Articles tagged as "China"

CD4 counts at antiretroviral therapy start rising globally, but could do better!

Immunodeficiency at the start of combination antiretroviral therapy in low-,  middle-, and high-income countries.

The IeDEA and ART Cohort Collaborations. J Acquir Immune Defic Syndr 2014 Jan 1;65(1):e8-e16. doi: 10.1097/QAI.0b013e3182a39979.

Objective: To describe the CD4 cell count at the start of combination antiretroviral therapy (cART) in low-income (LIC), lower middle-income (LMIC), upper middle-income (UMIC), and high-income (HIC) countries.

Methods: Patients aged 16 years or older starting cART in a clinic participating in a multicohort collaboration spanning 6 continents (International epidemiological Databases to Evaluate AIDS and ART Cohort Collaboration) were eligible. Multilevel linear regression models were adjusted for age, gender, and calendar year; missing CD4 counts were imputed.

Results: In total, 379 865 patients from 9 LIC, 4 LMIC, 4 UMIC, and 6 HIC were included. In LIC, the median CD4 cell count at cART initiation increased by 83% from 80 to 145 cells/µL between 2002 and 2009. Corresponding increases in LMIC, UMIC, and HIC were from 87 to 155 cells/µL (76% increase), 88 to 135 cells/µL (53%), and 209 to 274 cells/µL (31%). In 2009, compared with LIC, median counts were 13 cells/µL [95% confidence interval (CI): -56 to +30] lower in LMIC, 22 cells/µL (-62 to +18) lower in UMIC, and 112 cells/µL (+75 to +149) higher in HIC. They were 23 cells/µL (95% CI: +18 to +28 cells/µL) higher in women than men. Median counts were 88 cells/µL (95% CI: +35 to +141 cells/µL) higher in countries with an estimated national cART coverage >80%, compared with countries with <40% coverage.

Conclusions: Median CD4 cell counts at the start of cART increased 2000-2009 but remained below 200 cells/µL in LIC and MIC and below 300 cells/µL in HIC. Earlier start of cART will require substantial efforts and resources globally.

Abstract access 

Editor’s notes: In this multi-cohort analysis spanning six continents, median CD4 counts at initiation of combination antiretroviral therapy were substantially higher in high-income compared to low- or middle-income countries. Median CD4 counts at initiation increased between 2002 and 2009 in most countries studied, but these increases were greater in low- and middle-income than high-income countries and were greater among men than women. Baseline CD4 counts in low- and middle-income countries were higher among countries with national antiretroviral therapy coverage of 80% or above. Nevertheless, despite the massive scale-up of antiretroviral therapy in low-income countries since 2002, the increases in median CD4 count at the start of antiretroviral therapy have been modest. Substantial efforts and resources are needed to achieve earlier implementation of antiretroviral therapy globally.

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Intervention efforts needed to improve mental health status of young female sex workers in China

Age group differences in HIV risk and mental health problems among female sex workers in Southwest China.

Su S, Li X, Zhang L, Lin D, Zhang C, Zhou Y. AIDS Care 2014 Jan 13. [Epub ahead of print]

HIV risk and mental health problems are prevalent among female sex workers (FSWs) in China. The purpose of this research was to study age group differences in HIV risk and mental health problems in this population. In the current study, we divided a sample of 1 022 FSWs into three age groups (≤ 20 years, 21-34 years, and ≥ 35 years). Results showed that among the three groups (1) older FSWs (≥ 35 years) were likely to be socioeconomically disadvantaged (e.g., rural residency, little education, employment in low-paying venues, and low monthly income); (2) older FSWs reported the highest rates of inconsistent, ineffective condom use, and sexually transmitted diseases history; (3) younger FSWs (≤ 20 years) reported the highest level of depression, suicidal thoughts and suicide attempts, regular-partner violence, and substance use; (4) all health-related risks except casual-partner violence were more prevalent among older and younger FSWs than among FSWs aged 21-34 years; and (5) age had a significant effect on all health indicators except suicide attempts after controlling for several key demographic factors. These findings indicate the need for intervention efforts to address varying needs among FSWs in different age groups. Specific interventional efforts are needed to reduce older FSWs' exposure to HIV risk; meanwhile, more attention should be given to improve FSWs' mental health status, especially among younger FSWs.

Abstract access 

Editor’s notes: Previous research has shown that there are significant HIV risks persisting in the female sex worker (FSW) populations in China, including very low condom use, low HIV testing rates, and high rates of sexually transmitted infections. As with sex work populations in other parts of the world, research has also revealed high rates of substance use, depression, and violence among FSWs. In this study, conducted in two cities in south-western China, the research aimed to examine more closely the relationship between age, HIV risk, and mental health issues. The findings in this study reveal the older women (>35 years) tended towards more risky behaviour while the younger women (<20 years) expressed more issues around mental health. On first sight, this seems to contradict previous research; however, logically it makes sense that these two groups would tend towards more risky behaviour in order to gain and retain clients. The study has several implications for HIV and mental health interventions among FSWs in China. These include the need to provide knowledge, skills and counselling to improve coping strategies among FSWs, as well as extending health service coverage to women in sex work. 

Asia
China
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More evidence on men who have sex with men in Central Asia needed

Uncovering the epidemic of HIV among men who have sex with men in Central Asia.

Wirtz AL, Kirey A, Peryskina A, Houdart F, Beyrer C. Drug Alcohol Depend. 2013 Nov;132 Suppl 1:S17-24. doi: 10.1016/j.drugalcdep.2013.06.031. Epub 2013 Jul 29.

Background: Research among people who inject drugs (PWID) in Central Asia has described same sex behavior among male PWID and may be associated with HIV and other infections. Little is known about the population of men who have sex with men (MSM) and the burden of HIV among MSM in Central Asian countries.

Methods: We conducted a comprehensive search of peer-reviewed publications and gray literature on MSM and HIV in the region. Search strategies included terms for MSM combined with five Central Asian countries and neighbors, including Mongolia, Afghanistan, and Xinjiang Province, China.

Results: 230 sources were identified with 43 eligible for inclusion: 12 provided HIV prevalence and population size estimates for MSM, none provided incidence estimates, and no publications for Turkmenistan were identified. National reports estimate HIV prevalence among MSM to range from 1 to 2% in Kazakhstan, Kyrgyzstan, Tajikistan, Uzbekistan, Xinjiang, to 10% in Mongolia. Biobehavioral studies estimated HIV prevalence at 0.4% in Afghanistan and 20.2% in Kazakhstan. Sexual identities and behaviors vary across countries. Injection drug use was relatively low among MSM (<5% for most). Non-injection drugs, alcohol use prior to sex, and binge drinking were more common and potentially associated with violence. Criminalization of homosexuality (Afghanistan, Uzbekistan, and Turkmenistan) and stigma has limited research and HIV prevention.

Conclusion: Improved understanding of risks, including potential linkages between sexual exposures and substance use, among MSM are important for response. The little known about HIV among MSM in Central Asia speaks to the urgency of improvements in HIV research, prevention, and care.

Abstract access

Editor’s notes: In Central Asia, the HIV epidemic has historically been characterised as primarily being driven by injecting drug use. However, this is an over-simplification, and research with people who inject drugs is starting to show that some men who inject drugs, also have sex with men. This review compiled existing evidence about HIV among men who have sex with men (MSM) in the region, from both the academic and grey literature. The paper is important, both because of the insights that the findings provide, as well as because of the large gaps in data that it illustrates. Currently there is extremely limited data that can be used to characterise the burden of HIV and risk factors for HIV acquisition and transmission among MSM, including men who use drugs. This provides an incomplete picture of the HIV epidemic in the region. Stronger evidence about the broader range of vulnerable populations, and the interactions and overlapping of risk behaviours, is needed.  This is necessary to better understand and characterise the epidemic in each country in the region; and to help shape a more effective response.  

Asia
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An integrated investment approach for women’s and children’s health

Advancing social and economic development by investing in women's and children's health: a new Global Investment Framework.

Stenberg K, Axelson H, Sheehan P, Anderson I, Gülmezoglu AM, Temmerman M, Mason E, Friedman HS, Bhutta ZA, Lawn JE, Sweeny K, Tulloch J, Hansen P, Chopra M, Gupta A, Vogel JP, Ostergren M, Rasmussen B, Levin C, Boyle C, Kuruvilla S, Koblinsky M, Walker N, de Francisco A, Novcic N, Presern C, Jamison D, Bustreo F; on behalf of the Study Group for the Global Investment Framework for Women's Children's Health. Lancet. 2013 Nov 18. doi: S0140-6736(13)62231-X. pii: 10.1016/S0140-6736(13)62231-X. [Epub ahead of print]

A new Global Investment Framework for Women's and Children's Health demonstrates how investment in women's and children's health will secure high health, social, and economic returns. We costed health systems strengthening and six investment packages for: maternal and newborn health, child health, immunisation, family planning, HIV/AIDS, and malaria. Nutrition is a cross-cutting theme. We then used simulation modelling to estimate the health and socioeconomic returns of these investments. Increasing health expenditure by just $5 per person per year up to 2035 in 74 high-burden countries could yield up to nine times that value in economic and social benefits. These returns include greater gross domestic product (GDP) growth through improved productivity, and prevention of the needless deaths of 147 million children, 32 million stillbirths, and 5 million women by 2035. These gains could be achieved by an additional investment of $30 billion per year, equivalent to a 2% increase above current spending.

Abstract access 

Editor’s notes: Over the past 20 years there have been substantial gains in maternal and child health (MCH). However, much still needs to be done – assuming a continuation of current rates of progress, there would nevertheless be shortfalls in the achievement of MDG 4 and 5 targets. Especially in sub-Saharan Africa, HIV is an important underlying cause of maternal and child ill health. This paper models the costs and benefits of an accelerated action on MCH, including for HIV, the prevention of mother to child HIV transmission; first line treatment for pregnant women; cotrimoxazole for children, and the provision of paediatric antiretroviral therapy (ART). These HIV services are complemented by health systems strengthening; increased family planning provision; and packages for malaria, immunisation, and child health. The paper is interesting for many reasons, including both the breadth of its intervention focus, and the detailed modelling of the likely health, social and economic benefits of such investments.

Although the direct HIV related benefits are not described in detail in the main paper, it is likely that these result both from increased contraceptive use (prong 2 for preventing vertical HIV transmission), as well as ART and cotrimoxazole provision. It also illustrates the potential value of developing a cross-disease investment approach, as a means to ensure that services effectively respond to the breadth of women’s and children’s health needs. This more ‘joined up’, integrated perspective on strategies for health investment can support core investments in health systems strengthening. It can also potentially achieve important cross-disease synergies, e.g., ensuring that a child who has not acquired HIV at birth does not then die from malaria. 

Africa, Asia, Latin America, Oceania
Afghanistan, Angola, Azerbaijan, Bangladesh, Benin, Bolivia, Botswana, Brazil, Burkina Faso, Burundi, Cambodia, Cameroon, Central African Republic, Chad, China, Comoros, Congo, Côte d'Ivoire, Democratic People's Republic of Korea, Democratic Republic of the Congo, Djibouti, Egypt, Equatorial Guinea, Eritrea, Ethiopia, Gabon, Gambia, Ghana, Guatemala, Guinea, Guinea-Bissau, Haiti, India, Indonesia, Iraq, Kenya, Kyrgyzstan, Lao People's Democratic Republic, Lesotho, Liberia, Madagascar, Malawi, Mali, Mauritania, Mexico, Morocco, Mozambique, Myanmar, Nepal, Niger, Nigeria, Pakistan, Papua New Guinea, Peru, Philippines, Rwanda, Sao Tome and Principe, Senegal, Sierra Leone, Solomon Islands, Somalia, South Africa, Sudan, Swaziland, Tajikistan, Togo, Turkmenistan, Uganda, United Republic of Tanzania, Uzbekistan, Viet Nam, Yemen, Zambia, Zimbabwe
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Some evidence of impact from external funding for HIV, TB and malaria - and the need for more

Impact of external funding for HIV, tuberculosis and malaria: systematic review.

de Jongh TE, Harnmeijer JH, Atun R, Korenromp EL, Zhao J, Puvimanasinghe J, Baltussen R. Health Health Policy Plan. 2013 Aug 5. [Epub ahead of print]

Background:  Since 2002, development assistance for health has substantially increased, especially investments for HIV, tuberculosis (TB) and malaria control. We undertook a systematic review to assess and synthesize the existing evidence in the scientific literature on the health impacts of these investments.

Methods and Findings:  We systematically searched databases for peer-reviewed and grey literature, using tailored search strategies. We screened studies for study design and relevance, using predefined inclusion criteria, and selected those that enabled us to link health outcomes or impact to increased external funding. For all included studies, we recorded dataset and study characteristics, health outcomes and impacts. We analysed the data using a causal-chain framework to develop a narrative summary of the published evidence. Thirteen articles, representing 11 individual studies set in Africa and Asia reporting impacts on HIV, tuberculosis and malaria, met the inclusion criteria. Only two of these studies documented the entire causal-chain spanning from funding to programme scale-up, to outputs, outcomes and impacts. Nonetheless, overall we find a positive correlation between consecutive steps in the causal chain, suggesting that external funds for HIV, tuberculosis and malaria programmes contributed to improved health outcomes and impact.

Conclusions:  Despite the large number of supported programmes worldwide and despite an abundance of published studies on HIV, TB and malaria control, we identified very few eligible studies that adequately demonstrated the full process by which external funding has been translated to health impact. Most of these studies did not move beyond demonstrating statistical association, as opposed to contribution or causation. We thus recommend that funding organizations and researchers increase the emphasis on ensuring data capture along the causal pathway to demonstrate effect and contribution of external financing. The findings of these comprehensive and rigorously conducted impact evaluations should also be made publicly accessible.

Keywords: Africa, Asia, Health financing, developing countries, donors, health outcomes, impact

Abstract access

Editor’s notes: In the current context of resource constraints and after a decade of unprecedented increases in development assistance for health (particularly for HIV, tuberculosis and malaria), donors are increasingly concerned about the value for money of their investments. This study reviewed available evidence on the impact of external funding, finding a paucity of rigorous scientific evaluation data on the efficiency, effectiveness and impact.

The identified HIV studies found associations between programme investments and increased access and adherence to ART, as well as reduced HIV-related mortality, but limited evidence of preventive impacts on rates of HIV infection. There were many study limitations, including the lack of randomization or robust controls, and relatively small (or statistically insignificant) observed effects. Few studies provided a full analysis of effectiveness along the causal chain from inputs to impact, and none considered the potential undesirable effects of external funding.

Although the aims of the study were ambitious, this paper highlights the challenges of documenting the impacts of financial investments, with the authors arguing that future evaluations need to adopt a more systemic approach to impact evaluation that better captures the causal pathway between investment inputs and impacts, as well as broader system-wide effects. 

Africa, Asia
Cameroon, China, India, Kenya, Malawi, Zambia
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Combination HIV prevention for MSM needed urgently

The global HIV epidemics in MSM: time to act.

Beyrer C, Sullivan P, Sanchez J, Baral SD, Collins C, Wirtz AL, Altman D, Trapence G, Mayer K. AIDS. 2013 Aug6. [Epub ahead of print]

Epidemics of HIV in MSM continue to expand in most low, middle, and upper income countries in 2013 and rates of new infection have been consistently high among young MSM. Current prevention and treatment strategies are insufficient for this next wave of HIV spread. We conducted a series of comprehensive reviews of HIV prevalence and incidence, risks for HIV, prevention and care, stigma and discrimination, and policy and advocacy options. The high per act transmission probability of receptive anal intercourse, sex role versatility among MSM, network level effects, and social and structural determinants play central roles in disproportionate disease burdens. HIV can be transmitted through large MSM networks at great speed. Molecular epidemiologic data show marked clustering of HIV in MSM networks and high proportions of infections due to transmission from recent infections. Prevention strategies that lower biological risks, including those using antiretrovirals, offer promise for epidemic control, but are limited by structural factors including, discrimination, criminalization, and barriers to healthcare. Sub-epidemics, including among racial and ethnic minority MSM in the United States and UK, are particularly severe and will require culturally tailored efforts. For the promise of new and combined bio-behavioral interventions to be realized, clinically competent healthcare is necessary and community leadership, engagement, and empowerment are likely to be key. Addressing the expanding epidemics of HIV in MSM will require continued research, increased resources, political will, policy change, structural reform, community engagement, and strategic planning and programming, but it can and must be done.

Abstract access

Editor’s notes: This paper provides a useful summary of HIV epidemics among men who have sex with men, highlighting that infection levels continue to rise in most countries – both industrialized and developing, and including countries where HIV treatment is widely available. Drawing upon the findings from a range of comprehensive reviews, the paper presents important summary data on the prevalence of HIV among MSM.  It paints a global picture of the very high prevalence burdens found in the United States, the Caribbean, Peru, multiple African countries, Thailand, Myanmar, and parts of China, with the highest rates among the youngest age groups. The paper discusses options for prevention and treatment, arguing that much more needs to be done. The authors suggest that antiretrovirals – including both early treatment and PrEP, could be important additions for prevention.  However, these interventions will only be effective if strategies address structural barriers, including violence, stigmatization and criminalization. The authors argue that interventions and services need to be better equipped to respond to sub-epidemics in particularly marginalized MSM populations; and that an effective response will only be achieved through political will, community engagement and structural change.

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Distinct HIV and syphilis epidemics among MSM in China

HIV and syphilis prevalence among men who have sex with men: a cross-sectional survey of 61 cities in China.

Wu Z, Xu J, Liu E, Mao Y, Xiao Y, Sun X, Liu Y, Jiang Y, McGoogan JM, Dou Z, Mi G, Wang N, Sun J, Liu Z, Wang L, Rou K, Pang L, Xing W, Xu J, Wang S, Cui Y, Li Z, Bulterys M, Lin W, Zhao J, Yip R, Wu Y, Hao Y, Wang Y; the National MSM Survey Group. Clin Infect Dis. 2013 Apr 11. [Epub ahead of print]

Background: Human immunodeficiency virus (HIV) has rapidly spread among men who have sex with men (MSM) in China in recent years; the magnitude of the epidemic is unclear. We sought to test 3 hypotheses: (1) The prevalence of both HIV and syphilis among MSM in China is high, (2) the 2 epidemics each have unique geographical distributions, and (3) demographic and sexual behavior characteristics are different among segments of the MSM population in China.

Methods: A total of 47 231 MSM from 61 cities in China participated in a cross-sectional survey conducted from February 2008 to September 2009. Demographic and behavioral data were collected and analyzed and blood samples tested for HIV and syphilis. Three subgroups among the broader MSM sample were described. Main outcome measures were HIV and syphilis prevalence.

Results: An overall prevalence of 4.9% (2 314/47 231; 95% confidence interval [CI], 4.7%–5.1%) for HIV and 11.8% (5 552/47 231; 95% CI, 11.5%–12.0%) for syphilis was found. Syphilis-positive MSM had the highest HIV prevalence, 12.5% (693/5552; 95% CI, 11.6%–13.4%). However, correlations between HIV and syphilis prevalence were found in only 3 of 6 geographical regions (Northwest: r = 0.82, P = .0253; East: r = 0.78, P = .0004; and South-central: r = 0.63, P = .0276). Three subgroups—nonlocal MSM, Internet-using MSM, and female-partnering MSM—were found to have different profiles of characteristics and behaviors.

Conclusions: HIV and syphilis prevalences among MSM in China are high and the 2 epidemics are largely separate geographically. Three segments of the Chinese MSM population each have different demographic and sexual risk “profiles” that suggest high potential for bridging infection across geographies, generations, and sexes.

Abstract access

Editor’s notes: UNAIDS estimates that there are 740,000 people living with HIV in China, with an adult (15-49 years) prevalence of 0.1%. In the largest study of HIV and syphilis prevalence among MSM undertaken to date, the authors estimate the HIV prevalence among MSM in China to be 4.9% and of syphilis to be 11.8%. Survey participants were predominantly (92%) recruited by snowball sampling – a technique widely used in “hard-to-reach” populations, whereby existing study participants recruit future subjects from amongst their acquaintances. This can lead to biases, for example, those with more acquaintances may be more likely to be recruited. Nevertheless, the results suggest high prevalence of HIV and syphilis, with similar risk factors, but distinct geographical spread. These geographical diversities are attributed by the authors to different dominant modes of transmission of HIV in different regions, for example the spread of HIV through injecting drug use in the southwest. The Ministry of Health in China estimates that 17.4% of those living with HIV today were infected through homosexual transmission, making these results of importance for HIV prevention among MSM and other population groups. There is an interesting editorial commentary by Muessig and Cohen in the same issue of CID.

Comorbidity, Epidemiology
Asia
China
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The scale up of PMTCT in China

An integrated city-driven perinatal HIV prevention program covering 1.8 
million pregnant women in Shenzhen, China, 2000 to 2010.

Song J, Feng T, Bulterys M, Zhang D, Korhonen C, Shi X, Wang X, Cheng J, Chen L, Ma H. Sex Transm Dis. 2013
Apr;40(4):329-34. doi: 10.1097/OLQ.0b013e3182805186.

Background: Despite the scale-up of prevention of mother-to-child transmission (PMTCT) programs worldwide, the translation from research studies into public health policy has been slow. This report details the experiences of a city-driven PMTCT program in China using existing health resources.

Methods: The PMTCT program was devised to hospital based and city-wide. It achieves full use of available resources: the local Centers for Disease Control and Prevention, the Infectious Disease Hospital, Maternal and Child Health Hospitals, and all qualified comprehensive hospitals.

Results: From 2000 to 2010, 1 843 122 pregnant women attended prenatal care or labor and delivery services. Overall, 97.4% received pretest HIV counseling, and 96.2% were tested for HIV. Among the 81.1% (1 495 122) of women who attended prenatal clinics, 97.2% (1 452 753) received pretest counseling and 95.7% (1 430 799) were tested for HIV. Among the 18.9% (348 000) of women with an undocumented HIV status at labor and delivery, 98.6% (343 038) received pretest counseling, and 98.1% (341 371) were tested for HIV. In total, 229 women were determined HIV positive for a prevalence of 1.3 per 10 000 pregnant women. Among the 107 HIV-infected women who carried to delivery, 87.9% received antiretroviral prophylaxis for themselves and their infants. Among the 58 women who were identified HIV positive at labor, 10.3% of mothers and 72.4% of infants received antiretroviral prophylaxis. The estimated mother-to-child transmission rate was 5.3% (95% confidence interval, 2.2%, 10.7%).

Conclusions: With appropriate integration, existing health care resources are adequate for a comprehensive city-driven PMTCT program in an area with a low HIV prevalence.

Abstract access

Editor’s notes: The elimination of new HIV infections among children is an important UNAIDS goal. There is the potential for substantial numbers of vertical infections in countries such as China, that have a relatively low population prevalence of HIV infection, but large numbers of people that could be infected with HIV. This paper describes the findings from 10 years of implementing a city driven, large scale PMTCT programme that tested almost 1.5 million women over 10 years. The HIV infection rate detected was low (1.3/10 000 pregnant women), identifying 229 pregnant women living with HIV. Interestingly, less than a half (109) continued the pregnancy to delivery, with four-fifths of these women receiving ART drugs, resulting in a mother to child HIV transmission rate of 5.3%. This scale of programming and achievements is impressive, and illustrate the potential to deliver PMTCT programmes at scale. Questions remain regarding why so many women did not continue with their pregnancy, and the cost and cost-effectiveness of such a broad approach to PMTCT, compared to the potential use of a more targeted approach to PMTCT delivery.

Asia
China
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China's national free paediatric ART programme is shown to be effective and should be expanded

Mortality and treatment outcomes of China's National Pediatric antiretroviral therapy program.

Zhao Y, Li C, Sun X, Mu W, McGoogan JM, He Y, Cheng Y, Tang Z, Li H, Ni M, Ma Y, Chen RY, Liu Z, Zhang F. Clin Infect Dis. 2013 Mar;56(5):735-44. doi: 10.1093/cid/cis941.

BACKGROUND: The aim of this study was to describe 3-year mortality rates, associated risk factors, and long-term clinical outcomes of children enrolled in China's national free pediatric antiretroviral therapy (ART) program.

METHODS: Records were abstracted from the national human immunodeficiency virus (HIV)/AIDS case reporting and national pediatric ART databases for all HIV-positive children ≤15 years old who initiated ART prior to December 2010. Mortality risk factors over 3 years of follow-up were examined using Cox proportional hazards regression models. Life tables were used to determine survival rate over time. Longitudinal plots of CD4(+) T-cell percentage (CD4%), hemoglobin level, weight-for-age z (WAZ) score, and height-for-age z (HAZ) score were created using generalized estimating equation models.

RESULTS: Among the 1818 children included in our cohort, 93 deaths were recorded in 4022 child-years (CY) of observed time for an overall mortality rate of 2.31 per 100 CY (95% confidence interval [CI], 1.75-2.78). The strongest factor associated with mortality was baseline WAZ score <-2 (adjusted hazard ratio [HR] = 9.1; 95% CI, 2.5-33.2), followed by World Health Organization stage III or IV disease (adjusted HR = 2.4; 95% CI, 1.1-5.2), and hemoglobin <90 g/L (adjusted HR = 2.2; 95% CI, 1.2-3.9). CD4%, hemoglobin level, WAZ score, and HAZ score increased over time.

CONCLUSIONS: Our finding that 94% of children engaged in this program are still alive and of improved health after 3 years of treatment demonstrates that China's national pediatric ART program is effective. This program needs to be expanded to better meet treatment demands, and efforts to identify HIV-positive children earlier must be prioritized.

Abstract access 

Editor’s notes: This retrospective study presents encouraging treatment outcomes, in terms of both retention in care and mortality, among children in China’s national paediatric antiretroviral treatment programme. The very low loss to follow up is attributed to China’s household registration system and systems for tracking and following up people on ART. As the authors note, with a median age at ART initiation of 6.2 years, this cohort is biased towards children with a better chance of survival, given that it does not include children who acquired HIV by vertical transmission but died before starting ART. In addition, a substantial number of children were reported to the national HIV/AIDS Case Reporting System but were lost to follow up before starting ART. The report emphasises the need for earlier diagnosis and treatment initiation among children in China. 

Asia
China
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Lost in translation: antiretroviral treatment for discordant couples in the real world

Antiretroviral therapy to prevent HIV transmission in serodiscordant couples in China (2003-11): a national observational cohort study.

Jia Z, Ruan Y, Li Q, Xie P, Li P, Wang X, Chen RY, Shao Y. Lancet. 2012 Nov 30. pii: S0140-6736(12)61898-4. [Epub ahead of print]

Background: On the basis of the results of the randomised clinical trial HPTN 052 and observational studies, WHO has recommended that antiretroviral therapy be offered to all HIV-infected individuals with uninfected partners of the opposite sex (serodiscordant couples) to reduce the risk of transmission. Whether or not such a public health approach is feasible and the outcomes are sustainable at a large scale and in a developing country setting has not previously been assessed.

Methods: In this retrospective observational cohort study, we included treated and treatment-naive HIV-positive individuals with HIV-negative partners of the opposite sex who had been added to the national HIV epidemiology and treatment databases between Jan 1, 2003 and Dec 31, 2011. We analysed the annual rate of HIV infection in HIV-negative partners during follow-up, stratified by treatment status of the index partner. Cox proportional hazards analyses were done to examine factors related to HIV transmission.

Findings: Based on data from 38 862 serodiscordant couples, with 101 295·1 person-years of follow-up for the seronegative partners, rates of HIV infection were 2·6 per 100 person-years (95% CI 2·4-2·8) among the 14 805 couples in the treatment-naive cohort (median baseline CD4 count for HIV-positive partners 441 cells per μl [IQR 314-590]) and 1·3 per 100 person-years (1·2-1·3) among the 24 057 couples in the treated cohort (median baseline CD4 count for HIV-positive partners 168 cells per μl [62-269]). We calculated a 26% relative reduction in HIV transmission (adjusted hazard ratio 0·74, 95% CI 0·65-0·84) in the treated cohort. The reduction in transmission was seen across almost all demographic subgroups and was significant in the first year (0·64, 0·54-0·76), and among couples in which the HIV-positive partner had been infected by blood or plasma transfusion (0·76, 0·59-0·99) or heterosexual intercourse (0·69, 0·56-0·84), but not among couples in which the HIV-positive partner was infected by injecting drugs (0·98, 0·71-1·36).

Interpretation: Antiretroviral therapy for HIV-positive individuals in serodiscordant couples reduced HIV transmission across China, which suggests that the treatment-as-prevention approach is a feasible public health prevention strategy on a national scale in a developing country context. The durability and generalisability of such protection, however, needs to be further studied.

Funding: Chinese Government's 12th Five-Year Plan, the National Natural Science Foundation of China, and the Canadian International Development Research Centre.

Abstract access

Editor’s notes: There are numerous ways to look at treatment as prevention. The first important issue is somehow semantic. This paper very appropriately uses the wording "antiretrovirals to prevent transmission", which is the right definition for this kind of intervention. Indeed, the wording "treatment as prevention" shall imply a "clinical indication", which is not always there for prevention purposes.

Regarding the use of antiretrovirals for transmission prevention in discordant couples, the amazing 96% reduction shown by the HPTN052 study was appropriately described as the "Science — breakthrough of the year" in 2011. However, this very important paper from China emphasises the operational challenges, by describing the realistic efficiency, of this "public health prevention strategy on a national scale in a developing country context". Indeed, protection effect was there, but not 96%, just 26%. Not bad, but still significantly lower than that observed in the trial. Very clearly, some of the potential benefits have been "lost in translation". Indeed, as we know, real world data are very often different from what we see in trials. Indirectly, this paper raises another question:  the potential need to introduce PrEP (or possibly PEP) in discordant couples: clearly, the infected partner needs ART. However, there might be conditions (e.g. a desire to become pregnant) in which the HIV negative partner should take PrEP. In other words, as we seek discordant couples, are we more likely to recommend treating both partners?  In stable relationships: are we going to treat the HIV negative partner for a lifetime, as absolutely required for the index case?  These questions should clearly be addressed in future trials.

Asia
China
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