Dosage of methadone maintenance therapy (MMT) is an important factor influencing retention in methadone treatment. MMT clients in China received lower dosages of methadone compared with those provided in other countries. The objective of this study is to elucidate the reason for the low methadone dosage prescribed in MMT clinics in China.
Twenty-eight service providers were recruited from the MMT clinics in Zhejiang and Jiangxi Provinces, China. Qualitative in-depth interviews were conducted to ascertain the procedure for prescribing methadone in the MMT clinics.
The average dosage prescribed in the 28 clinics was 35 mg per person per day. Four major themes resulting in low dosage of methadone were identified: (1) the service providers fear the liability resulting from large doses of methadone in combination with other substances which might result in overdose fatalities, (2) lack of understanding of harm reduction which resulted in low acceptance of the long term maintenance treatment approach, (3) break-down in communication between clients and service providers about dosage adjustment, and (4) dosage reduction is perceived by most service providers as an effective way to treat the side-effects associated with MMT.
The findings of the study highlighted the necessity to formulate clear guidelines concerning individualized dosage management and to improve training among service providers’ in MMT clinics in China.
Methadone maintenance therapy; China; opioid use; dosage; qualitative study
Asymptomatic Chlamydia trachomatis (chlamydia) and Neisseria gonorrhoeae (gonorrhea) infections pose diagnostic and control problems in developing countries.
Participants in China, India, Peru, Russia, and Zimbabwe were screened for C. trachomatis and N. gonorrhoeae infections and symptoms.
A total of 18,014 participants were evaluated at baseline, 15,054 at 12 months, and 14,243 at 24 months. The incidence of chlamydia in men was 2.0 per 100 person years both from baseline to 12 months and from 12 to 24 months, and in women, 4.6 from baseline to 12 months and 3.6 from 12 to 24 months; a range of 31.2% to 100% reported no symptoms across the 5 countries. The incidence of gonorrhea in men was 0.3 per 100 person years both from baseline to 12 months and from 12 to 24 months, and in women, 1.4 from baseline to 12 months and 1.1 from 12 to 24 months; a range of 66.7% to 100% reported no symptoms. Being female, aged 18 to 24 years, and having more than 1 partner were associated with both the infections. In addition, being divorced, separated, or widowed was associated with gonorrhea. Being male, having 6+ years of education, and reporting only 1 partner were associated with having no symptoms among those infected with chlamydia. No variables correlated with asymptomatic gonorrhea among those infected.
A high prevalence and incidence of asymptomatic sexually transmitted infections was identified among men and women in a wide variety of settings. More effective programs are needed to identify and treat chlamydia and gonorrhea infections, especially among women, young adults, those with multiple partners, those repeatedly infected, and particularly those at risk without symptoms. The risk of transmission from persons with no symptoms requires further study.
Contact tracing is especially useful for identifying an infection with few cases in the population, such as HIV in China. Little such research is available in China.
Every newly diagnosed HIV case from 2008–2010 in Taizhou Prefecture, Zhejiang Province in China, was invited to participate as an “index case” in a contact tracing survey by providing contact information for up to eight sexual contacts who themselves were approached for voluntary HIV counseling and testing (VCT). Those who tested HIV-positive were then subjected to another contact tracing survey. This process was repeated until no more sexual contacts were reported or tested positive.
A total of 463 HIV-infected individuals were newly identified during the study period, including 338 cases who were identified from routine surveillance programs and 125 cases who were identified from the present contact tracing survey. Among these 463 cases, 398 (86.0%) served as ‘index cases’ in the survey, including 290 (85.8%) out of the 338 cases identified from routine surveillance programs and 108 (86.4%) out of the 125 cases identified from the present survey. These 398 ‘index cases’ reported a total of 1,403 contactable sexual contacts, of whom 320 (22.8%) received HIV testing and 125 (39.1%) tested positive for HIV. Willingness to receive HIV testing was high among spouses and long term heterosexual or homosexual partners but extremely low among casual and commercial sex partners of ‘index cases’. Consistent condom use was rare for all participants. A total of 290 independent sexual network components were constructed, with high complexity.
Contact tracing is useful for identifying new HIV infections from spouses or long term sexual partners of HIV-infected individuals. The complicated sexual networks existing between and beyond HIV-infected persons provide opportunities for rapid spread of HIV in such areas.
Contact tracing; Sexual behavior; Sexual networks; HIV testing; HIV infection
Methadone maintenance therapy (MMT) in China is facing challenges such as high relapse rates and low coverage. The study assessed factors influencing MMT utilization among opiate users. In-depth interviews were conducted among 30 opiate users in 2008 to ascertain the barriers against seeking MMT. Data were analyzed using ATLAS.ti. Barriers to the treatment included requirement of registration with police, perceived discrimination, logistic difficulties, side effects, fear of being addicted to another drug, lack of additional services, and economic burden. The result suggests the need for structural changes such as improving comprehensive services, simplifying application procedure, and enhancing referral system. The study's limitations are noted.
methadone maintenance therapy; China; qualitative; opiate users; HIV/AIDS
The risk of developing non-Hodgkin lymphoma (NHL) is greatly increased in HIV infection. The aim of this study was to determine if elevated serum levels of molecules associated with B cell activation precede the diagnosis of AIDS-associated NHL.
Serum levels of B cell activation-associated molecules, interleukin-6 (IL6), interleukin-10 (IL10), soluble CD23 (sCD23), soluble CD27 (sCD27), soluble CD30 (sCD30), C-reactive protein (CRP), and IgE were determined in 179 NHL cases and HIV+ controls in the Multicenter AIDS Cohort Study, collected at up to three time points per subject, 0–5 years prior to AIDS-NHL diagnosis.
Serum IL6, IL10, CRP, sCD23, sCD27, and sCD30 levels were all significantly elevated in the AIDS-NHL group, when compared to HIV+ controls or to AIDS controls, after adjusting for CD4 T cell number. Elevated serum levels of B cell activation-associated molecules were seen to be associated with the development of systemic (non-CNS) NHL, but not with the development of primary CNS lymphoma.
Levels of certain B cell stimulatory cytokines and molecules associated with immune activation are elevated for several years preceding the diagnosis of systemic AIDS-NHL. This observation is consistent with the hypothesis that chronic B cell activation contributes to the development of these hematologic malignancies.
Marked differences in serum levels of several molecules are seen for several years pre-diagnosis in those who eventually develop AIDS-NHL. Some of these molecules may serve as candidate biomarkers and provide valuable information to better define the etiology of NHL.
lymphoma; B cell; cytokines; AIDS; immune activation
We show that microRNA-21 is significantly elevated in peripheral B cells of HIV infected individuals who go on to develop AIDS-NHL (n=13, < 3 yrs prior to diagnosis) when compared to HIV negative (n = 18) or HIV positive controls (n = 21) (p < 0.01). Moreover, miR-21 is overex-pressed in activated B cells, and can be induced by IL4 alone, or with CD40 or IgM costimulation, and lipopolysaccharides (LPS), suggesting that miR-21 may help maintain B-cell hyperactivation, contributing to lymphomagenesis.
We examined an at-risk population in China, money boys (MBs), to evaluate their potential role for transmitting HIV and sexually transmitted infections (STIs). Data were collected from 418 MBs selected by time-location cluster sampling, using a self-administered computerized questionnaire and testing a small blood sample for HIV/STIs. One-third (32.1%) of participants self-identified as homosexual, 25.4% heterosexual, 33.5% bisexual, and 9.1% uncertain. Consistent condom use by participants was 70–80% with commercial sex partners, 43.9% with girlfriends, and 60–70% with other non-commercial partners. HIV prevalence was 3.3%; syphilis, 10.5%; and HSV-2, 11.0%; overall prevalence for any was 20.3%. Factors significantly associated with HIV/STIs included being minority (OR = 4.82), having only male partners (OR = 1.92), having more male casual partners in the last 6 months (OR = 1.28), being younger at sexual debut (OR = 1.14), and being older (OR = 1.11). This study emphasizes the importance of developing targeted interventions for MBs, particularly those who are homosexual or minority.
Money boys; Male sex workers; HIV; Sexually transmitted infections (STIs); Condom use; Risk factors; China
The major mode of HIV/AIDS transmission in China is now heterosexual activities, but risk for HIV and sexually transmitted diseases (STDs) may differ among different strata of female sex workers (FSWs). Respondent-driven sampling was used to recruit 320 FSWs in Guangdong Province, China. The respondents were interviewed using a structured questionnaire, and tested for HIV, syphilis, gonorrhea, and Chlamydia. The street-based FSWs had lower education levels, a higher proportion supporting their families, charged less for their services, and had engaged in commercial sex for a longer period of time than establishment-based FSWs. The proportion consistently using condoms with clients and with regular non-paying partners was also lower. The prevalence of syphilis, gonorrhea, and Chlamydia was higher among street-based sex workers. Being a street-based sex worker, having regular non-paying sex partners, and having non-regular non-paying partners were independent risk factors for inconsistent condom. Street-based FSWs had more risk behaviors than establishment-based FSWs, and should therefore be specifically targeted for HIV as well as STD intervention programs.
Behavior; HIV/AIDS; HIV; STD; Female sex workers
Money boys (MBs) who typically sell sex to males have not yet been extensively studied in China. In this 2009 study, 28 venue-based MBs were interviewed. We analyzed their condom use behaviors with various partners, including male and female clients, male and female casual partners, other MBs and female sex workers, and boyfriends and girlfriends. All participants were aware of the need for using condoms; however, usage with different partner types varied. The longer a relationship with a partner, the less frequent was condom use. A major reason for not using condoms was that they or their partners did not like the loss of sensation due to condom use. Other factors included sexual orientation, age, duration in commercial sex, concerns about HIV/AIDS, attractiveness of partners, and support of “mommies” (brothel supervisors). Both individual- and venue-level interventions are needed to promote condom use, and mommies need to be included in intervention strategies.
We investigated associations between stress and mental health (positive affect, depressive symptoms) among HIV-negative and HIV-positive midlife and older gay-identified men, along with the mediating and moderating effects of mastery and emotional support. We also studied the mental health effects of same-sex marriage.
We obtained data from self-administered questionnaires completed in 2009 or 2010 by a subsample (n=202; average age=56.91 years; age range= 44–75 years) of participants in the University of California, Los Angeles component of the Multicenter AIDS Cohort Study, one of the largest and longest-running natural-history studies of HIV/AIDS in the United States.
Both sexual minority stress (perceived gay-related stigma, excessive HIV bereavements) and aging-related stress (independence and fiscal concerns) appeared to have been detrimental to mental health. Sense of mastery partially mediated these associations. Being legally married was significantly protective net of all covariates, including having a domestic partner but not being married. Education, HIV status, and race/ethnicity had no significant effects.
Sexual minority and aging-related stress significantly affected the emotional lives of these men. Personal sense of mastery may help to sustain them as they age. We observed specific mental health benefits of same-sex legal marriage.
Chronic inflammation and B-cell hyperactivation are seen in HIV infection, contributing to an increased risk for the accrual of genetic errors that may result in B-cell lymphoma. The primary objective of this study was to determine the effect of highly active antiretroviral therapy (HAART) on serum levels of molecules that are associated with immune activation and/or inflammation, including several that are associated with B-cell activation, specifically IL-6, sCD30, sCD27, IgG, IgA, CXCL13 (B lymphocyte chemoattractant, BLC), a B-lymphocyte chemokine involved in B-cell trafficking, as well as C-reactive protein, an acute-phase protein.
We used a retrospective cohort study design, measuring serum levels of these markers at each of four 1-year intervals, 2 years before and 2 years after HAART initiation, in a subgroup of 290 HIV-infected men enrolled in the Multicenter AIDS Cohort Study (MACS).
Serum levels of immune activation-associated molecules were measured by ELISA and multiplexed immunometric assays. Reference values were determined by the 5th to 95th percentiles from a sample of 109 HIV-uninfected MACS men.
HAART use was associated with a reduction, but not normalization, of most biomarkers tested. Serum levels of IL-6 and C-reactive protein appeared to be unaffected by HAART.
These results suggest a partial normalization of serum cytokine levels post HAART. However, a chronic state of B-cell hyperactivation continues 2–3 years after HAART initiation. These findings may explain, in part, the excess incidence of lymphoma still occurring in HIV-infected persons in the post-HAART era.
activation; AIDS; antiretroviral therapy; B lymphocytes; highly active; HIV; non-Hodgkin’s lymphoma
Background.The HLA class II molecules play a central role in the generation of human immunodeficiency virus (HIV)–specific CD4+ T-helper cells, which are critical for the induction of cytotoxic CD8+ T cell responses. However, little is known about the impact of HLA class II alleles on HIV disease progression.
Methods.In this study we investigated the effect of HLA class II alleles on HIV disease outcome and HIV-specific T cell responses in a cohort of 426 antiretroviral therapy–naive, HIV-1 clade C–infected, predominantly female black South Africans.
Results.The HLA class II allele DRB1*1303 was independently associated with lower plasma viral loads in this population (P = .02), an association that was confirmed in a second cohort of 1436 untreated, HIV-1 clade B–infected, male European Americans, suggesting that DRB1*1303-mediated protection is independent of ethnicity, sex, and viral clade. Interestingly, DRB1*1303 carriage was not associated with an increased frequency of interferon (IFN) γ–positive HIV-specific CD4+ T cell responses.
Conclusions.These data demonstrate the independent effect of an HLA class II allele, DRB1*1303, on HIV disease progression, in the absence of increased IFN-γ–positive HIV-specific CD4+ T cell frequencies, suggesting that the protective activity of DRB1*1303 may be mediated via an alternative mechanism.
Adenoviruses are among the most promising vectors for the development of an HIV vaccine. The results of the phase IIB study of the adenovirus serotype 5-based Merck Trivalent HIV vaccine have raised the concern that serological immunity to Ad5 could be linked to HIV acquisition risk in high-risk individuals. We examined the association between adenovirus serostatus and the rate of incident HIV infection in populations at elevated risk of HIV acquisition.
We performed a nested case-control study of Ad5 serostatus among 299 HIV-infected and 590 matched HIV-uninfected persons participating in MACS and in HPTN 039, a study of HSV-2 suppression among adults in the U.S., South America and Africa. Appropriate HIV cases and controls were identified in each cohort, and Ad5 neutralizing antibody titers were compared in these two groups.
In MACS and HPTN 039, the relative risks of incident HIV infection among Ad5 seropositive vs. Ad5 seronegative individuals were 1.1 (95% CI 0.8–1.5, p = 0.57) and 1.0 (95% CI 0.4 – 2.3, p = 0.99) respectively. HIV-1 acquisition rates did not vary significantly by Ad5 neutralizing antibody titer.
The presence of Ad5 neutralizing antibodies is not linked to the risk of HIV acquisition among populations at elevated risk of HIV infection.
Adenovirus; serology; MSM; HIV; acquisition risk; vaccine
Develop a reliable and valid self-report health-related quality of life (HRQOL) instrument for human immunodeficiency virus (HIV)-infected children in Thailand.
The Thai Quality of Life for HIV-infected Children instrument, the ThQLHC (an HRQOL measure that uses the Pediatric Quality of Life Inventory as a generic core and a 17-item HIV-targeted scale), was developed and administered cross-sectionally to 292 HIV-infected children in Thailand. The disease-targeted scale included HIV-related symptoms, ability to adhere with their treatment regimens and self-image. The internal consistency reliability (Cronbach’s α) and construct validity of the ThQLHC scales were then evaluated.
Internal consistency reliability coefficients ranged from 0.57 to 0.82, with four of five scales reaching the minimal acceptable level (>0.70). Significant associations were found between poor HRQOL and poor self-rated disease severity, care giver’s rated overall quality of life, cluster of differentiation (CD) 4 percent and plasma HIV ribonucleic acid level.
Reliable and valid disease-targeted HRQOL measures for HIV-infected children are essential in the assessment of therapeutic effectiveness. The findings of this cross-sectional survey provide support for the reliability and validity of the ThQLHC as an HRQOL outcome measure for HIV-infected Thai children.
child; health-related quality of life (HRQOL); HIV
To investigate the patterns of concurrent sexual partnerships among young opiate users and sexual transmissibility of HIV in concurrent sexual partnerships in drug-use and sexual networks.
426 young opiate users in Yunnan, China.
Respondent-driven sampling (RDS) was used to recruit participants. Multiple logistic regressions were performed to analyze the relationships of concurrent sexual partnerships with egocentric social network components, risky sexual behavior for HIV, and drug-use practices.
The RDS-adjusted prevalence of concurrent sexual partners was 42.9% among opiate users. Opiate users with concurrent sexual partnerships were more likely to engage in risky HIV-related sexual behavior, compared to those without. Specifically, they were more likely to report having had four or more sexual partners (26.3% vs. 2.0%), having had a spouse or boy/girl friends who also had concurrent sexual partnerships (28.1% vs. 8.2%), having exchanged drug for sex (12.4% vs. 3.8%), having had sexual partners who were non-injection drug users (22.6% vs. 10.1%), having had sexual partners who were injection drug users (25.3% vs. 13.5%), and having used club drugs (26.3% vs. 13.5%). There were no significant differences in consistent condom use between opiate users with sexual concurrency and those without. The same proportion (25.8%) of opiate users in the two groups reported having consistently used condoms when having sex with regular partners, and 46.3% of opiate users with sexual concurrency and 36.4% of those without such concurrency consistently used condoms with non-regular partners.
The expansion of the HIV epidemic from high risk populations to the general population in China may be driven by concurrent sexual partnerships. Behavioral interventions targeting safer sex should be integrated into harm reduction programmes.
opiate use; concurrent sexual partnership; HIV; China
A community level randomised controlled trial of a Community Popular Opinion Leader (C-POL) intervention to reduce bacterial and viral sexually transmitted infections (STIs) and unprotected extramarital sex was carried out over 2 years in five countries. The main study results did not find significant intervention effects. This paper presents a sub-analysis examining the differential intervention impacts among high-risk and low-risk participants in the China site.
From 2002 – 2006, 3912 migrant market vendors aged 18 and 49 years were recruited at an urban site in China. Markets were randomly assigned to the C-POL intervention (N=20 markets; n=1979) or standard-care control condition (N=20; n=1933). Both study condition venues received HIV/STI education, free condoms, STI testing and treatment, and training for pharmacists in antibiotic treatments. In intervention markets, C-POLs were identified and trained to diffuse messages regarding safer sex, STI treatment and partner discussions of sex. The primary biological outcome was incidence of new STIs (chlamydia, gonorrhoea, syphilis, trichomonas, herpes or HIV). The primary sexual behaviour risk outcome was any unprotected extramarital sex in the prior 3 months.
In unadjusted analyses, women had significantly lower rates of STI infection at 24 months in the C-POL intervention (5.7%) compared to controls (8.3%; p=0.043). In mixed-effects regression models, intervention participants with STIs at previous assessments were about half as likely to have STIs at 24 months (OR 0.47, 95% CI 0.25 to 0.90) compared to controls.
The C-POL intervention lowers HIV risk among those at highest risk (ie, with a STI or engaging in high-risk sexual activities) rather than the general population.
The Methadone Maintenance Therapy (MMT) program has been initiated in China since 2004. As of the end of November, 2008, 558 MMT clinics had been established countrywide. The objective of this study was to elucidate the difficulties and challenges as perceived by service providers working in MMT clinics.
One service provider from each of the 28 MMT study clinics in Zhejiang and Jiangxi Provinces of China participated in a face-to-face in-depth interview for about 1–2 hours to describe their perceptions of working in MMT clinics. Qualitative data were analyzed using ATLAS.ti. The grounded theory was used to guide the data analysis.
Participants identified major problems in providing services in MMT clinics including lack of resources, professional training, and institutional support. Difficulties in pursuit of career, concern for personal safety, low income, heavy working load, and poor opinion of MMT by Chinese society often contributed to greater stress and burnout among the service providers.
The MMT programs in China desperately need additional resource allocation and institutional support for the current and perhaps future expansion of the programs. The service providers are in urgent need of professional training to improve the quality of care they can offer MMT clients.
Methadone Maintenance Therapy; China; qualitative; service providers
Sexually transmitted diseases; spontaneous remission; randomised controlled trials; HIV women; Africa; antenatal HIV; behavioural science; HIV; China; public health; social science; psychology; epidemiology; mathematical model; law ethics; notification; chlamydia; sexual health; behavioural interventions
This study identifies structural-level factors influencing methadone maintenance therapy (MMT) program implementation in China. Twenty-eight service providers and 560 randomly selected clients from 28 MMT clinics in the study area underwent face-to-face interviews. Number of clients, retention rate, coverage, and structural-level factors, were collected from a survey of service providers. Individual-level factors and self-reported illicit drug use information were obtained from clients. Urine specimens were collected from the client participants to test for heroin use. Clinics affiliated with the local CDC had more clients, higher retention rates, and broader coverage than those not affiliated with the CDC. Longer operating hours, incentive for compliant clients, and comprehensive services were positively associated with client recruitment and coverage. Comprehensive services and incentives for compliant clients were negatively associated with concurrent illicit drug use. Comprehensive services should be incorporated into the MMT program. Extended operating hours and incentives for compliant clients should be implemented.
Methadone Maintenance Therapy; China; structural-level factors; drug users; HIV/AIDS
To assess the prevalence of human immunodeficiency virus (HIV) and sexually transmitted infections (STIs) and associated factors among female sex workers (FSWs) in Guangdong, China.
Respondent driven sampling was used to recruit 320 FSWs. The recruited participants were interviewed face-to-face using a structured questionnaire and tested for HIV, syphilis, gonorrhea, and Chlamydia.
The prevalence of syphilis, gonorrhea, and Chlamydia were 8.0% (4.6-12.2%), 9.5% (5.6-14.3%) and 3.9% (1.7-6.2%), respectively, and of any STIs was 19.7% (13.9- 26.2%). None of the participants was HIV-positive. The median number of clients during the previous week was 5. The proportion of consistent condom use with the clients during the previous week was 58.0% (50.4, 65.5%), use with regular non-paying partners and non-regular non-paying partners were much lower than that with clients. Multivariate analysis indicated that years of education and perception of HIV risk were protective factors. Awareness of HIV/AIDS, regular sex partners deciding about condom use when having sex, recruiting clients at hotels, hair/beauty salons, or streets instead of massage parlors, and higher charge for last sexual service were associated with STI infection.
Future intervention programs should not only address personal risk factors, but also empower FSWs to require condom use by both clients and non-paying partners.
HIV/AIDS; STD; Sex workers; Behavior; China
To determine the sensitivity and specificity of tests for HBsAg, HCV, and syphilis conducted by laboratories of three blood collection organizations in a rural area of China.
From October to December 2003, 1068 samples were collected from blood donors presenting to the three collection centers. All samples were tested twice using two different test kits for HBsAg, HCV, and syphilis. An aliquot was sent to the China National Center for Clinical Laboratories (NCCL) to confirm the local test results. Sensitivities and specificities of the three local blood centers/banks were calculated, using the results of the NCCL as the gold standard.
The sensitivity of the three blood collection center/banks ranged from 0% to 63.2% for HBsAg. For HCV, the sensitivity was 0%, and for syphilis, ranged from 0% to 85.7%. There were no HBsAg-positives in one of the blood center/banks, and no syphilis-positives in the other. Thus, sensitivity could not be measured for these tests in these two facilities. Combining all three tests, the overall sensitivity was 55.6%. The specificity was 100%.
The sensitivity of the local laboratories was inadequate, and could cause possible infection for an unacceptable number of blood recipients. Action needs to be taken to improve the quality of testing to ensure the safety of the rural blood supply.
Blood safety; Hepatitis-B; hepatitis-C; Syphilis; Rural China
To assess the prevalence of HIV and selected STDs among MSM in Chengdu, China and the risk factors associated with HIV infection.
A cross-sectional study using a snowball sampling method was conducted from March to July, 2007. Participants were asked to complete a questionnaire about sexual history, high risk behaviors, STD infection history, HIV knowledge and testing, and an assessment of depression. Blood samples were taken for antibody testing for HIV, HSV-2, and syphilis.
A total of 538 MSM were recruited and 513 (95.4%) consented to complete the questionnaire. HIV, HSV-2 and syphilis prevalence were 9.1%, 24.7%, and 28.1%, respectively. The rate of consistent condom use was low and varied by types of sexual partners. The highest was with casual male partners (38.6%) and the lowest was with wife or girl friend (17.8%). Money boys (MB) were 6 times more likely to be infected with HIV compare to clerks/students. Infection with either HSV or syphilis increased the risk of HIV infection more than 4 fold.
The prevalences of HIV and STDs were high among MSM in Chengdu. To prevent HIV/STDs, campaigns promoting condom use are needed not only to boost the frequency of condom use, but also to educate MSM about proper condom use.
Men who have sex with men; Prevalence; HIV; STD; China