all three viruses, but considerable genetic diversity between them, across the genomes, indicating that this is not a newly created CRF, only newly detected. CRF78_cpx differs from previously documented CRF01-AE/B'/C forms in its distinct backbone, inserted fragment size, and breakpoints, and is not related to other described recombinants in the region such as CRF07_BC or CRF65_cpx (also composed of CRF01_AE, B', and C). Our present findings further enrich the diversity of the prevalent HIV-1 CRFs in Yunnan, which is considered as an epicenter of HIV-1 infections in China.

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.

HIV-1 prevalence and subtype/recombinant distribution among travelers entering China from Vietnam at the HeKou port in the Yunnan province, China, between 2003 and 2012

The aim of this study was to assess HIV-1 prevalence and the distribution of HIV-1 subtypes among travelers crossing the border at the HeKou land port. Between 2003 and 2012, 22,799 persons were randomly recruited from people entering China from Vietnam. In this crossing border population, a total of 161 (0.71%) travelers were determined as HIV-1-positive. From them, 140 HIV-1-positive serum samples were collected for RNA extraction and subsequent RT-nested PCR amplification of the group-specific antigen (gag)-RT with a length of 2.6 kb. The DNA sequences were analyzed to determine the HIV-1 subtypes/recombinants. We found that the circulating recombinant form 01_AE (CRF01_AE) was the most common HIV-1 subtype, accounting for 49.4% (41/83) of the subtyped 83 samples, followed by CRF08_BC (26.5%, 22/83) and CRF07_BC (7.2%, 6/83). Only 1 sample was classified as subtype C. Thirteen cases could not be clustered into any known subtypes or CRFs and presented as unique recombinant forms (URFs). Of them, 6 recombination patterns were identified. They had distinct structures consisting of fragments of subtypes B, C, CRF01_AE, CRF07_BC and CRF08_BC. Between 2003 and 2012, CRF01_AE and CRE08_BC were shown to be the most prevalent recombinant forms identified each year. But yearly change of each subtype is uncertain regular among in these travelers during the past decade. Understanding the distribution of HIV-1 subtypes/recombinants and how it changes across time among individuals entering China from Vietnam through this land port is crucial to establish strategies for the prevention of HIV cross-border transmission.

Antiretroviral therapy reduces HIV transmission in discordant couples in rural Yunnan, China

Background

Although HIV treatment as prevention (TasP) via early antiretroviral therapy (ART) has proven to reduce transmissions among HIV-serodiscordant couples, its full implementation in developing countries remains a challenge. In this study, we determine whether China's current HIV treatment program prevents new HIV infections among discordant couples in rural China.

Methods

A prospective, longitudinal cohort study was conducted from June 2009 to March 2011, in rural Yunnan. A total of 1,618 HIV-discordant couples were eligible, 1,101 were enrolled, and 813 were followed for an average of 1.4 person-years (PY). Routine ART was prescribed to HIV-positive spouses according to eligibility (CD4<350 cells/µl). Seroconversion was used to determine HIV incidence.

Results

A total of 17 seroconversions were documented within 1,127 PY of follow-up, for an overall incidence of 1.5 per 100 PY. Epidemiological and genetic evidence confirmed that all 17 seroconverters were infected via marital secondary sexual transmission. Having an ART-experienced HIV-positive partner was associated with a lower rate of seroconvertion compared with having an ART-naïve HIV-positive partner (0.8 per 100 PY vs. 2.4 per 100 PY, HR = 0.34, 95%CI = 0.12–0.97, p = 0.0436). While we found that ART successfully suppressed plasma viral load to <400 copies/ml in the majority of cases (85.0% vs. 19.5%, p<0.0001 at baseline), we did document five seroconversions among ART-experienced subgroup.

Conclusions

ART is associated with a 66% reduction in HIV incidence among discordant couples in our sample, demonstrating the effectiveness of China's HIV treatment program at preventing new infections, and providing support for earlier ART initiation and TasP implementation in this region.

Identification of 3 distinct HIV-1 founding strains responsible for expanding epidemic among men who have sex with men in 9 Chinese cities

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Objectives:

To investigate the epidemiological relationships between HIV-1 strains that are spread among the men who have sex with men (MSM) populations of 9 cities across China and to analyze the origins and divergence times of the major epidemic strains found in the MSM population.

Methods:

A total of 583 HIV-1-positive subjects were recruited from high-risk MSM populations in 9 cities across China between 2009 and 2011. Nucleotide sequences of 1.0-kb pro-RT regions were amplified and sequenced. Phylogenetic and Bayesian molecular clock analyses were performed.

Results:

The overall distribution of HIV-1 genotypes was as follows: CRF01_AE, 62.1%; CRF07_BC, 18.2%; subtype B (United States–European), 15.9%; subtype B', 0.7%; other recombinants, 3.1%. In addition to the 2 distinct CRF01_AE clusters [cluster 1 (n = 157, 26.9%) and cluster 2 (n = 196, 33.6%)] previously reported by our group, we identified a novel CRF07_BC cluster (cluster 3) (n = 94, 16.1%) unique to China's MSM population whose strains were homologous and could be detected in all 9 cities. These 3 lineages of HIV-1 strains (clusters 1–3) accounted for 76.7% (447 of 583) of infections among MSM in China as a whole. Clusters 1, 2, and 3 were estimated to have been introduced into the MSM population in 1999, 2001, and 2001, respectively, indicating that the newly identified CRF07_BC cluster 3 is not a young lineage. However, it spread quickly in recent years.

Conclusions:

We identified 3 distinct HIV-1 lineages (clusters 1–3) responsible for the recent upsurge of the AIDS epidemic among MSM in China. These 3 HIV-1 variants are spread widely among MSM throughout China, demonstrating remarkable founding effects.

Prevalence and mutation patterns of HIV drug resistance from 2010 to 2011 among ART-failure individuals in the Yunnan Province, China

BACKGROUND

Assessing the prevalence of HIV-1 drug-resistance and the mutation patterns associated with resistance in the geographical regions implementing free antiretroviral therapy (ART) in China is necessary for preventing the spread of resistant strains and designing the regimens for the subsequent therapies with limited resources.

METHODS

Plasma samples in different cities/prefectures were collected at Yunnan Provincial Hospital of Infectious Disease from January 2010 to December 2011. Genotyping of drug-resistant individuals was conducted using an in-house assay on plasma samples. Viral load, CD4 T cell counts and demographic data were obtained from medical records and an administered questionnaire.

RESULTS

A total of 609 pol sequences (515 ART-failure and 94 therapy-naïve individuals) derived from 664 samples were obtained. The prevalence of drug-resistance was 45.1% in the ART-failure individuals. Of these, 26.8% harbored HIV strains dually resistant to nucleoside reverse transcriptase inhibitors and non-nucleoside reverse transcriptase inhibitors, and 14.8% harbored HIV strains resistant to only one drug category. Mutations such as M184V/I, K103N, V106A, Y181C and G190A were common among the ART-failure individuals, and the frequencies of M184V/I, K103N and V106A were 28.2%, 19.2%, and 22.1%, respectively. The percentages of individuals exhibiting intermediate or high-level resistance to 3TC, FTC, EFV and NVP drugs were 28.4%, 28.2%, 37.3%, and 37.5%, respectively. Factors such as ethnicity, transmission route, CD4 counts, viral load and the duration of ART were significantly correlated with development of drug resistance in the ART-failure individuals.

CONCLUSIONS

The high prevalence of HIV drug-resistance observed among the ART-failure individuals from 2010 to 2011 in Yunnan province should be of increasing concern in regions where the implementation of ART is widespread. Education about the risk factors associated with HIV drug resistance is important for preventing and controlling the spread of HIV drug-resistant strains.

Prevalence, incidence, and residual risks for transfusion-transmitted human immunodeficiency virus Types 1 and 2 infection among Chinese blood donors

BACKGROUND

There are little data on human immunodeficiency virus (HIV) prevalence, incidence, or residual risks for transfusion-transmitted HIV infection among Chinese blood donors.

STUDY DESIGN AND METHODS

Donations from five Chinese blood centers in 2008 to 2010 were screened using two rounds of enzyme-linked immunosorbent assay for anti-HIV-1/2. A reactive result in either or both rounds led to Western blot confirmatory testing. HIV prevalence among first-time donors and incidence among repeat donors were examined. Weighted multivariable logistic regression analysis examined correlates of HIV confirmatory status among first-time donors. Residual risks were evaluated based on incidence among repeat donors.

RESULTS

Among 821,320 donations, 40% came from repeat donors. A total of 1837 (0.34%) first-time and 577 (0.17%) repeat donations screened reactive, among which 1310 and 419 were tested by Western blot. A total of 233 (17.7%) first-time and 44 (10.5%) repeat donations were confirmed positive. Prevalence was 66 infections per 100,000 (95% confidence interval [CI], 59-74) first-time donors. Incidence was 9 of 100,000 (95% CI, 7-12) person-years among repeat donors. Multivariable logistic regression analysis indicates that first-time donors 26 to 45 years old were 1.6 to 1.8 times likely to be HIV positive than those 25 years and younger. Donors with some college or above education were less likely to be HIV positive than those with middle school education, odds ratios (ORs) ranging from 0.35 to 0.60. Minorities were 1.5 times likely to be HIV positive than Han majority donors (OR, 1.6; 95% CI, 1.2-2.1). HIV residual risk was 5.4 (95% CI, 1.2-12.5) infections per million whole blood donations.

CONCLUSION

Despite the declining HIV epidemic in China, estimated residual risks for transfusion-transmitted HIV infection are still high.

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.

The human immunodeficiency virus-1 genotype diversity and drug resistance mutations profile of volunteer blood donors from Chinese blood centers

BACKGROUND

The global human immunodeficiency virus (HIV)-1 epidemic is becoming increasingly diverse and complex. Molecular epidemiologic characteristics were studied for HIV-1-infected blood donors from five Chinese regions to determine genotype diversity and drug resistance mutations (DRMs) profile.

STUDY DESIGN AND METHODS

HIV-1 confirmed-reactive serum samples were collected from 172 blood donors from five blood centers during 2007 to 2010. HIV-1 Pol including whole protease and partial reverse transcriptase genes was amplified, sequenced, and analyzed for the subtype determination and drug resistance profile description.

RESULT

A total of 113 amplified sequences including 82 from Kunming blood center and 31 from four other blood centers had the following genotype characteristics: G (0.9%), B (2.7%), circulating recombinant form (CRF) 01_AE (32.7%), CRF07_BC (22.1%), and CRF08_BC (41.6%). Female donors represent 45.1% of all cases and 63.9% cases with DRMs. The prevalence of samples with potential low or higher resistance among Chinese blood donors is 4.4%.

CONCLUSION

HIV-1 infection in Chinese blood donors is genetically diverse and the subtype distribution reflects that from the high-risk populations. Our results support continuous molecular epidemiologic surveillance for HIV-1 in blood donors as a part of a comprehensive HIV control program.

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 global status of HIV drug resistance: clinical and public-health approaches for detection, treatment and prevention

Antiretroviral therapy (ART) scale-up in resource limited settings (RLS) has been successful, utilizing a standardized population-based approach to ART delivery. An unintended consequence of treatment scale-up is the inevitable emergence of HIV drug resistance (HIV DR) in populations even when patient adherence to ART is optimally supported. HIV DR has the potential to undermine the dramatic gains that ART has had in reducing the morbidity and mortality of HIV-infected patients in RLS. Sustaining and expanding ART coverage in RLS will depend upon the ability of ART programs to deliver ART in a way that minimizes the emergence of HIVDR. Fortunately, current evidence demonstrates that HIVDR in RLS has neither emerged nor been transmitted to the degree that had initially been feared. However, due to a lack of standardized methodologies, HIVDR data from RLS can be difficult to interpret and may not provide the programmatic evidence necessary for public health action. The World Health Organization has developed simple, standardized surveys that generate comparable results to assess acquired and transmitted HIVDR for routine public health implementation in RLS. These HIVDR surveys are designed to be implemented in conjunction with annual monitoring of program and site factors known to create situations favorable to the developments of HIV DR.

Quality assurance in the HIV/AIDS laboratory network of China

Background In 2009, there were 8273 local screening laboratories, 254 confirmatory laboratories, 35 provincial confirmatory central laboratories and 1 National AIDS Reference Laboratory (NARL) in China. These laboratories were located in Center for Disease Control and Prevention (CDC) facilities, hospitals, blood donation clinics, maternal and child health (MCH) hospitals and border health quarantine health-care facilities.

Methods The NARL and provincial laboratories provide quality assurance through technical, bio-safety and managerial training; periodic proficiency testing; on-site supervisory inspections; and commercial serologic kit evaluations.

Results From 2002 to 2009, more than 220 million HIV antibody tests were performed at screening laboratories, and all reactive and indeterminate samples were confirmed at confirmatory laboratories. The use of highly technically complex tests, including CD4 cell enumeration, viral load, dried blood spot (DBS)-based early infant diagnosis (EID), drug resistance (DR) genotyping, HIV-1 subtyping and incidence assays, have increased in recent years and their performance quality is closely monitored.

Conclusion China has made significant progress in establishing a well-coordinated HIV laboratory network and QA systems. However, the coverage and intensity of HIV testing and quality assurance programmes need to be strengthened so as to ensure that more infected persons are diagnosed and that they receive timely prevention and treatment services.

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.

Near full-length genomic characterization of a novel HIV type 1 subtype B/C recombinant strain from Yunnan, China

Recombination contributes substantially to the genetic diversity of HIV-1, and mosaic strains arise frequently, especially in populations in which multiple subtypes circulate. Yunnan, which borders the "Golden triangle" region of Southeast Asia in the south, was considered as the epicenter of China. B, CRF01_AE, CRF07_BC, and CRF08_BC are all currently involved in the HIV-1 epidemiology in the area, which suggested the possible emergence of a new recombination. This study presented a near full-length genomic analysis of a novel HIV-1 recombination involving B and C. Different from the reported CRF07_BC and CRF08_BC, the new recombination revealed more breakpoints. This is the first report of a novel recombination involving subtype B and C in Yunnan, China. More work is needed to determine the epidemiologic significance of the new recombination.

Resistance considerations in sequencing of antiretroviral therapy in low-middle income countries with currently available options

PURPOSE OF REVIEW

Access to antiretroviral therapy (ART) has been scaled-up in low-middle income countries (LMICs), where the majority of the world's HIV-1-infected population is living. Concerns towards the emergence and spread of HIV-1 drug resistance exist, given the lack of virological monitoring which may give rise to accumulation of resistance as well as the use of suboptimal ART in pregnant women with the aim to reduce perinatal transmission. Knowledge of the prevalence of transmitted and emerging drug resistance as well as its specific patterns is of help in guiding the selection of appropriate ART types and sequencing strategies.

RECENT FINDINGS

Whereas transmitted drug resistance in LMIC is still limited, resistance in pregnant women as a consequence of suboptimal ART for the prevention of vertical transmission is frequent and dependent on viral subtype and load. Accumulation of drug resistance during first-line ART depends on the frequency of monitoring, whereas mutational patterns are influenced by type of ART and, partly, viral subtype.

SUMMARY

Optimized ART for prevention of mother-to-child transmission and closer monitoring of ART programs with the inclusion of viral load may help reducing unnecessary development of HIV drug resistance in LMIC and preserve the limited available treatment options.