https://www.thelancet.com/pdfs/journals/lancet/PIIS0140-6736(08)60886-7.pdf

Behavioural strategies to reduce HIV transmission: how to make them work better

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. Subepidemics, 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.

The increase in global HIV epidemics in MSM.

Injecting drug users are vulnerable to infection with HIV and other blood borne viruses as a result of collective use of injecting equipment as well as sexual behaviour. This review looks at original studies that reported the frequency or prevalence of risk behaviours, or information on HIV infection related to substitution treatment of opioid dependence to assess the extent to which oral substitution treatment prevents the transmission of HIV infection. It was not possible to accurately estimate the extent of reduction, but it is clear that oral substitution treatment reduces risk behaviours and also the probability of HIV infection amongst injecting drug users in substitution treatment. [Click on link above for Cochrane review]

Oral substitution treatment of injecting opioid users for prevention of HIV infection

Summary Background Asian HIV epidemics are concentrated among particular behavioural groups, but large variations exist in epidemic types, timing, and geographical spread between countries and within countries, especially in China. We aimed to understand the complexity of HIV epidemics in China by systematically analysing prevalence trends by data source, region, population group, and time period. Methods We collected HIV prevalence data from official national sentinel surveillance sites at the provincial level from Jan 1, 1995, to Dec 31, 2010. We also searched PubMed, VIP Chinese Journal Database (VIP), China National Knowledge Infrastructure, and Wanfang Data from Jan 1, 1990, to Dec 31, 2012, for independent studies of HIV prevalence. We integrated both sets of data, and used an intraclass correlation coefficient test to assess the similarity of geographical pattern of HIV disease burden across 31 Chinese provinces in 2010. We investigated prevalence trends (and 95% CIs) to infer corresponding incidence by region, population group, and year. Findings Of 6850 articles identified by the search strategy, 821 studies (384 583 drug users, 52 356 injecting drug users, 186 288 female sex workers, and 87 834 men who have sex with men) met the inclusion criteria. Official surveillance data and findings from independent studies showed a very similar geographical distribution and magnitude of HIV epidemics across China. We noted that HIV epidemics among injecting drug users are decreasing in all regions outside southwest China and have stabilised at a high level in northwest China. Compared with injecting drug users, HIV prevalence in female sex workers is much lower and has stabilised at low levels in all regions except in the southwest. In 2010, national HIV prevalence was 9·08% (95% CI 8·04–10·52) in injecting drug users and 0·36% (0·12–0·71) in female sex workers, whereas incidence in both populations stabilised at rates of 0·57 (0·43–0·72) and 0·02 (0·01–0·04) per 100 person-years, respectively. By comparison, HIV prevalence in men who have sex with men increased from 1·77% (1·26–2·57) in 2000, to 5·98% (4·43–8·18) in 2010, with a national incidence of 0·98 (0·70–1·25) per 100 person-years in 2010. We recorded strong associations between HIV prevalence among at-risk populations in each province, supporting the existence of overlap in risk behaviours and mixing among these populations. Interpretation HIV epidemics in China remain concentrated in injecting drug users, female sex workers, and men who have sex with men. HIV prevalence is especially high in southwest China. Sex between men has clearly become the main route of HIV transmission. Funding The World Bank Group, the Australian Research Council, the University of New South Wales, and Chinese Center for Disease Control and Prevention.

https://www.thelancet.com/pdfs/journals/laninf/PIIS1473-3099(13)70245-7.pdf

HIV prevalence in China: integration of surveillance data and a systematic review.

A randomized clinical trial of methadone maintenance for prisoners: results at 12 months postrelease.

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% (2314/47 231; 95% confidence interval [CI], 4.7%–5.1%) for HIV and 11.8% (5552/47 231; 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.

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

Objective: To evaluate the effectiveness of the first phase of eight methadone maintenance treatment (MMT) clinics in China. Design: Repeated cross-sectional surveys. Methods: Three surveys of clients attending the first phase of eight MMT clinics were carried out at entry, and 6 and 12 months after enrolment. Drug using behaviours, drugrelated criminal activity, and relationships with families were compared for the three periods. Blood specimen were collected and tested for HIV for each client at entry, and HIV-negative clients were re-tested after 12 months. Results: A total of 585, 609 and 468 clients participated in the first, second and third surveys,respectively. The proportion of clients who injecteddrugs reduced from 69.1to 8.9 and 8.8%, and the frequency of injection in the past month had reduced from 90 times per month to twice per month, employment increased from 22.9 to 43.2 and 40.6%, and self-reported criminal behaviours reduced from 20.7 to 3.6 and 3.8% in the three surveys. By the third survey, 65.8% of clients reported a harmonious relationship with families, an increase from 46.8% at entry, and 95.9% of clients were satisfied with MMT services. Eight HIV seroconversions were found among 1153 clients during 12 months. Conclusion: The study demonstrated that the first phase MMT contributed to a reduction in drug use, drug injecting behaviours, drug-related criminal behaviours, HIV infections, and improved relationships within families among heroin users who participated in the MMT programme. MMT needs to be scaled up nationwide rapidly with improved services. 2007 Wolters Kluwer Health | Lippincott Williams & Wilkins

Effectiveness of first eight methadone maintenance treatment clinics in China

Background Prior to 2003, there was limited capacity for an HIV/AIDS response in China. In early 2003, China launched a 5-year China Comprehensive AIDS Response Programme (China CARES) to contain the spread of HIV infection and reduce its impact. This article describes the China CARES’ practices and experiences.

Methods China CARES covered 83.3 million people in 127 programme sites chosen from 28 provinces based on HIV prevalence. Each China CARES site was required to carry out surveillance and surveys to understand the local HIV/AIDS epidemic, to deliver primary interventions to reduce new HIV infections among and from high-risk groups, to prevent mother-to-child transmission, to treat AIDS patients with antiretroviral medicines and to provide support services to families affected by HIV/AIDS. Data were collected to monitor and evaluate implementation.

Results HIV/AIDS prevention knowledge and awareness improved significantly in China CARES sites from <30% in 2004 to 86% in 2008. The number of persons tested for HIV increased by 67% between 2005 and 2007 from 1.5 to 2.5 million. China CARES enrolled 23 000 patients in anti-retroviral treatment and supported 6007 AIDS orphans. Among pregnant women, 81.8% received counselling and 75.8% received HIV testing during antenatal care, while 92.9% of HIV-infected pregnant women and 85.5% of their newborns received anti-retroviral prophylaxis. During the project period, no known HIV transmissions occurred through blood transfusions.

Conclusion China CARES has facilitated AIDS prevention, treatment and care in resource-poor, rural and ethnic minority areas of China.

/pdf/design-and-implementation-of-a-china-comprehensive-aids-1gbbmj82o7.pdf

Yang Hao

Papers

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

Effectiveness of first eight methadone maintenance treatment clinics in China

Design and implementation of a China comprehensive AIDS response programme (China CARES), 2003–08