HIV, syphilis, and behavioral risk factors among female sex workers before and after implementation of harm reduction programs in a high drug-using area of China

HIV testing and its associated factors among female sex workers in Iran in 2020: Finding from a respondent-driven sampling survey

HIV testing uptake was around 70% among female sex workers (FSWs) in Iran in 2015. Due to the recognized importance of HIV testing in prevention, care, and treatment among FSWs, this study aimed to provide an update and also an improvement as it uses respondent-driven sampling (RDS) for the frequency and the correlates of HIV testing among FSWs in Iran. A total of 1,515 FSWs were recruited from eight cities in Iran between 2019-2020 using RDS. Data were collected using face-to-face interviews. Also, rapid diagnostic tests (RDT) were used to determine HIV and syphilis status as per national guidelines. We used multivariable logistic regression to explore correlates of HIV testing in the last 12 months. Of 1,399 FSWs who had data for HIV testing, 44.7% (95% Confidence Intervals (CI): 40.7; 48.7) reported HIV testing in the last 12 months. The odds of HIV testing in the last 12 months was higher among FSWs who used a condom at last sex with a non-paying partner (Adjusted OR = 1.78; 95% CI: 1.39; 2.27), never used alcohol (Adjusted OR = 1.72; 95% CI: 1.33; 2.23), ever used drug (Adjusted OR = 1.60; 95% CI: 1.22; 2.08). HIV testing among FSWs in Iran is considerably low. It is necessary to know the barriers to HIV testing to improve the cascade of HIV treatment in the country.

Application of Bayesian networks to identify factors influencing acceptability of HIV pre-exposure prophylaxis in Guilin, China

Pre-exposure prophylaxis (PrEP) is an effective strategy to prevent uninfected individuals from contracting human immunodeficiency virus (HIV), however it must be acceptable to stakeholders in order to be effective. This study aimed to assess the acceptability of PrEP and related influencing factors. A cross-sectional survey was conducted among female sex workers (FSW), people who inject drugs (PWID), and men who have sex with men (MSM) using respondent driven sampling. Factors influencing PrEP acceptability were estimated using ordinal logistic regression and Bayesian networks. The survey included 765 eligible participants. The mean score of the perceived acceptability index was 3.9 (SD = 1.97). Multivariable logistic regression analysis revealed a higher acceptance of PrEP was associated with elder age, having other medical insurance, higher perceived utility of PrEP in facilitating prevention of HIV, higher perceived ease of use, higher perceived risk of increased risk behavior, higher perceived privacy problem in using PrEP, higher perceived comparative advantage over condom use, higher perceived comparative advantage of having sex when the urge arises, and higher perceived image of PrEP user as having sexual risky behavior, as public-minded and as health-conscious. The Bayesian network model showed perceived ease of use, perceived image of user as health-conscious, and perceived comparative advantage of having sex when the urge arises were directly associated with acceptability of PrEP. If these three factors were at a high level, 74.6% of the participants would have a high level of acceptability of PrEP. Effective education strategies to promote the acceptance of PrEP are needed. Implementation strategies should incorporate more inclusive messaging and build positive publicity for PrEP to reduce the stigma that PrEP use indicates risky behavior.

HIV/AIDS Among Female Sex Workers in China: Epidemiology and Recent Prevention Strategies

PURPOSE OF REVIEW

This review aims to describe the epidemiology of HIV among female sex workers (FSWs) in China over the past decade, to summarize current gaps in knowledge regarding risk factors, and to identify new directions for HIV prevention strategies.

RECENT FINDINGS

We summarized national and regional levels of HIV prevalence among FSWs based on reported rates in the literature from 2008 to 2018. Studies identified cases of HIV infection among FSWs in all but one province during this time period, and demonstrated a sporadic pattern in most provinces, with a low overall national HIV prevalence below 1%. However, in Yunnan and Guanxi Zhuang Autonomous Regions, the median-reported prevalence rates were close to or slightly above 1%. National prevention programs have widely promoted male condoms as a primary and practical measure for HIV prevention, but studies evaluating condom use practices among FSWs demonstrated wide variability. A rise in illicit use of synthetic drugs and changing sexual practices in the setting of sex work (e.g., anal sex) may represent newer risk factors for HIV transmission among FSWs; however, more data are needed to better characterize these trends. Limited studies have examined the feasibility and efficacy of innovative prevention tools (e.g., female condoms) or strategies (e.g., pre-exposure prophylaxis, PrEP) to prevent HIV among FSWs. We call for a more comprehensive understanding of current trends in HIV risk among FSWs, as well as more research focuses on innovative strategies to reduce the spread of HIV in this vulnerable population.

Systematic Review and Meta-Analysis of Global Prevalence of HBsAg and HIV and HCV Antibodies among People Who Inject Drugs and Female Sex Workers

The main objective of this study was to evaluate the prevalence of human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS), hepatitis C virus (HCV) and hepatitis B virus (HBV) and their co-infections among people who inject drugs (PWID) and female sex workers (FSWs). Data sources were searched from January 2008 to October 2018 in different databases. Data were analyzed in Stata 16 software using the Metaprop command. The results showed that the prevalence of HIV, HCV and HBV among PWID was 15%, 60% and 6%, respectively. The prevalence of HIV, HCV and HBV among FSWs was 5%, 1% and 3%, respectively. The prevalence of HIV/HCV, HIV/HBV, HCV/HBV and HIV/HCV/HBV co-infections among PWID was 13%, 2%, 3% and 2%, respectively. The prevalence of HIV/HCV and HIV/HBV co-infections among FSWs was 3% and 1%, respectively. The results show that the prevalence of HCV and HIV infections in PWID and the prevalence of HIV in FSWs is higher than their prevalence in the general population. Interventions for the prevention of HIV and HCV in PWID appear to be poor, and may not be sufficient to effectively prevent HIV and HCV transmission.

HIV Epidemiology and Prevention in Southwestern China: Trends from 1996-2017

The aim of this review is to describe long-term HIV epidemiology and prevention trends in Guangxi, a provincial-level region located along a major drug trafficking corridor in southwestern China. Between 1996 and 2006, HIV transmission in Guangxi was primarily fueled by Injection Drug Use (IDU). Since 2006, heterosexual sex has become the dominant mode of HIV transmission, followed by drug injection. Moreover, older, heterosexual adults appear to be at increased risk for HIV. The vast majority of new HIV cases are attributed to local HIV subtypes already circulating within Guangxi (93%), though imported subtypes are associated with younger age groups. Since 2011, HIV incidence in Guangxi has stabilized, due in part to HIV prevention efforts that include expanded HIV testing, antiretroviral treatment, and other intervention measures. Between 1996 and 2017, Guangxi, China experienced dramatic changes in the primary HIV transmission mode and at-risk age group. Due in part to local and National AIDS control and prevention campaigns, HIV incidence trends in Guangxi no longer appear to be increasing.

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.

Disparities in HIV and syphilis prevalence and risk factors between older male clients with and without steady sex partners in southwestern rural China

Background

Heterosexual intercourse accounted for 93% of reported HIV cases in Guangxi, and Guangxi had 10% of China’s total number of reported HIV cases. Older men are particularly vulnerable to STIs, for example, 46% of Guangxi’s HIV cases were men over 50 years of age. As this is an under-studied population in China, effective prevention and control policies have yet to be developed. Thus, the aim of this study was to use a large-scale cross-sectional survey to understand the demographic and behavior factors associated with HIV and syphilis infections among older male clients of female sex workers (FSWs) in a high epidemic area of rural Guangxi, China.

Methods

A large-scale cross-sectional survey was conducted in 2012 among older male clients of FSWs in low-cost commercial sex venues. Questionnaire interviews were administered to collect sociodemographic and sexual behavior information. Blood samples were collected for HIV and syphilis infection tests.

Results

Of the 3485 participants, 2509 (72.0%) clients had a steady sex partner and 976 (28.0%) clients had no steady sex partner. The overall prevalence of HIV and syphilis infection were 3.0% and 3.2%, respectively. Compared to those with a steady sex partner, clients with no steady partner had higher odds of HIV infection (AOR: 1.90, 95% CI: 1.27–2.86), syphilis infection (AOR: 1.53, 95% CI: 1.02–2.30), and having factors associated with HIV or syphilis infection, including non-commercial casual sex encounters in last month (AOR: 3.29, 95% CI: 2.42–4.46), >10 years of commercial sex history (AOR: 1.31, 95% CI: 1.12–1.53), >2 incidents of commercial sex in last month (AOR: 1.53, 95% CI: 1.19–1.96), and aphrodisiac use in last month (AOR: 1.40, 95% CI: 1.16–1.70). Clients with no steady partner had lower odds of having heterosexual intercourse (AOR: 0.66, 95% CI: 0.56–0.79), awareness and knowledge of HIV/AIDS (AOR: 0.75, 95% CI: 0.64–0.88), and having had HIV tests (AOR: 0.65, 95% CI: 0.44–0.98).

Conclusion

Older male clients of low-cost commercial sex venues in rural southwestern China are at high risk for HIV and syphilis infection, especially those with no steady sex partner. Improved interventions are urgently needed for this neglected risk population.

Clinical Outcomes of In Vitro Fertilization among Chinese Infertile Couples Treated for Syphilis Infection

To compare the clinical outcomes of infertile patients with and without syphilis after in vitro fertilization and embryo transfer (IVF-ET), in this case-control study, 320 infertile couples were enrolled and divided into syphilis (n = 160) and control groups (n = 160). The primary IVF outcomes were the clinical pregnancy rate and the birth of a healthy baby. All syphilis patients received the standard anti-syphilis treatment before undergoing IVF/ICSI. Our results showed that the endometrial thickness of the syphilis group was greater than that of the control group following hCG injection (16.9±5.4 vs. 13.0±4.7 mm, P<0.001). The numbers of normally fertilized eggs and normally cleaved fertilized eggs and the implantation rate were 6.8±4.8, 6.3±4.7 and 24.2%, respectively, for the syphilis group and 8.3±4.6, 8.1±4.6 and 34.4%, respectively, for the control group, and these values were significantly different between the groups. The clinical pregnancy rate was lower in the syphilis group compared with that in the control group (43.8% vs. 55.6%, P = 0.03). Lower offspring birth weight was observed in the infected male group compared with those in the infected female (2.7±0.4 vs. 3.0±0.4 kg, P = 0.01) and infected couple groups (2.7±0.4 vs. 3.1±0.5 kg, P = 0.007). Therefore, syphilis infection reduces the clinical pregnancy rate after IVF/ICSI.

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

The Chinese national observational cohort study suggests that the treatment-as-prevention (TasP) approach can be an effective public health HIV-1 prevention strategy. However, results from that study may have been biased because the follow-up time of index patients prior to their initiation of antiretroviral therapy (ART) was excluded. In this study, we correct for such bias by using an extended time-dependent Cox regression model to conduct a cohort study analysis of serodiscordant couples in Guangxi of China, inclusive of all follow-up time. During the follow-up of this observational cohort study of HIV-1 sero-discordant couples, the positive index partners may have never be treated with ART, or enter untreated but subsequently began treatment, or may have been treated immediately upon entry into the public health system. The treatment effectiveness of ART in HIV-1 acquisition among HIV-negative partners is assessed by the extended Cox regression model with treatment status as a time-varying covariate. A total of 6548 sero-discordant couples were included in the cohort study analysis. Among them, 348 negative partners sero-converted. HIV seroincidence was significantly higher among the nontreated (4.3 per 100 person-years, 3.7-4.9) compared with those receiving ART (1.8 per 100 person-years, 1.5-2.0). An overall 35% reduction in risk of HIV transmission was associated with receiving ART (adjusted hazard ratio [AHR] 0.65, 95% confidence interval [CI] 0.51-0.83), and the yearly risk reduction was also significant in the first 3 consecutive years of follow-up. Moreover, ART was found to be significantly inversely associated with multiple baseline characteristics of index partners. TasP may be feasible on a national or regional scale. In addition to other proven preventive strategies such as the use of condoms, ART adherence to maintain viral suppression would then be the key challenge for successful TasP implementation.

Bridging the epidemic: a comprehensive analysis of prevalence and correlates of HIV, hepatitis C, and syphilis, and infection among female sex workers in Guangxi Province, China

INTRODUCTION

Female sex workers (FSWs) are at highest risk for contracting HIV and facilitating the current heterosexual HIV epidemic in Guangxi, China, yet little is known of the impact of recent harm reduction campaigns in the province. We analyzed sentinel surveillance data collected between 2010 and 2012 in Guangxi to explore correlations between the prevalence of HIV, hepatitis C (HCV), and syphilis and risk behaviors of different categories of FSWs in Guangxi.

METHODS

The sentinel surveillance data for 5,1790 FSWs in all 14 prefectures and 64 city/county regions of Guangxi, China from 2010 to 2012 were collected. Differences between three categories of FSWs (grouped by venue) and disease trends (HIV, HCV, and syphilis) by year were analyzed using bivariate and multivariate logistic regression analyses as to evaluate risk factors correlated with HIV, HCV, or syphilis infection.

RESULTS

HIV and HCV prevalence remained constant across the three FSW categories; however, syphilis prevalence showed a significant increase from 5.7% to 7.3% for low-tier FSWs. Most cases with HIV, HCV, syphilis and intravenous drug use were seen in low-tier FSWs. Testing positive for HIV and syphilis were most correlated with being HCV positive (AOR 4.12 and AOR 4.36), only completing elementary school (AOR 3.71 and AOR 2.35), low tier venues (AOR 2.02 and AOR 2.00), and prior STI (AOR 1.40 and AOR 3.56), respectively. HCV infection was correlated with ever injecting drugs (AOR 60.65) and testing positive for syphilis (AOR 4.16) or HIV (AOR 3.74).

CONCLUSIONS

This study highlights that low tier FSWs with lower formal education levels are the most vulnerable population at risk for acquiring and transmitting HIV, HCV, and syphilis in Guangxi, China. Condom distribution with evolution to safer sex practices are the reasons to explain the non-increasing prevalence of HIV, HCV in Guangxi for 2010-2012.

Introducing rapid oral-fluid HIV testing among high risk populations in Shandong, China: feasibility and challenges

BACKGROUND

This study was conducted to ascertain the feasibility of using rapid oral fluid testing as an alternative HIV testing method in China.

METHOD

This is a mixed-method study among men who have sex with men (MSM), female sex workers (FSW) and VCT clients, conducted in 4 cities in Shandong Province. A pre-tested questionnaire was administered to 1137 participants through face-to-face interview to assess demographic characteristics, HIV testing histories and willingness to accept rapid oral fluid testing. VCT clients were provided with the saliva test kits for a screening test and errors in operation were recorded. Testing results were compared between oral and blood testing. Short feedback questionnaire was administered to 200 FSW who had undergone oral testing.

RESULTS

The rate of willingness to take oral-fluid HIV testing among MSM, FSW and VCT clients was 72.8%, 72.1% and 67.4% respectively. Common errors recorded during test kit operation by the 229 VCT clients included: unpreparedness, wrong swab sampling, wrong dilution, wrong testing and inability to read test results. Advantages of oral testing listed by participants included: less intrusive, painlessness, easy self- testing and privacy. Disadvantages included perceived unreliable results (55.5%) and not nationally recognised (9%). Comparison of saliva and the blood testing results recorded a consistency rate of 0.970 (χ2 = 153.348, P < 0.001), implying an excellent consistency.

CONCLUSION

Introduction of oral rapid fluid testing as an alternative HIV testing method in China is highly feasible but with some challenges including low recognition and operation errors.