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1.  Sex with Women Among Men Who Have Sex with Men in China: Prevalence and Sexual Practices 
AIDS Patient Care and STDs  2013;27(9):524-528.
Men who have sex with men and women (MSMW) are a potential bridge population for transmitting HIV to heterosexual women. This study assessed key characteristics of this subgroup of men who have sex with men (MSM) in China. Of 1141 eligible MSM, 45.6% reported bisexual behaviors. Besides marriage as a strong predictor (odds ratio: 23.90, 95% confidence interval: 14.29–39.98), older age (1.12, 1.10–1.15) and lower education (or no college education) (1.98, 1.52–2.59) were also independently associated with having ever had sex with women. MSMW reported higher proportions of alcohol drinking, heterosexual/bisexual orientation, and preference for an insertive role in anal sex than men who had sex with men only; but there was no statistically significant difference between two groups in prevalence of HIV and syphilis infections and in history of sexually transmitted infections. HIV prevention intervention programs should break the bridging role of HIV transmission in MSMW population.
PMCID: PMC3760059  PMID: 23931683
2.  Home-Based HIV Testing for Men Who Have Sex with Men in China: A Novel Community-Based Partnership to Complement Government Programs 
PLoS ONE  2014;9(7):e102812.
The coverage of HIV testing among Chinese men who have sex with men (MSM) remains low after the scale-up of free HIV testing at government-sponsored testing sites. We evaluated the feasibility of home-based HIV self-testing and the willingness to be HIV tested at community-based organizations (CBO).
We recruited MSM via on-line advertisement, where they completed an on-line informed consent and subsequent questionnaire survey. Eligible MSM received HIV rapid testing kits by mail, performed the test themselves and reported the result remotely.
Of the 220 men taking a home-based HIV self-testing, 33 MSM (15%) were seropositive. Nearly 65% of the men reported that they were willing to take HIV testing at CBO, while 28% preferred receiving free HIV testing in the government programs at local Centers for Disease Control and Prevention (CDC). Older and lower-income MSM, those who self-reported homosexual orientation, men with no history of sexually transmitted diseases and a lower number of sexual partners in the past six months were associated with preference for taking HIV testing at CBOs. The top three self-reported existing barriers for HIV testing were: no perception of HIV risk (56%), fear of an HIV positive result being reported to the government (41%), and fear of a positive HIV test result (36%).
Home-based HIV self-testing is an alternative approach for increasing the coverage of HIV testing among Chinese MSM. CBO-based HIV testing is a potential alternative, but further studies are needed to evaluate its feasibility.
PMCID: PMC4106852  PMID: 25051160
3.  Are Low- and Middle-Income Countries Repeating Mistakes Made by High-Income Countries in the Control of HIV for Men who have Sex with Men? 
PMCID: PMC3893757  PMID: 24455449
Homosexual; HIV; AIDS; Developing countries; Human rights; Transmission; Public policy; Disease control; Prevention; Antiretroviral therapy
4.  Meta-Analysis of Interventions for Reducing Number of Sexual Partners and Drug and Alcohol Abuse among People Living with HIV/AIDS 
To perform a systematic review and meta-analysis of the efficacy of risk reduction interventions on HIV-related risk behaviors among people living with HIV/AIDS (PLWHA)
Studies included in the meta-analysis were randomized clinical trials (RCTs) of risk reduction interventions, which targeted PLWHA aged 18 year or older and assessed the changes of number of sexual partners, drug use, needle sharing, and/or alcohol abuse between pre- and post-intervention. The standardized mean differences (SMD) between study arms as well as between baseline and post-intervention, defined as the effect sizes (ES), were calculated in random effects models. Heterogeneity of studies was estimated by the I2 statistic.
Twelve RCTs involving 3993 PLWHA were included in our analysis: seven reported impacts on the number of sexual partners, and three reported impacts on drug use, needle sharing, and alcohol abuse, respectively. There were no statistically significant impacts of risk reduction interventions on the number of total sexual partners (mean ES, -0.10; 95% confidence interval [CI], -0.26, 0.06; P=0.22) or on the subset of HIV-negative or unknown-status sexual partners (mean ES, 0.003; 95% CI, -0.54, 0.54; P=0.99). Overall, risk reduction intervention studies documented a reduction of drug abuse (mean ES: -0.26; 95% CI: -0.51, -0.01; P=0.04) among HIV-infected drug users, but this impact was mainly attributable to one study. Risk reduction interventions did not show a reduction of needle sharing (mean ES, -0.15; 95% CI, -0.43, 0.13; P=0.29) or of alcohol abuse (mean ES, -0.10; 95% CI, -0.36, 0.17; P=0.47). No heterogeneity or publication bias was found across individual studies.
Our meta-analysis did not find a positive impacts of risk reduction interventions on number of sexual partners, drug use, needle sharing, or alcohol abuse among PLWHA, but the small number of studies meeting our review criteria limits these findings.
PMCID: PMC3819193  PMID: 24224118
People living with HIV/AIDS (PLWHA); Randomized clinical trial (RCT); Sexual partners; Positive prevention; Drug use; Alcohol abuse; Meta-analysis
5.  The Relationships between Injection and Non-injection Drug Use and HIV Disease Progression 
Injection drug use is associated with poor HIV outcomes even among persons receiving highly active antiretroviral therapy (HAART), but there are limited data on the relationship between non-injection drug use and HIV disease progression.
We conducted an observational study of HIV-infected persons entering care between January 1, 1999 and December 31, 2004, with follow-up through December 31, 2005.
There were 1,712 persons in the study cohort: 262 with a history of injection drug use (IDU), 785 with a history of non-injection drug use, and 665 with no history of drug use; 56% were white, and 24% were females. Median follow-up was 2.1 years, 33% had HAART prior to first visit, 40% initiated first HAART during the study period, and 306 (17.9%) had an AIDS-defining event or died. Adjusting for sex, age, race, prior antiretroviral use, CD4 cell count, and HIV-1 RNA, patients with a history of injection drug use were more likely to advance to AIDS or death than non-users (adjusted hazard ratio (HR) = 1.97, 95% confidence interval (CI) 1.43-2.70, P<0.01). There was no statistically significant difference of disease progression between non-injection drug users and non-users (HR=1.19, 95% CI 0.92-1.56, P=0.19). An analysis among the subgroup who initiated their first HAART during the study period (n=687) showed a similar pattern (IDUs: 1.83, 1.09-3.06, P=0.02; non-IDUs: 1.21, 0.81-1.80, P=0.35). Seventy-four patients had active IDU during the study period, 768 active non-IDU, and 870 no substance use. Analyses based on active drug use during the study period did not substantially differ from those based on history of drug use.
This study shows no relationship between non-injection drug use and HIV disease progression. This study is limited by using history drug use and lumping together different types of drugs. Further studies ascertaining specific type and extent of non-injection drug use in a prospective way, and with longer follow-up, are needed.
PMCID: PMC3110534  PMID: 21349679
Injection drug use; non-injection drug use; CD4 cell count; HIV viral load; HIV disease progression; antiretroviral therapy
6.  Non-injection Drug Use and HIV Disease Progression in the Era of Combination Antiretroviral Therapy 
Little is known about the effects of non-injection drug use (NIDU) on HIV antiretroviral treatment outcomes. We conducted a systematic literature search and identified 9 publications from prospective cohort studies investigating the relationship between NIDU and clinical HIV disease progression. Hazard ratios from studies estimating the effect of drug use on time to AIDS-related mortality ranged from 0.89 to 3.61 and only two of these were statistically significant. Hazard ratios from studies assessing time to an AIDS-defining event ranged from 1.19 to 2.51, with 8 of the 14 estimates falling between 1.55 to 1.65 regardless of drug use definition and measurement of use or frequency. It is suggested that NIDU may have a moderate effect of increasing the risk of progression to AIDS, but its impact on AIDS-related mortality is uncertain. NIDU may affect HIV antiretroviral treatment outcomes primarily through interaction with antiretroviral therapy and, to a lesser extent, through immune-modulation and deterioration of general health. The limitations about published studies are discussed and future perspectives on research on this topic are provided.
PMCID: PMC3081970  PMID: 21353444
Non-injection drug use; HIV; antiretroviral therapy; disease progression
7.  High HIV risk among Uigur minority ethnic drug users in northwestern China 
To assess differences of HIV risk between ethnicities in northwestern China.
Cross-sectional serosurvey and structured questionnaire interview of 383 injection drug users of either Han or Uigur ethnicity in Urumqi, Xinjiang.
Both Uigur minority ethnicity and residence in a Uigur or mixed Uigur/Han community were independently associated with higher HIV risk.
HIV prevention programs should give special focus on minority ethnic drug users and their communities.
PMCID: PMC2746442  PMID: 18363583
injection drug users; HIV; risk environment; China
8.  Risk factors associated with prevalent and incident syphilis among an HIV-infected cohort in Northeast China 
BMC Infectious Diseases  2014;14(1):658.
Sexually transmitted infections (STIs) increase HIV infectivity through local inflammatory processes. Prevalent and incident STIs among people who live with HIV/AIDS (PLWHA) are indicators of high-risk sexual behaviors and imply potential spread of HIV. Little is known about the prevalence and incidence of concurrent syphilis and associated risk behaviors among PLWHA in China.
A retrospective cohort study was conducted among PLWHA who attended the outpatient clinic of a designated AIDS treatment hospital in Shenyang, China, between March 2009 and May 2013. Physical examinations and syphilis serology were conducted at each visit. A questionnaire on demographic characteristics was also collected.
A total of 1010 PLWHA were enrolled, of whom 77.0% were men who have sex with men (MSM). The baseline syphilis prevalence among PLWHA was 19.8% (95% confidence interval [CI]:17.3–22.3%). During follow-up, 78.3% retained in the cohort, and contributed a median follow-up of 9.4 months (interquartile range: 5.9-18.7 months). Syphilis incidence among PLWHA was 18.7 (95% CI: 15.5–21.8) per 100 person years. Mulitvariate logistic analysis showed that receiving antiretroviral therapy (ART) (adjusted OR [aOR] = 0.48), older age (≥40 years vs. ≤24 years, aOR = 2.43), being MSM (aOR = 2.30) and having higher baseline HIV viral load (>100000 copies/mL vs. ≤100000 copies/mL, aOR = 1.56) were independent predictors for syphilis infection among PLWHA at enrollment (p < 0.05 for all). Mulivariate Cox regression found that receiving ART (adjusted hazard ratio [aHR] = 1.81), older age (≥40 years vs. ≤24 years, aHR: 5.17) and MSM status (aHR = 2.68) were independent risk factors for syphilis seroconversion (each p < 0.05).
Syphilis prevalence and incidence were high among PLWHA in Shenyang. A campaign focusing on detection and treatment of syphilis among PLWHA is urgently needed, especially one with a focus on MSM who are at a higher risk for syphilis.
PMCID: PMC4265485  PMID: 25471736
Retrospective cohort study; Syphilis; Prevalence; Incidence; Antiretroviral therapy (ART)
9.  Recreational drug use and risks of HIV and sexually transmitted infections among Chinese men who have sex with men: Mediation through multiple sexual partnerships 
BMC Infectious Diseases  2014;14(1):642.
Recreational drug use (RDU) may result in sexual disinhibition and higher risk for HIV and other sexually transmitted infections (STIs) among men who have sex with men (MSM) in China. We assessed whether RDU was associated with HIV, syphilis, and herpes simplex virus type 2 (HSV-2) within the context of multiple sexual partnerships and unprotected sex.
We conducted a cross-sectional study among sexually-active MSM in six Chinese cities (Kunming, Jinan, Changsha, Zhengzhou, Nanjing, and Shanghai) in 2012–2013. We interviewed participants regarding RDU and sexual activity and drew blood for HIV, syphilis, and HSV-2. We fit multiple logistic regression models to assess associations of drug use and HIV, syphilis and HSV-2 infections, controlling for number of sexual partners and unprotected sex.
Of 3830 participants, 28% reported ever using ≥1 of these drugs in the past 6 months: popper (alkyl nitrites), ecstasy, ice (methamphetamine), amphetamine, tramadol, and ketamine. In the past six months, 62% of MSM reported ≥2 sexual partners and 76% did not use condoms at last sexual encounter. HIV, syphilis and HSV-2 prevalences were 9.2%, 12.2%, and 10.3%, respectively.RDU was associated with HIV infection (aOR = 1.67; 95% CI, 1.31-2.13). Men with RDU were more likely to report multiple sexual partners (OR = 1.69; 95% CI, 1.44-1.98) and unprotected sex (aOR = 1.25; 95% CI, 1.05-1.49). The RDU-HIV association persisted (aOR = 1.58; 95% CI = 1.23-2.02) after adjusting for numbers of partners.
RDU was associated with multiple sexual partnerships, unprotected sex, and HIV among Chinese MSM. It is plausible that RDU is a driver of increased sexual/HIV risk and/or may be an associated behavior with sexually risky lifestyles. Community engagement is needed.
Electronic supplementary material
The online version of this article (doi:10.1186/s12879-014-0642-9) contains supplementary material, which is available to authorized users.
PMCID: PMC4272794  PMID: 25443542
Men who have sex with men; Multiple sexual partners; Unprotected sex; HIV; Syphilis; HSV-2; Recreational drug use; Substance use; China
10.  High prevalence of HIV infection and unprotected anal intercourse among older men who have sex with men in China: a systematic review and meta-analysis 
BMC Infectious Diseases  2014;14(1):531.
China has the largest number of the elderly in the world. As the proportion of elderly is rapidly increasing among national reported HIV/AIDS cases, it is a concern about HIV epidemic among older MSM in China. However, studies on HIV prevalence and unprotected anal intercourse (UAI) among Chinese older MSM were relatively few or generally had small sample sizes.
English and Chinese articles published in peer-reviewed journals were identified by systematically searching 5 electronic databases including PubMed and through cross-referencing. Summary prevalence rates of HIV infection and UAI with male sexual partners were calculated, and analyses were performed using the software Comprehensive Meta-Analysis V2.0 and SPSS V17.0. Subgroup analyses were performed separately by sample size, study year, study location, recruitment settings and sampling method.
Twenty eligible cross-sectional studies (3 in English and 17 in Chinese), published between 2005 and 2013, with a total of 2812 older MSM participants, were identified. Our meta-analyses showed that the prevalence of HIV, syphilis and UAI in the last 6 months were 11.6% (95% confidence interval [CI]: 8.0%-16.6%), 23.0% (95% CI: 15.8%-32.3%) and 79.5% (95% CI: 72.7%-84.9%), respectively. HIV prevalence increased over the study period (6.3% in 2003–2007; 8.6% in 2008–2009, and 11.5% in 2010–2011, trend test Chi-square = 7.02, p = 0.008). The pooled prevalence of HIV (11.6% vs. 5.2%, Chi-square value = 36.2, p < 0.001) and UAI (79.5% vs. 52.6%, Chi-square value = 440.04, p < 0.001) among older MSM were both significantly higher than among younger age group (age < 50 years).
Older Chinese MSM have high prevalence of HIV and syphilis. Unprotected anal sex is common and further puts them at high risks of acquiring and transmitting HIV, which was one of reasons for the rapid increasing of national reported older male HIV/AIDS cases. Prevention intervention programs should be specially tailored for this high risk MSM subgroup.
Electronic supplementary material
The online version of this article (doi:10.1186/1471-2334-14-531) contains supplementary material, which is available to authorized users.
PMCID: PMC4287343  PMID: 25287717
HIV; Syphilis; Unprotected anal intercourse (UAI); Men who have sex with men (MSM); Older MSM; China
11.  Sexual Risk Reduction for HIV-Infected Persons: A Meta-Analytic Review of “Positive Prevention” Randomized Clinical Trials 
PLoS ONE  2014;9(9):e107652.
Prevention intervention trials have been conducted to reduce risk of sexual transmission among people living with HIV/AIDS (PLWHA), but the findings were inconsistent. We performed a systematic review and meta-analysis to evaluate overall efficacy of prevention interventions on unprotected vaginal or anal intercourse (UVAI) among PLWHA from randomized clinical trials (RCTs).
RCTs of prevention interventions among PLWHA published as of February 2012 were identified by systematically searching thirteen electronic databases. The primary outcome was UVAI. The difference of standardized mean difference (SMD) of UVAI between study arms, defined as effect size (ES), was calculated for each study and then pooled across studies using standard meta-analysis with a random effects model.
Lower likelihood of UVAI was observed in the intervention arms compared with the control arms either with any sexual partners (mean ES: −0.22; 95% confidence interval [CI]: −0.32, −0.11) or with HIV-negative or unknown-status sexual partners (mean ES and 95% CI: −0.13 [−0.22, −0.04]). Short-term efficacy of interventions with ≤10 months of follow up was significant in reducing UVAI (1–5 months: −0.27 [−0.45, −0.10]; 6–10 months: −0.18 [−0.30, −0.07]), while long-term efficacy of interventions was weaker and might have been due to chance (11–15 months: −0.13 [−0.34, 0.08]; >15 months: −0.05 [−0.43, 0.32]).
Our meta-analyses confirmed the short-term impact of prevention interventions on reducing self-reported UVAI among PLWHA irrespective of the type of sexual partner, but did not support a definite conclusion on long-term effect. It is suggested that booster intervention sessions are needed to maintain a sustainable reduction of unprotected sex among PLWHA in future risk reduction programs.
PMCID: PMC4171502  PMID: 25243404
12.  Current drug use and lack of HIV virologic suppression: point-of-care urine drug screen versus self-report 
BMC Infectious Diseases  2014;14(1):508.
There have been inconsistent findings on the association between current drug use and HIV disease progression and virologic suppression. Drug use was often measured using self-report of historical use. Objective measurement of current drug use is preferred.
In this cross-sectional study, we assessed drug use through Computer-Assisted Self Interviews (CASI) and point-of-care urine drug screen (UDS) among 225 HIV-infected patients, and evaluated the association between current drug use and virologic suppression.
About half (54%) of participants had a positive UDS, with a lower self-reported rate by CASI (42%) (Kappa score = 0.59). By UDS, 36.0% were positive for marijuana, 25.8% for cocaine, 7.6% for opiates, and 2.2% for methamphetamine or amphetamine. Factors associated with virologic suppression (plasma HIV RNA <50 copies/mL) were Caucasian race (P = 0.03), higher CD4 count (P < 0.01), current use of antiretroviral therapy (ART) (P < 0.01), and a negative UDS (P < 0.01). Among 178 current ART users, a positive UDS remained significantly associated with lower likelihood of virologic suppression (P = 0.04).
UDS had good agreement with CASI in detecting frequently used drugs such as marijuana and cocaine. UDS at routine clinic visits may provide “real-time” prognostic information to optimize management.
PMCID: PMC4175271  PMID: 25234368
Drug use; HIV; Computer-assisted self-interview; Urine drug screen; Antiretroviral therapy; Virologic suppression
13.  Modeling the Impact on HIV Incidence of Combination Prevention Strategies among Men Who Have Sex with Men in Beijing, China 
PLoS ONE  2014;9(3):e90985.
To project the HIV/AIDS epidemics among men who have sex with men (MSM) under different combinations of HIV testing and linkage to care (TLC) interventions including antiretroviral therapy (ART) in Beijing, China.
Mathematical modeling.
Using a mathematical model to fit prevalence estimates from 2000–2010, we projected trends in HIV prevalence and incidence during 2011–2020 under five scenarios: (S1) current intervention levels by averaging 2000–2010 coverage; (S2) increased ART coverage with current TLC; (S3) increased TLC/ART coverage; (S4) increased condom use; and (S5) increased TLC/ART plus increased condom use.
The basic reproduction number based upon the current level of interventions is significantly higher than 1 ( confidence interval (CI), 1.83–2.35), suggesting that the HIV epidemic will continue to increase to 2020. Compared to the 2010 prevalence of 7.8%, the projected HIV prevalence in 2020 for the five prevention scenarios will be: (S1) Current coverage: 21.4% (95% CI, 9.9–31.7%); (S2) Increased ART: 19.9% (95% CI, 9.9–28.4%); (S3) Increased TLC/ART: 14.5% (95% CI, 7.0–23.8%); (S4) Increased condom use: 13.0% (95% CI, 9.8–28.4%); and (S5) Increased TLC/ART and condom use: 8.7% (95% CI, 5.4–11.5%). HIV epidemic will continue to rise () for S1–S4 even with hyperbolic coverage in the sensitivity analysis, and is expected to decline () for S5.
Our transmission model suggests that Beijing MSM will have a rapidly rising HIV epidemic. Even enhanced levels of TLC/ART will not interrupt epidemic expansion, despite optimistic assumptions for coverage. Promoting condom use is a crucial component of combination interventions.
PMCID: PMC3953201  PMID: 24626165
14.  Alcohol Use among Chinese Men Who Have Sex with Men: An Epidemiological Survey and Meta-Analysis 
BioMed Research International  2014;2014:414381.
The HIV/AIDS epidemic among Chinese men who have sex with men (MSM) has become a significant public health concern. Knowledge of alcohol consumption in this population is limited. In this study, 1,155 Chinese MSM were surveyed to assess alcohol use and its correlates. A meta-analysis was also performed to aggregate pooled prevalence of current alcohol use. MSM who were unmarried (aOR: 1.87; 95% CI: 1.29–2.71) or unemployed/retired (aOR: 2.77; 95% CI: 1.73–4.45) were more likely to drink alcohol more than once per week. MSM who consumed alcohol more than once per week were more likely to use drug (P < 0.01), have sex with women (P < 0.01), have unprotected insertive (P = 0.04) or receptive (P = 0.03) anal sex with men, have more than 10 lifetime male sex partners (P < 0.01), predominantly practice insertive anal sex (P < 0.01), and trade sex for money (P < 0.01). Pooled overall alcohol use prevalence was 32%. Pooled prevalence for MSM who drank alcohol more than once per week and who drank alcohol before sex with male partners was 23%. Our findings provide the basis for further exploring the alcohol-HIV association and developing risk reduction interventions.
PMCID: PMC3966324  PMID: 24711993
15.  Efficacy of Peer-Led Interventions to Reduce Unprotected Anal Intercourse among Men Who Have Sex with Men: A Meta-Analysis 
PLoS ONE  2014;9(3):e90788.
To conduct a systematic review and meta-analysis to evaluate the efficacy of peer-led interventions in reducing unprotected anal intercourse (UAI) among men who have sex with men (MSM).
Randomized clinical trials (RCTs), quasi-experimental studies, pre- and post-intervention studies without control groups, and serial cross-sectional assessments involving peers delivering interventions among MSM and published as of February 2012 were identified by systematically searching 13 electronic databases and cross-referencing. Effect sizes (ES) were calculated as the changes of standardized mean difference (SMD) in UAI between groups or pre-post intervention.
A total of 22 studies met the eligibility criteria, including five RCTs, six quasi-experimental studies, six pre-and-post intervention studies, and five serial cross-sectional intervention studies. We used 15 individual studies including 17 interventions for overall ES calculation; peer-led interventions reduced UAI with any sexual partners in meta-analysis (mean ES: -0.27; 95% confidence interval [CI]: −0.41, −0.13; P<0.01). Subgroup analyses demonstrated a statistically significant reduction on UAI in quasi-experimental studies (mean ES: −0.30; 95% CI: −0.50, −0.09; P = 0.01) and serial cross-sectional intervention studies (mean ES: −0.33; 95% CI: −0.57, −0.09; P = 0.01), but non-significant reduction in RCTs (mean ES: −0.15; 95% CI: −0.36, 0.07; P = 0.18) or pre- and post-intervention studies (mean ES: −0.29; 95% CI: −0.69, 0.11; P = 0.15). Heterogeneity was large across these 15 studies (I2 = 77.5%; P<0.01), largely due to pre-and-post intervention studies and serial cross-sectional intervention studies.
Peer-led HIV prevention interventions reduced the overall UAI among MSM, but the efficacy varied by study design. More RCTs are needed to evaluate the effect of peer-led interventions while minimizing potential bias.
PMCID: PMC3948720  PMID: 24614809
16.  Active cocaine use is associated with lack of HIV-1 virologic suppression independent of non-adherence to antiretroviral therapy: use of a rapid screening tool during routine clinic visits 
AIDS care  2012;25(1):109-117.
Clarifying the relationship between illicit drug use and HIV-1 virologic suppression requires characterization of both illicit drug use activity and adherence to antiretroviral therapy (ART). We developed a rapid clinical questionnaire to assess prior 7-day illicit drug use and ART adherence in a cross-sectional study among 1,777 HIV-infected persons in care. Of these, 76% were male, 35% were African-American, and 8% reported injection drug use as their probable route of HIV-1 infection. Questionnaire-reported frequencies of cocaine and marijuana use within the previous 7 days were 3.3% and 12.1%, respectively. Over three quarters (77.8%) of participants were on ART, of whom 69.7% had HIV-1 virologic suppression (HIV-1 RNA<48 copies/mL). Univariate analyses revealed that compared to no use, cocaine and marijuana use were both associated with missed ART doses (P<0.01). Multivariable logistic regression analysis adjusting for non-adherence demonstrated that cocaine use was independently associated with failing to achieve virologic suppression (adjusted odds ratio (aOR), 0.46; 95% confidence interval (CI), 0.22–0.98) but marijuana use was not (aOR, 1.08; 95% CI, 0.72–1.62). This result strengthens the evidence of a direct effect of cocaine on virologic control, independent of non-adherence to ART.
PMCID: PMC3443534  PMID: 22670566
Drug use; cocaine; marijuana; antiretroviral therapy; HIV-1 virologic suppression
17.  Anal human papillomavirus infection among HIV-infected and uninfected men who have sex with men in Beijing, China 
To determine prevalence, genotypes and predictors of anal human papillomavirus (HPV) among HIV-infected and uninfected men who have sex with men (MSM) in Beijing, China. In 2010–2011, we recruited MSM (age range 18–61; median 28 years) through peer volunteers, and collected demographic/behavioral information via interviewer-administrated questionnaires. Trained health workers collected anal swabs for HPV genotyping by PCR and blood samples for HIV/syphilis serologies . We obtained anal specimens from 212 HIV-infected and 459 HIV-uninfected participants. Among HIV-infected MSM, 82.1% were HPV-infected vs. 57.5% in HIV-uninfected (p<0.01). HIV-infected men had the greatest likelihood of multiple types: 17.9% uninfected; 36.3% with one type; 36.8% with 2–3; 9.0% with >4. Oncogenic HPV prevalence was higher among HIV- infected (61.3%) than uninfected participants (39.7%; p<0.01). HIV-uninfected MSM reporting always using condoms during insertive anal intercourse (past 6 months) were less likely to be HPV-infected (OR=0.49, 95%CI: 0.31–0.77). Among HIV-uninfected MSM, HPV infection was associated with unprotected receptive anal intercourse (past 6 months; OR=1.92, 95%CI: 1.19–3.11) and being forced to have sex (previous year; OR=3.32, 95%CI: 1.10–10.0). Multivariable logistic analysis among HIV infected MSM suggested that unprotected oral intercourse (past 6 months) was associated with HPV (adjusted OR=2.12, 95%CI: 1.00–4.48). Syphilis occurred in 55.8% of HIV-infected/HPV-infected, 50.0% of HIV-infected/HPV-uninfected, 19.6% of HIV-uninfected/HPV-infected, and 13.0% of HIV-uninfected/HPV-uninfected MSM. HPV anal infections were more common among HIV-infected than uninfected MSM in China, including oncogenic and multiple types. Unprotected oral and receptive anal sex were significant HPV risk factors. Promotion of safer sex and HPV vaccination is strongly recommended among MSM.
PMCID: PMC3780393  PMID: 23732908
Human papillomavirus; HIV; syphilis; genotype; men who have sex with men; China
18.  Effectiveness of Integrated HIV Prevention Interventions among Chinese Men Who Have Sex with Men: Evaluation of a 16-City Public Health Program 
PLoS ONE  2012;7(12):e50873.
To examine the impacts of a multi-city HIV prevention public health program (China Global Fund Round 5 Project) on condom use and HIV infection, we analyzed four yearly cross-sectional surveys from 2006 through 2009 among 20,843 men who have sex with men (MSM) in 16 Chinese cities. Self-reported condom use at last sex with a male partner increased from 58% in 2006 to 81% in 2009 (trend test, P<0.001). HIV prevalence increased from 2.3% in 2006 to 5.3% in 2009 (P<0.001). Multivariable logistic regression analysis showed that self-reported receipt of interventions was an independent predictor of increased condom use at last sex with a male partner over time (adjusted odds ratio [aOR], 1.63 in 2006 to 2.33 in 2009; P<0.001), and lower HIV prevalence (aOR, 1.08 in 2006 to 0.45 in 2009; P<0.001). HIV prevalence increased from 2006–2009 for participants with no self-reported receipt of interventions (2.1% in 2006 to 10.3% in 2009) and less so for those with interventions (2.4% to 4.7%). This Chinese public health program had positive impacts on both behaviors and disease rate among MSM population. Escalation of the coverage and intensity of effective interventions is needed for further increasing condom use and for reversing the rising trend of HIV epidemic.
PMCID: PMC3534092  PMID: 23300528
19.  Predictors of HIV and Syphilis among Men Who Have Sex with Men in a Chinese Metropolitan City: Comparison of Risks among Students and Non-Students 
PLoS ONE  2012;7(5):e37211.
Men who have sex with men (MSM) are at a substantial risk of HIV, given rising HIV prevalence in urban China. Adolescent and adult students often take HIV-related risk as part of sexual exploration. We compared the risks of HIV and syphilis infections and risky sexual behaviors between student and non-student among urban MSM.
Respondent driven sampling approach was used to recruit men who were self-identified as MSM in Chongqing Metropolitan City in southwestern China in 2009. Each participant completed a computer-assisted self-interview which collected demographic and behavioral data, and provided blood specimens for HIV and syphilis testing. Multivariable logistic regression analyses identified predictors for HIV and syphilis infections while comparing student and non-student MSM.
Among 503 MSM participants, 36.4% were students, of whom 84.2% were in college. The adjusted prevalence of HIV infection was 5.5% (95% confidence interval [CI]: 2.1%–10.2%) in students and 20.9% (95% CI: 13.7%–27.5%) in non-students; the adjusted prevalence of syphilis was 4.4% (95% CI: 0.7%–9.0%) in students and 7.9% (95% CI: 3.6%–12.9%) in non-students (P = 0.12). Two groups had similar risky sexual behaviors such as number of sexual partners and exchanging sex for money. Multivariate analysis showed that students had lower HIV prevalence than non-students (adjusted odds ratio [AOR]: 0.3; 95% CI: 0.1–0.8) adjusting for age, ethnicity and other variables.
Student MSM have lower HIV and similar syphilis prevalence compared with non-student MSM. However, due to a shorter duration of sexual experience and high prevalence of at-risk sexual behaviors among student MSM, HIV risk might be quite high in students as in non-students.
PMCID: PMC3356386  PMID: 22623994
20.  Factors Associated with Recent Risky Drug Use and Sexual Behaviors among Drug Users in Southwestern China 
Journal of AIDS & clinical research  2011;2(120):2155-6113-2-120.
A cross-sectional survey was conducted in 2007 among 504 drug users who were recruited mainly from detoxification centers in southwest China. About one-third (34.3%) of participants reported recent risky drug use behavior, which was defined as injecting drugs in the past 3 months, and more than one-fifth (21.6%) reported recent risky sexual behavior, or had multiple sexual partners in the past 30 days. Male sex (odds ratio [OR], 1.9; 95% confidence interval [CI], 1.2–3.2) and more episodes of detoxification (OR, 3.7; 95% CI, 2.3–6.0) were associated with higher odds of risky drug use behavior, while unmarried status (OR, 1.7; 95% CI, 1.0–2.9), higher personal annual income (OR, 1.8; 95% CI, 1.1–2.8) and history of sexually transmitted infections (OR, 3.7; 95% CI, 2.1–6.6) were associated with higher odds of having risky sexual behavior. Subgroup analyses showed 15% participants who used drugs in the past 3 months also shared needles, and 77% participants who had multiple sexual partners in the past 30 days did not use condoms during sex with non-primary sexual partners. The study findings are useful for developing HIV risk reduction intervention programs among drug users.
PMCID: PMC3238800  PMID: 22180851
HIV; Drug use; Sexual behavior; China
21.  Expenditures for the care of HIV-infected patients in rural areas in China's antiretroviral therapy programs 
BMC Medicine  2011;9:6.
The Chinese government has provided health services to those infected by the human immunodeficiency virus (HIV) under the acquired immunodeficiency syndrome (AIDS) care policy since 2003. Detailed research on the actual expenditures and costs for providing care to patients with AIDS is needed for future financial planning of AIDS health care services and possible reform of HIV/AIDS-related policy. The purpose of the current study was to determine the actual expenditures and factors influencing costs for untreated AIDS patients in a rural area of China after initiating highly active antiretroviral therapy (HAART) under the national Free Care Program (China CARES).
A retrospective cohort study was conducted in Yunnan and Shanxi Provinces, where HAART and all medical care are provided free to HIV-positive patients. Health expenditures and costs in the first treatment year were collected from medical records and prescriptions at local hospitals between January and June 2007. Multivariate linear regression was used to determine the factors associated with the actual expenditures in the first antiretroviral (ARV) treatment year.
Five ARV regimens are commonly used in China CARES: zidovudine (AZT) + lamivudine (3TC) + nevirapine (NVP), stavudine (D4T) + 3TC + efavirenz (EFV), D4T + 3TC + NVP, didanosine (DDI) + 3TC + NVP and combivir + EFV. The mean annual expenditure per person for ARV medications was US$2,242 (US$1 = 7 Chinese Yuan (CNY)) among 276 participants. The total costs for treating all adverse drug events (ADEs) and opportunistic infections (OIs) were US$29,703 and US$23,031, respectively. The expenses for treatment of peripheral neuritis and cytomegalovirus (CMV) infections were the highest among those patients with ADEs and OIs, respectively. On the basis of multivariate linear regression, CD4 cell counts (100-199 cells/μL versus <100 cells/μL, P = 0.02; and ≥200 cells/μL versus <100 cells/μL, P < 0.004), residence in Mangshi County (P < 0.0001), ADEs (P = 0.04) and OIs (P = 0.02) were significantly associated with total expenditures in the first ARV treatment year.
This is the first study to determine the actual costs of HIV treatment in rural areas of China. Costs for ARV drugs represented the major portion of HIV medical expenditures. Initiating HAART in patients with higher CD4 cell count levels is likely to reduce treatment expenses for ADEs and OIs in patients with AIDS.
PMCID: PMC3025874  PMID: 21241494
22.  HIV and hepatitis C virus infections among hanka injection drug users in central Ukraine: a cross-sectional survey 
Ukraine has experienced an increase in injection drug use since the 1990s. An increase in HIV and hepatitis C virus infections has followed, but not measures of prevalence and risk factors. The purposes of this study are to estimate the prevalence of HIV, HCV, and co-infection among injection drug users (IDUs) in central Ukraine and to describe risk factors for HIV and HCV.
A sample of 315 IDUs was recruited using snowball sampling for a structured risk interview and HIV/HCV testing (81.9% male, 42% single, average age 28.9 years [range = 18 to 55]).
HIV and HCV antibodies were detected in 14.0% and 73.0%, respectively, and 12.1% were seropositive for both infections. The most commonly used drug was hanka, home-made from poppy straw and often mixed with other substances including dimedrol, diazepines, and hypnotics. The average period of injecting was 8.5 years; 62.5% reported past-year sharing needles or injection equipment, and 8.0% shared with a known HIV-positive person. More than half (51.1%) reported multiple sexual partners, 12.9% buying or selling sex, and 10.5% exchanging sex and drugs in the past year. Those who shared with HIV positive partners were 3.4 times more likely to be HIV positive than those who did not. Those who front- or back-loaded were 4 times more likely to be HCV positive than those who did not.
Harm reduction, addiction treatment and HIV prevention programs should address risk factors to stop further spread of both HIV and HCV among IDUs and to the general population in central Ukraine.
PMCID: PMC2741433  PMID: 19698166
23.  Duration of Viraemia in Chinese Acute Sporadic Hepatitis E 
Acute sporadic hepatitis E (ASHE) cases induced by hepatitis E virus genotype 4 (HEV-4) are increasing in China. Our study aimed to estimate the duration of HEV-4 viraemia in Chinese ASHE.
A total of 619 serum specimens from 499 ASHE patients were examined for the presence of HEV RNA. The association between viraemia detection and serum sampling time was compared between subtypes. The cumulative probability of HEV viraemia detection was determined using Kaplan-Meier survival analysis, and the viraemia duration was estimated.
A total of 42.7% serum specimens were positive for HEV RNA and all the isolated strains were identified as genotype 4 and subsequently assigned to five subtypes. Among the patients infected with subtypes 4d and 4i, the time interval from the initiation of clinical symptoms to serum specimen sampling was shorter than that among the patients with subtypes 4a, 4b, and 4h. Kaplan-Meier analysis was conducted with 101 sequential specimens as well as with both 101 sequential specimens and 236 single negative specimens. The cumulative probability of HEV-4 viraemia detection was estimated to decline quickly to approximately 10% within 32 days after the initiation of clinical symptoms and then to decline very slowly to 5% by the 41st day and to zero by the 131st day.
The majority of ASHE cases maintain detectable HEV-4 viraemia within one month after onset, whereas a small portion of cases maintain long-term viraemia and may act as a reservoir for further transmission.
PMCID: PMC4201985  PMID: 24241947
Hepatitis E virus; Genotype 4; Viraemia; Phylogenetic analysis; China
24.  Recreational Drug Use among Chinese Men Who Have Sex with Men: A Risky Combination with Unprotected Sex for Acquiring HIV Infection 
BioMed Research International  2014;2014:725361.
Objective. To investigate the prevalence of recreational drug use and its relationship with HIV infection among Chinese MSM. Methods. A cross-sectional study of 625 MSM was conducted in Shenyang, China. Questionnaires were administered to collect information on recreational drug use and sexual behaviors. Blood specimens were collected to test for HIV and syphilis antibodies. Results. Nearly a quarter (23.2%, 145/625) of participants reported ever using recreational drugs, among which alkyl nitrites (poppers) was the most frequently used drug (19.2%), followed by methylmorphine phosphate (5.1%), methamphetamine (4.0%), and ketamine (0.8%). The overall prevalence of HIV and syphilis was 9.6% and 10.4%, respectively. Multivariate logistic analysis showed that recreational drug use was significantly correlated with age ≤25 year (adjusted odds ratio [aOR] = 1.6, 95% CI, 1.1–2.9), single marital status (aOR = 2.1, 95% CI, 1.2–3.6), and seeking male sexual partners mainly through Internet (aOR = 1.8, 95% CI, 1.8–2.8). Recreational drug use was independently associated with an increased risk of HIV infection (aOR = 3.5, 95% CI, 2.0–6.2). Conclusions. Our study suggests that recreational drug use is popular among Chinese MSM and is associated with significantly increased HIV infection risk. HIV prevention intervention programs should reduce both drug use and risky sexual behaviors in this population.
PMCID: PMC4009331  PMID: 24829916
25.  HIV Risk Perception among HIV Negative or Status-Unknown Men Who Have Sex with Men in China 
BioMed Research International  2014;2014:232451.
Objective. To evaluate HIV risk perception and its associated factors among Chinese MSM. Methods. A cross-sectional study was conducted among MSM with an HIV negative or unknown status in Beijing, China, between 2011 and 2012. A questionnaire interview was conducted and a blood sample was collected for HIV and syphilis testing. Results. Of 887 MSM who reported they were HIV negative or did not know their HIV status before recruitment, only 7.3% reported a high risk of HIV infection, 28.0% medium risk, 52.2% low risk, and 12.5% no risk. In multivariate logistic regression models using those who reported a medium self-perceived risk as a reference group, self-reported high risk of HIV perception was associated with minority ethnicity (odds ratio [OR]: 2.91; 95% confidence interval [CI]: 1.03–8.19), self-reported history of sexually transmitted diseases (OR: 2.27; 95% CI: 1.25–4.10), and HIV testing times since the last HIV testing (OR: 0.47; 95% CI: 0.26–0.84); low self-perceived risk of HIV infection was related to full-time employment (OR: 1.58; 95% CI: 1.15–2.18) and illicit drug use (OR: 0.28; 95% CI: 0.10–0.75). Conclusions. The HIV/AIDS epidemic is rapidly rising among Beijing MSM, but more than half MSM did not perceive this risk.
PMCID: PMC3985141  PMID: 24795880

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