AIDS incidence trends at presentation and during follow-up among HIV-at-risk populations: a 15-year nationwide cohort study in Taiwan

Emerging and Reemerging Parasitic Diseases in Taiwan: A Retrospective Study of Clinical Case Reports in 2001~2018

Emerging and re-emerging parasitic diseases can cause significant economic burdens at national and global levels. However, governments often underestimate or ignore these diseases, especially in developed countries. This retrospective, case-oriented study analyzed parasitic diseases reported in Taiwan between 2001 and 2018. One hundred and thirty-two eligible clinical profiles of Taiwanese patients obtained from the NCBI, Scopus, Google Scholar, and Web of Science databases and local journals according to age, sex, source of infection, symptoms, risk factors, and geographical regions were analyzed. The analysis results showed that the number/frequency of cases caused by nematodes (46.97%) or protozoa (37.88%) was significantly higher than that of trematodes (9.85%) or cestodes (5.30%) (p < 0.0001). Northern Taiwan (46.97%) had a significantly higher rate than Southern Taiwan (33.33%), Central Taiwan (8.33%), and Eastern Taiwan (5.30%) (p < 0.05). The 15-65 age group (68.94%) had a significantly higher rate than the 65-90 age group (22.73%) and the 0-15 age group (8.33%) (p < 0.0001). Males (70.46%) had a significantly higher number/frequency of cases than females (29.54%) (p < 0.0001). People who acquired the infection through the food/soil route (32.58%) or who had a low immune status (32.58%) had a higher rate than travel-related infections (15.15%) (p < 0.001). The present study showed that emerging/reemerging parasitic infections continue to be of great concern to the lives and health of Taiwanese citizens and, if ignored, will threaten the health of the Taiwanese people; therefore, the delineation of preventive measures by health authorities is urgently warranted.

Enhancing indicator condition-guided HIV testing in Taiwan: a nationwide case-control study from 2009 to 2015

BACKGROUND

Although indicator condition (IC)-guided HIV testing (IC-HIVT) is effective at facilitating timely HIV diagnosis, research on IC categories and the related HIV risk in Taiwan is limited. To improve the adoption and spread of IC-HIVT in Taiwan, this study compared the IC categories of people living with HIV (PLWH) and non-HIV controls and investigated delays in the diagnosis of HIV infection.

METHODS

This nationwide, retrospective, 1:10-matched case-control study analyzed data from the Notifiable Diseases Surveillance System and National Health Insurance Research Database to evaluate 42 ICs for the 5-year period preceding a matched HIV diagnostic date from 2009 to 2015. The ICs were divided into category 1 ICs (AIDS-defining opportunistic illnesses [AOIs]), category 2 ICs (diseases associated with impaired immunity or malignancy but not AOIs), category 3 ICs (ICs associated with sexual behaviors), and category 4 ICs (mononucleosis or mononucleosis-like syndrome). Logistic regression was used to evaluate the HIV risk associated with each IC category (at the overall and annual levels) before the index date. Wilcoxon rank-sum test was performed to assess changes in diagnostic delays following an incident IC category by HIV transmission routes.

RESULTS

Fourteen thousand three hundred forty-seven PLWH were matched with 143,470 non-HIV controls. The prevalence results for all ICs and category 1-4 ICs were, respectively, 42.59%, 11.16%, 15.68%, 26.48%, and 0.97% among PLWH and 8.73%, 1.05%, 4.53%, 3.69%, and 0.02% among non-HIV controls (all P < 0.001). Each IC category posed a significantly higher risk of HIV infection overall and annually. The median (interquartile range) potential delay in HIV diagnosis was 15 (7-44), 324.5 (36-947), 234 (13-976), and 74 (33-476) days for category 1-4 ICs, respectively. Except for category 1 for men who have sex with men, these values remained stable across 2009-2015, regardless of the HIV transmission route.

CONCLUSIONS

Given the ongoing HIV diagnostic delay, IC-HIVT should be upgraded and adapted to each IC category to enhance early HIV diagnosis.

Comprehensive Comparisons of Family Health Between Families With One Immigrant Parent and Native Families in Taiwan: Nationwide Population-Based Cohort Study

BACKGROUND

Mothers and children in families with one immigrant parent have been reported to be healthier than those in native families; however, the health of the fathers in these families has rarely been discussed in literature.

OBJECTIVE

We aimed to comprehensively compare the health of all the family members between families with one immigrant parent (native fathers, immigrant mothers, and their children) and native families (native fathers, native mothers, and their children).

METHODS

We conducted a cohort study by using the Taiwan Maternal and Child Health Database to recruit live-born children and their parents from 2004 to 2016. Overall, we identified 90,670 fathers, 91,270 mothers, and 132,457 children in families with one immigrant parent and 1,666,775 fathers, 1,734,104 mothers, and 2,637,191 children in native families and followed up with them from 2004 to 2017. The outcomes comprised common physical and mental disorders, catastrophic illnesses, mortality, and child adversities and accidents. The covariates comprised the child's year of birth, parental age, low-income status, and physical or mental disorder status. Logistic regression was performed to compare the risks of the outcomes between families with one immigrant parent and native families.

RESULTS

The parents in families with one immigrant parent were more likely to be of low-income status and were older than the parents in native families. After adjusting for the covariates, fathers in families with one immigrant parent were found to have higher risks of physical and mental disorders, catastrophic illness, and mortality than fathers in native families. Conversely, mothers in families with one immigrant parent had lower risks of physical and mental disorders, catastrophic illness, and mortality than mothers in native families. Finally, the children in families with one immigrant parent generally had better physical and mental health but higher risks for leukemia, liver diseases, autism spectrum disorder, and road traffic accidents than children in native families.

CONCLUSIONS

The health status of the members of families with one immigrant parent was nonhomogeneous, and the poorer general health of fathers in such families suggests health inequalities in families with one immigrant parent.

Sex stratification of the trends and risk of mortality among individuals living with HIV under different transmission categories

We retrospectively examined 33,142 persons living with HIV (PLWH) in Taiwan from a nationwide database to assess sex-stratified trends and risk of all-cause mortality under different transmission categories from 1984 to 2016. Overall, 61.25% were men who have sex with men (MSM), 14.37% were men who have sex with women (MSW), 18.32% were male persons who inject drugs (M-PWID), 3.30% were women who have sex with men (WSM), and 2.74% were female PWID (F-PWID). All-cause mortality (per 100 person-years) among heterosexual people and PWID was higher in men (4.04 and 3.39, respectively) than in women (2.93 and 2.18, respectively). In each sex-stratified transmission category, the all-cause mortality reduced substantially from 1984–1996 to 2012–2016, but evolved distinctly from 2007–2011 to 2012–2016. Since 2007–2011, the decline in all-cause mortality has slowed notably in the groups with sexually transmitted HIV, but has increased in PWID, surpassing even that among groups with sexually transmitted HIV in 2012–2016. PLWH with sexually transmitted HIV had lower risks of all-cause mortality than PWID, regardless of sex. Sex and transmission category did not interact significantly on all-cause mortality. Understanding the reasons for the distinct evolving trends of all-cause mortality in each transmission category serves as a reference for developing strategies to reduce mortality in PLWH in Taiwan further.

Late cART Initiation Consistently Driven by Late HIV Presentation: A Multicenter Retrospective Cohort Study in Taiwan from 2009 to 2019

INTRODUCTION

Late initiation (LI) of combination antiretroviral therapy (cART)-defined as having a CD4⁺ count of < 200 cells/μL or an AIDS-defining disease at cART initiation-has detrimental outcomes but remains prevalent worldwide, with LI trends and etiologies following the implementation of various HIV policies remaining underinvestigated. We assessed key concerns, characterized the determinants of various statuses at cART initiation, and evaluated the effects of those statuses on all-cause mortality after cART initiation.

METHODS

This multicenter retrospective cohort study enrolled 1198 patients with newly diagnosed HIV infection during 2009-2019 who were grouped by status at cART initiation: those without LI (non-LI group, 56.01%); those with LI but without late presentation (LP) of HIV (LP: a CD4 + count of < 200 cells/μL at HIV presentation or AIDS events ≤ 3 months of HIV diagnosis) [LILP(-) group, 4.51%]; and those with LI and with LP of HIV [LILP(+) group, 39.48%]. Joinpoint regression was used to identify changes in LI proportion.

RESULTS

The median CD4⁺ count at cART initiation increased significantly between 2009 (98 cells/μL) and 2015 (325 cells/μL) and stabilized thereafter (P for trend < 0.001). For LI, we identified one joinpoint in 2015: a substantial decrease from 77.14% in 2009 to 34.45% in 2015, followed by a nonsignificant increase to 39.1% in 2019. Overall, LILP(+) explained 89.8% of LI, without significant changes (92.59% in 2009 to 94.23% in 2019). In addition to HIV diagnosis during 2009-2012, multinomial logistic regression identified an age over 30 years and acute HIV infection as risk factors for LILP(+) and LILP(-), respectively. LILP(-) and LILP(+) were associated with a higher all-cause mortality risk.

CONCLUSION

Given the rise in LI from 2015 in the era of treat-all and rapid cART initiation, strategic interventions to increase earlier cART initiation must be intensified in Taiwan, especially among populations with delayed access to HIV testing services.

Familism and HIV Risk Among Men Who Have Sex With Men in Taiwan: The Mediating Roles of Stressful Life Events and Coping Strategies

Familism may play an important role in HIV risk behaviors among men who have sex with men (MSM) living in a collectivist culture. This study examined a hypothesized path from familism, stressful life events (i.e., adverse childhood experiences, intimate partner violence, and sexuality-related discriminatory experiences), and coping strategies to condomless anal sex (CAS) among Taiwanese MSM. Participants were 1,000 MSM (mean age = 28.5 years) recruited through five community-based organizations. Structural equation modeling using bootstrapping with 3,000 iterations evaluated the mediating effects of 14 coping strategies. We found a pathway from familism to CAS through stressful life events and substance use coping. The protective effects of familism on stressful life events and CAS suggest that integrating components of family support and family connection into HIV prevention and education programs may increase the effectiveness of these programs in reducing HIV risk behaviors and dysfunctional coping strategies among MSM in Taiwan.

Different Trends of Distinct Time Points of AIDS Events Following HIV Diagnosis in Various At-risk Populations: A Retrospective Nationwide Cohort Study in Taiwan

Introduction

Acquired immune deficiency syndrome (AIDS) events at distinct time points after human immunodeficiency virus (HIV) diagnosis require various AIDS prevention strategies. However, no nationwide epidemiological surveillance studies have been conducted to explore the trends of distinct AIDS event time points in various at-risk populations. The aim of this study was to explore the issues and characterize the determinants of AIDS status after HIV diagnosis.

Methods

This nationwide cohort study enrolled HIV-positive Taiwanese during 1984–2016. AIDS events were classified into three time points (≤ 3, 4–12, > 12 months) by their occurrence time after HIV diagnosis. The periods of HIV/AIDS diagnosis were divided into six categories according to the calendar year of HIV/AIDS diagnosis: 1984–1991, 1992–1996, 1997–2001, 2002–2006, 2007–2011, and 2012–2016. HIV-positive Taiwanese during 1984–2011 were then selected to determine the factors associated with four AIDS statuses within 5 years after HIV diagnosis (no AIDS, AIDS ≤ 3 months, within 4–12 months, > 12 months) using multinomial logistic regression.

Results

Of 33,142 cases, we identified 15,254 (46%) AIDS events. The overall AIDS incidence (events/100 person-years) peaked during 1992–1996 (20.61), then declined, and finally stabilized from 2002 (8.96–9.82). The evolution of the proportion of distinct time points of AIDS events following HIV diagnosis changed significantly in heterosexuals and intravenous drug users (IDUs) during 1984–2016 (decline at ≤ 3 months in IDUs, decline at 4–12 months in IDUs, and increase at > 12 months in heterosexuals and IDUs) but not among men who have sex with men (MSM). Time points at ≤ 3 months remained at > 50% among MSM and at > 55% among heterosexuals. In multinomial logistic regression, IDUs (vs. men who have sex with men; MSM) had a lower risk of all AIDS statuses; heterosexuals (vs. MSM) had a higher risk of AIDS events ≤ 3 months after HIV diagnosis.

Conclusion

The magnitude of AIDS in Taiwan has been stable since 2002. Enhancing early diagnosis among people with sexual contact and optimizing the HIV care continuum among heterosexuals and IDUs should be priorities for further AIDS prevention strategies.

Cascade Analysis of Anonymous Voluntary HIV Counseling and Testing Among Patients with HIV Infection in Taiwan

Despite successful implementation of anonymous voluntary human immunodeficiency virus (HIV) counseling and testing (aVCT) in Taiwan, the trend of late HIV presentation in sexually active populations has remained unchanged in Taiwan over the past decade. We evaluated the effect and acceptance of an aVCT cascade program among Taiwanese individuals by surveying 572 participants (mean age: 29.6 years; 99.3% men; and 79.5% same-sex sexual contact) diagnosed with HIV/acquired immune deficiency syndrome (AIDS) from 2015 to 2019. We designed a five-stage continuum based on acceptance of the program before HIV diagnosis: at high risk of HIV infection (Stage 1), heard of aVCT (Stage 2), wants to receive aVCT (Stage 3), has received aVCT (Stage 4), and regularly receives aVCT (Stage 5). Four domains established from exploratory factor analysis described reasons for inability to reach the next aVCT stage: low perceived HIV risk, fear of testing positive because of discrimination/stigmatization, and structural barriers to aVCT. Regular aVCT (vs. never receiving aVCT) protected against AIDS on diagnosis (p < 0.001). There were no significant differences in program acceptance across 2015-2019. However, uptake reduced markedly across the program; the largest reduction (37.4.0-61.0%) occurred from Stage 4 to Stage 5. Fear of testing positive because of discrimination/stigmatization was the main reason for not proceeding to the next aVCT stage. Although the findings indicate the benefits of regular aVCT for early HIV diagnosis, additional strategies to reduce fear of negative social consequences of HIV infection are prioritized to optimize aVCT in Taiwan.

Reduced economic burden of AIDS-defining illnesses associated with adherence to antiretroviral therapy

OBJECTIVES

We assessed the economic burden of AIDS-defining illnesses (ADIs), which was further stratified by adherence to antiretroviral therapy (ART).

METHODS AND MATERIALS

A nationwide longitudinal cohort of 18,234 incident cases with HIV followed for 11years was utilized. Adherence to ART was measured by medication possession ratio (MPR). Generalized estimating equations modeling was used to estimate the cost impact of ADIs.

RESULTS

Having opportunistic infections increased the annual cost by 9% (varicella-zoster virus infection) to 98% (cytomegalovirus disease), while the annual costs increased by 26% (Kaposi's sarcoma) to 95% (non-Hodgkin's lymphoma) in the year when AIDS-related cancer occurred. ADIs occurred more frequently in the years with low adherence for ART compared to the high-adherence years (e.g., 0.1≤MPR<0.8 vs. MPR≥0.8, event rate of cytomegalovirus disease 4.03% vs. 0.51%). The annual baseline costs in the years with MPR<0.1, 0.1≤MPR<0.8, and MPR≥0.8 were $250, $4,752, and $8,990 (in 2018 USD), respectively. The economic impact of ADIs in the years with low adherence (MPR<0.1) was larger than that in the high-adherence years (MPR≥0.8) (e.g., MPR<0.1 vs. MPR≥0.8, annual cost increased by 244% vs. 9% when candidiasis occurred).

CONCLUSIONS

Adherence to ART may increase the baseline medical costs but mitigate the incidence and economic burden of ADIs.

Changing Spectrum of Opportunistic Illnesses among HIV-Infected Taiwanese Patients in Response to a 10-Year National Anti-TB Programme

The current trends and spectrum of acquired immunodeficiency syndrome (AIDS)-related opportunistic illnesses (AOIs) among newly diagnosed human immunodeficiency virus (HIV)-infected patients after the implementation of the 2006–2015 national anti-tuberculosis (TB) programmes in Taiwan remain unknown. We retrospectively reviewed 1757 patients at two centres in southern Taiwan between 2001 and 2015. Based on the anti-TB programme, patients were classified into periods 1 (2001–2005), 2 (2006–2010), and 3 (2011–2015). We further analysed factors associated with Mycobacterium tuberculosis (MTB) at presentation and during follow-up. The overall AOI incidence rate (23.6%) remained unchanged across the periods, with 81.4% of AOIs occurring at presentation. Pneumocystis jirovecii pneumonia was the leading AOI across the periods. MTB declined significantly from period 1 to period 3 (39.3% vs. 9.3%). Age and CD4+ cell count <200 cells/µL (vs. ≥501) were the risk factors associated with MTB at presentation, whereas period 2/3 (vs. period 1) was the protective factor. Intravenous drug use (vs. homosexual contact) was the risk factor associated with MTB during follow-up, and period 3 (vs. period 1) was the protective factor. AOI statistics in Taiwan must be closely monitored for fluctuations. Although MTB decreased substantially after implementation of the anti-TB programmes, additional efforts to reduce MTB are required.

No Association Between Human Immunodeficiency Virus Infections And Dementia: A Nationwide Cohort Study In Taiwan

BACKGROUND

The associations between the human immunodeficiency virus (HIV) and dementias are as yet to be studied in Taiwan. The aim of this study is to clarify as to whether HIV infections are associated with the risk of dementia.

METHODS

A total of 1,261 HIV-infected patients and 3,783 controls (1:3) matched for age and sex were selected between January 1 and December 31, 2000 from Taiwan's National Health Insurance Research Database (NHIRD). Fine and Gray's survival analysis (competing with mortality) analyzed the risk of dementias during the 15-year follow up. The association between the highly active antiretroviral therapy (HAART) and dementia was analyzed by stratifying the HAART status among the HIV subjects.

RESULTS

During the follow-up period, 25 in the HIV group (N= 1,261) and 227 in the control group (N= 3,783) developed dementia (656.25 vs 913.15 per 100,000 person-years). Fine and Gray's survival analysis revealed that the HIV patients were not associated with an increased risk of dementia, with the adjusted hazard ratio (HR) as 0.852 (95% confidence interval [CI]: 0.189-2.886, p=0.415) after adjusting for sex, age, comorbidities, geographical region, and the urbanization level of residence. There was no significant difference between the two groups of HIV-infected patients with or without HAART in the risk of dementia.

CONCLUSION

This study found that HIV infections, either with or without HAART, were not associated with increased diagnoses of neurodegenerative dementias in patients older than 50 in Taiwan.