Nationwide Cohort Study of Antiretroviral Therapy Timing: Treatment Dropout and Virological Failure in China, 2011-2015

Factors associated with antiretroviral treatment adherence among people living with HIV in Guangdong Province, China: a cross sectional analysis

BACKGROUND

Understanding factors associated with antiretroviral treatment (ART) adherence is crucial for ART success among people living with HIV (PLHIV) in the "test and treat" era. Multiple psychosocial factors tend to coexist and have a syndemic effect on ART adherence. We aimed to explore factors associated with ART adherence and the syndemic effect of multiple psychosocial factors on ART adherence among PLHIV newly starting ART in Guangdong Province, China.

METHODS

Newly diagnosed PLHIV from six cities in Guangdong Province were recruited between May 2018 and June 2019, and then followed up from May 2019 to August 2020. Baseline and follow-up data were collected from a questionnaire and the national HIV surveillance system, the follow-up data of which were analyzed in this study. A Center for Adherence Support Evaluation (CASE) index > 10 points was defined as optimal ART adherence, which was measured via participants' self-reported adherence during follow-up survey. Multivariable logistic regression was used to identify factors associated with ART adherence. Exploratory factor analysis (EFA) and multi-order latent variable structural equation modeling (SEM) were performed to explore the syndemic effect of multiple psychosocial factors on ART adherence.

RESULTS

A total of 734 (68.53%) follow-up participants were finally included in this study among the 1071 baseline participants, of whom 91.28% (670/734) had self-reported optimal ART adherence. Unemployment (aOR = 1.75, 95%CI: 1.01-3.02), no medication reminder (aOR = 2.28, 95%CI: 1.09-4.74), low medication self-efficacy (aOR = 2.28, 95%CI: 1.27-4.10), low social cohesion (aOR = 1.82, 95%CI: 1.03-3.19), no social participation (aOR = 5.65, 95%CI: 1.71-18.63), and ART side effects (aOR = 0.46, 95%CI: 0.26-0.81) were barriers to optimal ART adherence. The EFA and second-order latent variable SEM showed a linear relationship (standardized coefficient = 0.43, P < 0.001) between ART adherence and the latent psychosocial (syndemic) factor, which consisted of the three latent factors of medication beliefs and self-efficacy (standardized coefficient = 0.65, P < 0.001), supportive environment (standardized coefficient = 0.50, P < 0.001), and negative emotions (standardized coefficient=-0.38, P < 0.01). The latent factors of medication beliefs and self-efficacy, supportive environment, and negative emotions explained 42.3%, 25.3%, and 14.1% of the variance in the latent psychosocial factor, respectively.

CONCLUSIONS

About nine out of ten PLHIV on ART in Guangdong Province self-reported optimal ART adherence. However, more efforts should be made to address barriers to optimal ART adherence.

Recommendations for the use of antiretroviral therapy in adults living with human immunodeficiency virus in Singapore

ABSTRACT

Since the advent of combination antiretroviral therapy (ART), the mortality attributable to human immunodeficiency virus (HIV) infection has decreased by 80%. Newer antiretroviral agents are highly efficacious, have minimal side effects as compared to older drugs, and can be formulated as combination tablets to reduce patients' pill burden. Despite these advances, 680,000 people worldwide died of acquired immunodeficiency syndrome-related illnesses in 2020. The National ART and Monitoring Recommendations by the National HIV Programme have been created to guide physicians on the prescribing of ART based on the patients' needs. These recommendations are based on international guidelines and tailored to the local context and unique domestic considerations. We hoped that with the publication of these recommendations, the care of people living with HIV can be enhanced, bringing us closer to ending HIV in our lifetime.

Rapid Initiation of Antiretroviral Therapy Under the Treat-All Policy Reduces Loss to Follow-Up and Virological Failure in Routine Human Immunodeficiency Virus Care Settings in China: A Retrospective Cohort Study (2016-2022)

Following the World Health Organization's guidelines for rapid antiretroviral therapy (ART) initiation [≤7 days after human immunodeficiency virus (HIV) diagnosis], China implemented Treat-All in 2016 and has made significant efforts to provide timely ART since 2017. This study included newly diagnosed HIV adults from Tianjin, China, between 2016 and 2022. Our primary outcome was loss to follow-up (LTFU) at 12 months after enrollment. The secondary outcome was 12-month virological failure. The association between rapid ART and LTFU, as well as virological failure, was assessed via Cox regression and logistic regression. A total of 896 (19.1%) of 4688 participants received ART ≤7 days postdiagnosis. The rate of rapid ART has increased from 7.5% in 2016 to 33.3% by 2022. The rapid ART group had an LTFU rate of 3.3%, as opposed to 5.0% in the delayed group. The rapid ART group had a much reduced virological failure rate (0.6% vs. 1.8%). Rapid ART individuals had a reduced likelihood of LTFU [adjusted hazard ratio: 0.65, 95% confidence intervals (CI): 0.44-0.96] and virological failure (adjusted odds ratio: 0.35, 95% CI: 0.12-0.80). The real-world data indicated that rapid ART is practicable and beneficial for Chinese people with HIV, providing evidence for its widespread implementation and scaling up.

Interruptions in treatment among adults on anti-retroviral therapy before and after test-and-treat policy in Tanzania

INTRODUCTION

The World Health Organization recommended the initiation of antiretroviral therapy (ART) for people living with HIV (PLHIV) regardless of CD4 cell counts. Tanzania adopted this recommendation known as test-and-treat policy in 2016. However, programmatic implementation of this policy has not been assessed since its initiation. The objective of the study was to assess the impact of this policy in Tanzania.

METHODS

This was a cross-sectional study among PLHIV aged 15 years and older using routinely collected program data. The dependent variable was interruption in treatment (IIT), defined as no clinical contact for at least 90 days after the last clinical appointment. The main independent variable was test-and-treat policy status which categorized PLHIV into the before and after groups. Co-variates were age, sex, facility type, clinical stage, CD4 count, ART duration, and body mass index. The associations were assessed using the generalized estimating equation with inverse probability weighting.

RESULTS

The study involved 33,979 PLHIV-14,442 (42.5%) and 19,537 (57.5%) were in the before and after the policy groups, respectively. Among those who experienced IIT, 4,219 (29%) and 7,322 (38%) were in the before and after the policy groups respectively. Multivariable analysis showed PLHIV after the policy was instated had twice [AOR 2.03; 95%CI 1.74-2.38] the odds of experiencing IIT than those before the policy was adopted. Additionally, higher odds of experiencing IIT were observed among younger adults, males, and those with advanced HIV disease.

CONCLUSION

Demographic and clinical status variables were associated with IIT, as well as the test-and-treat policy. To achieve epidemic control, programmatic adjustments on continuity of treatment may are needed to complement the programmatic implementation of the policy.

Prevalence of delayed antiretroviral therapy initiation among people living with HIV: A systematic review and meta-analysis

OBJECTIVE

HIV continues to be a global challenge. Key recommendations for HIV prevention and treatment are presented on rapid antiretroviral therapy (ART) initiation. However, several studies showed a high prevalence of delayed ART initiation. The aim of this systematic review and meta-analysis was to assess the prevalence of delayed ART initiation among HIV-infected patients globally.

METHODS

This review summarised eligible studies conducted between January 2015 and August 2022 on the prevalence of delayed ART initiation in HIV-infected adults (age ≥ 15). Relevant studies were systematic searched through PubMed/Medline, EMBASE, Web of Science, China National Knowledge Infrastructure, Wanfang, and Chongqing VIP databases. Random-effects models were used to calculate pooled prevalence estimates. The heterogeneity was evaluated using Cochran's Q test and I2 statistics. Moreover, potential sources of heterogeneity were explored using univariate subgroup analysis.

RESULTS

Data on the prevalence of delayed ART initiation was pooled across 29 studies involving 34,937 participants from 15 countries. The overall pooled prevalence of delayed ART initiation was 36.1% [95% confidence interval (CI), 29.7-42.5%]. In subgroup analysis, the estimated pooled prevalence decreased with age. By sex, the prevalence was higher among male patients (39.3%, 95% CI: 32.2-46.4%) than female (36.5%, 95% CI: 26.9-50.7%). Patients with high CD4 cell count were more likely to delay ART initiation than those with low CD4 cell count (>500cells/mm3: 40.3%; 201-500cells/mm3: 33.4%; and ≤200cells/mm3: 25.3%).

CONCLUSIONS

Our systematic review and meta-analysis identified a high prevalence of delayed ART initiation. The prolonged time interval between diagnosis and treatment is a prevalent and unaddressed problem that should spur initiatives from countries globally. Further research is urgently needed to identify effective strategies for promoting the early ART initiation.

Factors Associated With Delayed and Late Initiation of Antiretroviral Therapy Among Patients With HIV in Beijing, China, 2010-2020

Objectives: To determine factors associated with late and delayed antiretroviral therapy (ART) initiation in China and provide evidence for HIV prevention. Methods: Logistics regression model was used to determine factors associated with three outcomes: late (CD4 cell count <200 cells/µL or clinical AIDS diagnosis prior to ART initiation), delayed (more than 1 month between HIV diagnosis date and ART initiation) and either late or delayed ART initiation. Results: Multivariable analysis revealed that male, heterosexual, HIV diagnosis before 2014, HBV/HCV seropositive, and tuberculosis were associated with increased odds of all three outcomes. Conversely, married or cohabiting patients were less likely to have delayed ART initiation and either late or delayed ART initiation, while people who inject drugs were more likely to have these two outcomes. Additionally, older age was associated with an increased risk of having either late or delayed ART initiation, but a decreased risk of delayed ART initiation. Conclusion: The proportion of late and delayed ART initiation decreased significantly after the release of the 2016 guidelines in China. To further improve late diagnosis and early treatment, precise interventions for key populations are required.

HIV Late Presenters in Asia: Management and Public Health Challenges

Many individuals are diagnosed with human immunodeficiency virus (HIV) infection at an advanced stage of illness and are considered late presenters. We define late presentation as a CD4 cell count below 350 cells/mm³ at the time of HIV diagnosis, or presenting with an AIDS-defining illness regardless of CD4 count. Across Asia, an estimated 34-72% of people diagnosed with HIV are late presenters. HIV late presenters generally have a higher disease burden and higher comorbidity such as opportunistic infections than those who are diagnosed earlier. They also have a higher mortality rate and generally exhibit poorer immune recovery following combined antiretroviral therapy (cART). As such, late HIV presentation leads to increased resource burden and costs to healthcare systems. HIV late presentation also poses an increased risk of community transmission since the transmission rate from people unaware of their HIV status is approximately 3.5 times higher than that of early presenters. There are several factors which contribute to HIV late presentation. Fear of stigmatisation and discrimination are significant barriers to both testing and accessing treatment. A lack of perceived risk and a lack of knowledge by individuals also contribute to late presentation. Lack of referral for testing by healthcare providers is another identified barrier in China and may extend to other regions across Asia. Effective strategies are still needed to reduce the incidence of late presentation across Asia. Key areas of focus should be increasing community awareness of the risk of HIV, reducing stigma and discrimination in testing, and educating healthcare professionals on the need for early testing and on the most effective ways to engage with people living with HIV. Recent initiatives such as intensified patient adherence support programs and HIV self-testing also have the potential to improve access to testing and reduce late diagnosis.

Perceptions toward antiretroviral therapy and delayed ART initiation among people living with HIV in Changsha, China: mediating effects of treatment willingness

Introduction

Delayed antiretroviral therapy (ART) initiation is associated with poor HIV outcomes and a higher likelihood of HIV transmission.

Methods

This cross-sectional study assessed the proportion of delayed ART initiation which was defined as initiating ART after 30 days of HIV diagnosis, and evaluated the pathways influencing ART initiation among adult PLWH in Changsha, China who were diagnosed between 2014 and 2022.

Results

Of 518 participants, 37.8% delayed in initiating ART. Based on the theory of reasoned action (TRA), delayed initiation was indirectly associated with perceptions toward ART through the mediating pathway of patients' treatment willingness, with treatment willingness significantly being the full mediator.

Discussion

The findings may guide the development of interventions to improve timely uptake of ART in people who are newly diagnosed with HIV.

Peer-Led Community-Based Support Services and HIV Treatment Outcomes Among People Living With HIV in Wuxi, China: Propensity Score-Matched Analysis of Surveillance Data From 2006 to 2021

BACKGROUND

Community-based organizations deliver peer-led support services to people living with HIV. Systematic reviews have found that peer-led community-based support services can improve HIV treatment outcomes; however, few studies have been implemented to evaluate its impact on mortality using long-term follow-up data.

OBJECTIVE

We aimed to evaluate the associations between the receipt of peer-led community-based support services and HIV treatment outcomes and survival among people living with HIV in Wuxi, China.

METHODS

We performed a propensity score-matched retrospective cohort study using data collected from the Chinese National HIV/AIDS Comprehensive Information Management System for people living with HIV in Wuxi, China, between 2006 and 2021. People living with HIV who received adjunctive peer-led community-based support for at least 6 months from a local community-based organization (exposure group) were matched to people living with HIV who only received routine clinic-based HIV care (control group). We compared the differences in HIV treatment outcomes and survival between these 2 groups using Kaplan-Meier curves. We used competing risk and Cox proportional hazards models to assess correlates of AIDS-related mortality (ARM) and all-cause mortality. We reported adjusted subdistribution hazard ratio and adjusted hazard ratio with 95% CIs.

RESULTS

A total of 860 people living with HIV were included (430 in the exposure group and 430 in the control group). The exposure group was more likely to adhere to antiretroviral therapy (ART; 396/430, 92.1% vs 360/430, 83.7%; P<.001), remain retained in care 12 months after ART initiation (402/430, 93.5% vs 327/430, 76.1%; P<.001), and achieve viral suppression 9 to 24 months after ART initiation (357/381, 93.7% vs 217/243, 89.3%; P=.048) than the control group. The exposure group had significantly lower ARM (1.8 vs 7.0 per 1000 person-years; P=.01) and all-cause mortality (2.3 vs 9.3 per 1000 person-years; P=.002) and significantly higher cumulative survival rates (P=.003). The exposure group had a 72% reduction in ARM (adjusted subdistribution hazard ratio 0.28, 95% CI 0.09-0.95) and a 70% reduction in all-cause mortality (adjusted hazard ratio 0.30, 95% CI 0.11-0.82). The nonrandomized retrospective nature of our analysis prevents us from determining whether peer-led community-based support caused the observed differences in HIV treatment outcomes and survival between the exposure and control groups.

CONCLUSIONS

The receipt of peer-led community-based support services correlated with significantly improved HIV treatment outcomes and survival among people living with HIV in a middle-income country in Asia. The 15-year follow-up period in this study allowed us to identify associations with survival not previously reported in the literature. Future interventional trials are needed to confirm these findings.

Comparison of Immunological and Virological Recovery with Rapid, Early, and Late Start of Antiretroviral Treatment in Naive Plwh: Real-World Data

Background

Rapid initiation of antiretroviral therapy (ART) reduces the transmission of HIV infection in the community. This study aimed to determine whether rapid ART initiation is effective compared to standard ART treatment in our country.

Methods

Patients were grouped based on time to treatment initiation. HIV RNA levels, CD+4 T cell count, CD4/CD8 ratio, and ART regimens were recorded at baseline and follow-up visits for 12 months.

Results

There were 368-ART naive adults (treatment initiated at the time of HIV diagnosis; 143 on the first day, 48 on the second-seventh day, and 177 after the seventh day). Although virological suppression rates at 12^th months were higher in all groups, over 90% on average, there were no statistically significant differences in HIV-1 RNA suppression rates, CD+4 T cell count, and CD4/CD8 ratio normalization in the studied months but in multivariate logistic regression analysis; showed a significant correlation between both virological and immunological response and those with CD4+ T <350 cells/mL at 12th month in total patients.

Conclusion

Our findings support the broader application of recommendations for rapid ART initiation in HIV patients.

Association of low-level viremia with mortality among people living with HIV on antiretroviral therapy in Dehong, Southwest China: A retrospective cohort study

OBJECTIVES

To investigate the association of low-level viremia (LLV) with mortality among people living with HIV (PLHIV) on antiretroviral therapy (ART) in Dehong, Southwest China.

METHODS

We analysed data collected from a cohort of PLHIV on ART in Dehong. PLHIV were enrolled in this cohort after they started ART, with viral load (VL) tested once a year afterwards. Each VL level was then categorized into one of the four groups: <50, 50-199, 200-999 and ≥1000 copies/ml. VL levels of 50-199 and 200-999 copies/ml were defined as LLV. The VL level for each participant was re-categorized and fitted into an extended Cox regression model as a time-varying covariate to examine the associations of VL level with all-cause and AIDS-related deaths.

RESULTS

Among the included 7273 of 8762 PLHIV in this study, median age (interquartile range, IQR) was 36 (30-43) years and 59.9% were male. The patients were followed up for a median duration (IQR) of 6.2 (4.3-8.2) years. Compared with VL <50 copies/ml, LLV 200-999 copies/ml (adjusted hazard ratio [aHR] and 95% confidence interval [95% CI]: 1.56 [1.04, 2.32]) were associated with elevated risk of all-cause mortality and LLV50-199 (aHR [95% CI]: 1.00 [0.68, 1.45]) were not. Similarly, only LLV200-999 copies/ml (aHR [95% CI]: 2.37 [1.36, 4.14]) corresponded to higher risk of AIDS-related mortality.

CONCLUSIONS

This study suggests that PLHIV on ART may have elevated death risks even though the viremia is suppressed at a low level. Interventions targeting PLHIV with LLV should be developed to reduce their mortality.

Game-based health education to improve ART adherence of newly diagnosed young people with HIV: protocol for a stepped-wedge design randomized controlled trial

BACKGROUND

Antiretroviral therapy (ART) is one of the most effective ways for HIV-infected to treat AIDS. However, it is difficult to start ART among young people those newly diagnosed HIV-infection in China, and their adherence to ART is poor. We have designed an AIDS educational game called AIDS Fighter · Health Defense, which could improve the AIDS-related knowledge and has the potential to improve AIDS prevention ability of young students. In this study, AIDS Fighter · Health Defense will be used with newly diagnosed young people with HIV to evaluate the education effect of the game in improving ART adherence.

DESIGN

A stepped-wedge design randomized controlled trial will be conducted to confirm the education effect of AIDS Fighter · Health Defense on improving ART adherence of newly diagnosed young people with HIV, and to verify when to start game-based health education could be more effective for newly diagnosed young people with HIV.

METHODS

Participants will receive AIDS education from health workers and start ART when diagnosed with HIV and assigned into four groups randomly. The first step group to the fourth step group will receive AIDS Fighter · Health Defense in turn at the star of ART, one week, one month and three months after the start of ART. The primary outcomes are medication adherence, CD4( +) T cell count, and HIV viral load. The secondary outcomes are ART-related knowledge, ART-related skills, psychological resilience, and self-discrimination. Assessments will be completed before the intervention and one week, first month, and third month of the intervention, and then a one-year follow-up evaluation will be conducted after the intervention.

DISCUSSION

AIDS Fighter · Health Defense may be an effective approach to help newly diagnosed young people with HIV to improve ART adherence. A stepped-wedge design randomized controlled trial of this study may find the optimal time of AIDS education to improve ART adherence of newly diagnosed young people with HIV.

REGISTRATION NUMBER

Chinese Clinical Trial Registry: ChiCTR2200059766, registered 11 May 2022. http://www.chictr.org.cn/showproj.aspx?proj=169420.

Antiretroviral therapy initiation within 7 and 8-30 days post-HIV diagnosis demonstrates similar benefits in resource-limited settings

We estimated the optimum time to initiate antiretroviral therapy (ART) in a retrospective observational cohort. We observed that ART initiation 7 days or less ( n  = 817) and 8-30 days ( n  = 1009) were the most important factors with viral suppression, and had similar viral suppression rate, CD4 + T-cell count increase and fractions of individuals with links at least 4 and individuals linked to recent HIV infection in HIV molecular networks. This study provides real-world evidence on the benefits of rapid ART initiation in resource-limited setting.

Effect of Late Testing and Antiretroviral Treatment on Mortality Among People Living With HIV in the Era of Treat-All in Guangdong Province, China, 1992–2018: A Cohort Study

Late testing and antiretroviral therapy (ART) prevailed among people living with HIV (PLHIV) and impacted the benefit of immediate ART. This study aimed to identify the benefit of the test-and-immediate-treat policy in China, the effect of immediate ART, and the influence of late testing and ART on the whole PLHIV in Guangdong Province, China. We designed two tendency analyses in aggregative form and two cohorts (surveillance and ART cohort) in individuals' perspectives based on the HIV/AIDS Comprehensive Response Information Management System. Two interrupted time series models were conducted for tendency analysis from 2009 to 2018 to explore the all-cause and short-term mortality decrease after the test-and-immediate-treat policy. A time-dependent Cox model was performed for the surveillance cohort from 1992 to 2018 and a joint model was utilized for the ART cohort to identify the effect of immediate ART and the influence of late testing and ART on death. The tendency analysis included 324,914 and 68,679 person-year for all-cause/short-term mortality. A total of 49,289 and 26,287 PLHIV were recruited in the surveillance and ART cohort with 5,557 and 459 deaths, respectively. The short-term mortality dropped from 4.69 cases/100 person-year in January 2009 to 0.35 cases/100 person-year in December 2018 (standardized rate). The all-cause mortality saw a decreasing trend from 1.46 cases/100 person-year in January 2009 to 0.14 cases/100 person-year in December 2018 (standardized rate). The tendency analysis showed a significant short-term mortality slope decrease after the test-and-immediate-treat policy (P = 0.024). From the surveillance cohort, late testing, in general, was a risk factor for all-cause mortality [hazard ratio (HR) = 1.330, 95% CI, 1.250, 1.416]. ART cohort showed higher hazards of all-cause mortality among PLHIV with no late testing, but late ART (HR = 1.690, 95% CI, 1.166, 2.451) and both the late testing and late ART (HR = 1.335, 95% CI, 1.042, 1.710). Immediate ART might decrease the hazard of all-cause death though it is insignificant (HR = 0.923, 95% CI: 0.755, 1.129) in the ART cohort. The test-and-immediate-test policy brought benefit to PLHIV. We should enlarge HIV testing using comprehensive approaches to decrease late testing and ART and increase the benefit of immediate ART.

The Enigma of the Human Immunodeficiency Virus (HIV) Epidemic in China

Nearly 17 years ago China launched its National HIV/AIDS Response Program, yet the epidemic still is not slowing. New cases and new deaths increase every year—in 2005, 40 711 people living with human immunodeficiency virus (HIV; PLWH) were diagnosed and 5729 died, whereas in 2019, 148 598 PLWH were diagnosed and 31 522 died. Moreover, the estimated PLWH population in China has risen to >1.25 million. However, epidemic data are worryingly complex and difficult to interpret, presenting challenges to the redirection and refocusing of efforts toward achievement of control. Here we present three “windows” into China’s epidemic data. From these viewpoints, it appears we still do not know how much infection exists, how much transmission is occurring, and in what contexts transmission happens. The enigma that is China’s HIV epidemic must be better understood. A new research agenda must be developed and executed if we are to change the future of HIV in China.

Human immunodeficiency virus/acquired immunodeficiency syndrome prevalence, incidence, and mortality in China, 1990 to 2017: a secondary analysis of the Global Burden of Disease Study 2017 data

BACKGROUND

Despite almost two decades of well-funded and comprehensive response efforts by the Chinese Government, human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) remains a major problem in China. Yet, few studies have recently examined long-term trends in HIV/AIDS prevalence, incidence, and mortality at the national level. This study aimed to determine the prevalence, incidence, and mortality trends for HIV/AIDS over the past 28 years in China.

METHODS

We conducted a descriptive, epidemiological, secondary analysis of the Global Burden of Diseases, Injuries, and Risk Factors Study 2017 data. To evaluate trends in prevalence, incidence, and mortality over the study period from 1990 to 2017, we calculated values for annual percentage change (APC) and corresponding 95% confidence intervals (CIs) using joinpoint regression analysis.

RESULTS

A significant increase in HIV/AIDS prevalence was observed for 1990 to 2009 (APC: 10.7; 95% CI: 10.4, 11.0; P < 0.001), and then remained stable for 2009 to 2017 (APC: 0.7; 95% CI: -0.3, 1.7; P = 0.1). A significant increase in HIV incidence was also observed for 1990 to 2005 (APC: 13.0; 95% CI: 12.6, 13.4; P < 0.001), and then a significant decrease was detected for 2005 to 2017 (APC: -6.5; 95% CI: -7.0, -6.1; P < 0.001). A significant increase in AIDS-related mortality rate was detected for 1990 to 2004 (APC: 10.3; 95% CI: 9.3, 11.3; P < 0.001), followed by a period of stability for 2004 to 2013 (APC: 1.3; 95% CI: -0.7, 3.3; P = 0.2), and then another significant increase for 2013 to 2017 (APC: 15.3; 95% CI: 8.7, 22.2; P < 0.001).

CONCLUSIONS

Although prevalence has stabilized and incidence has declined, AIDS-related mortality has risen sharply in recent years. These findings suggest more must be done to bring people into treatment earlier, retain them in treatment more effectively, actively seek to reenter them in treatment if they dropout, and improve the quality of treatment and care regimens.

Modelling the impact of an HIV testing intervention on HIV transmission among men who have sex with men in China

OBJECTIVES

An intervention developed through participatory crowdsourcing methods increased HIV self-testing among men who have sex with men [MSM; relative risk (RR) = 1.89]. We estimated the long-term impact of this intervention on HIV transmission among MSM in four cities (Guangzhou, Shenzhen, Jinan and Qingdao).

METHODS

A mathematical model of HIV transmission, testing and treatment among MSM in China was parameterized using city-level demographic and sexual behaviour data and calibrated to HIV prevalence, diagnosis and antiretroviral therapy (ART) coverage data. The model was used to project the HIV infections averted over 20 years (2016-2036) from the intervention to increase self-testing, compared with current testing rates.

RESULTS

Running the intervention once would avert < 2.2% infections over 20 years. Repeating the intervention (RR = 1.89) annually would avert 6.4-10.7% of new infections, while further increases in the self-testing rate (hypothetical RR = 3) would avert 11.7-20.7% of new infections.

CONCLUSIONS

Repeated annual interventions would give a three- to seven-fold increase in long-term impact compared with a one-off intervention. Other interventions will be needed to more effectively reduce the HIV burden in this population.

The Benefits of Immediate ART

The benefits of “early” antiretroviral therapy (ART; ie, initiation when CD4 ≥500 cells/mm³) are now well accepted as reflected in the removal of the CD4-based eligibility from new ART guidelines by the World Health Organization (WHO). However, neither the “treat-all” strategy recommendations presented in the guidelines nor the HIV care cascade goals in the Joint United Nations Programme on HIV/AIDS (UNAIDS) 90-90-90 targets adequately address the issue of ART timing. Our recent study on “immediate” ART (ie, ≤30 days after HIV diagnosis) adds important evidence demonstrating the real and meaningful benefits of rapid ART initiation even among those who have CD4 ≥500 cells/mm³. We call on WHO and UNAIDS to consider this research and encourage a shift from the treat-all strategy to an “immediately-treat-all” strategy, and from a slow, fragmented, complicated, multistep HIV care cascade to a fast, easy, and simple cascade with effectiveness measures that incorporate the important aspect of time.

"Getting to Zero" Among Men Who Have Sex with Men in China: a Review of the HIV Care Continuum

PURPOSE OF REVIEW

To review the literature on progress towards UNAIDS 90-90-90 targets for HIV prevention and treatment among men who have sex with men (MSM) in China.

RECENT FINDINGS

China has made progress towards UNAIDS 90-90-90 targets among MSM. However, socio-structural barriers, including HIV-related stigma and homophobia, persist at each stage of the HIV care continuum, leading to substantial levels of attrition and high risk of forward HIV transmission. Moreover, access to key prevention tools, such as pre-exposure prophylaxis, is still limited. Multilevel interventions, many using digital intervention, have been shown effective in pragmatic randomized controlled trials in China. Multilevel interventions incorporating digital health have led to significant improvement in engagement of Chinese MSM in the HIV care continuum. However, interventions that address socio-structural determinants, including HIV-related stigma and discrimination, towards Chinese MSM are needed.

Evolving HIV Epidemiology in Mainland China: 2009-2018

PURPOSE OF REVIEW

This review is intended to provide an overview of the evolution of HIV epidemiology over the past decade in China.

RECENT FINDINGS

We provided a succinct overall view of the epidemic, followed by surveillance data, profiles of key populations, HIV molecular epidemiology, and drug resistance, as well as survival in the age of antiretroviral therapy usage. For each topical issue, we first reviewed the latest empirical evidence, followed by a brief summary assessment. We briefly addressed the challenges and opportunities of the next generation of HIV control and prevention efforts in China. Notably, macro-social factors need to be integrated into the next generation of clinical and/or behavioral HIV research to inform disease progression and management, as well as control and prevention.

Delayed Treatment for People Living With HIV in China, 2004-2016: An Analysis of An Observational Cohort

Early universal access to antiretroviral treatment (ART) is critical in the control of the HIV epidemic. However, prompt initiation of ART remains problematic in China. This study analyzed the late testing and lag time between HIV diagnosis and initiation of ART from 2004 to 2016 and identified the risk factors for delayed initiation of ART. Data from 16,957 people living with HIV were abstracted from a hospital electronic health record database and a case report database for AIDS prevention and control in Yunnan province. Reasons for delayed initiation of ART were categorized into late testing, defined as CD4 count of < 350 cells/μL at baseline HIV diagnosis, and delayed access, defined as a lag time of > 1 month between the diagnosis and initiation of ART. Binary logistic regression models were used to identify risk factors for late testing and delayed access. The CD4 counts at diagnosis increased from 201 ± 147 cells/μL (mean ± SD) in 2004 to 324 ± 238 cells/μL in 2016 (p = 0.024). The CD4 count was higher for persons < 45 years, unmarried, and men who have sex with men (MSM) (356, 357, and 409 cells/μL, respectively) compared to their peers in 2016 (p < 0.05). The lag time from diagnosis to initiation of ART was significantly reduced from 59.2 months in 2004 to 0.9 months in 2016 (p < 0.05). The shorter lag time over the years was consistent when analysis was stratified by sex, age, marital status, and transmission routes, even though the lag time for people using drugs was longest in 2016 (> 2 months versus 0.82 and 0.72 month of heterosexuals and MSM, respectively). Compared to their peers, married persons (AOR = 0.63, 95%CI: 0.57, 0.69) were less likely to have delayed access to ART, and drugs-using patients (AOR = 3.58, 95%CI: 2.95,4.33) were more likely to have delayed access to ART. Late testing rather than delayed access to ART after a diagnosis remains problematic in China, although improvements have been seen for both parameters from 2004 to 2016. Our data highlight the importance of continued efforts to promote early diagnosis of HIV to prevent transmission, morbidity, and early mortality in HIV infection.

Too fast to stay on track? Shorter time to first anti-retroviral regimen is not associated with better retention in care in the French Dat'AIDS cohort

BACKGROUND

Rapid antiretroviral therapy (ART) initiation has been proven beneficial for patients and the community. We aimed to analyze recent changes in timing of ART initiation in France and consequences of early start.

METHODS

We selected from a prospective nationwide cohort, on 12/31/2017, patients with HIV-1 infection diagnosed between 01/01/2010 and 12/31/2015. We described time from (1) diagnosis to first specialized medical encounter, (2) from this encounter to ART initiation, (3) from diagnosis to first undetectable HIV viral load (VL). We analyzed the determinants of measured temporal trends. A multivariate logistic regression was performed to assess characteristics related with 1-year retention in care.

RESULTS

In the 7 245 included patients, median time (1) from HIV diagnosis to first medical encounter was 13 (IQR: 6-32) days, (2) to ART initiation was 27 (IQR: 9-91) days, decreasing from 42 (IQR: 13-272) days in 2010 to 18 (IQR: 7-42) in 2015 (p<0.0001), (3) to first undetectable VL was 257 (IQR: 151-496) days, decreasing from 378 (IQR: 201-810) days in 2010 to 169 (IQR: 97-281) in 2015. After one year, proportion of patients alive and still in care was significantly lower in those in the lower quartile of time from first encounter to ART (<9 days) than those in the higher quartile (>90 days), 79.9% and 85.2%, respectively (p<0.0001).

CONCLUSIONS

In a country with unrestricted rapid access to ART, keeping recently diagnosed HIV infected patients in care remains challenging. Starting ART rapidly did not seem to be profitable for all and every patient.