Needle and syringe exchange programmes and prevalence of HIV infection among intravenous drug users in China.

AIM: To examine the association between needle and syringe exchange programme (NSEP) participation and human immunodeficiency virus (HIV) infection among intravenous drug users (IDUs) in China. DESIGN: Cross-sectional survey study design. SETTING: Six counties with active NSEP were selected from each of the seven provinces with active NSEP sampled, resulting in a sample of 42 counties in China. PARTICIPANTS: Subjects were aged more than 18 years and had injected drugs in the past month before the survey, but were excluded if they were currently enrolled in methadone maintenance treatment in order to avoid mixed effects. MEASUREMENTS: HIV prevalence was the primary measure. Odds ratios (ORs), 95% confidence intervals (CIs) and P-values were calculated to evaluate associations between HIV infection and NSEP participation. FINDINGS: A total of 3494 IDUs were interviewed, of whom 1928 (55.2%) were NSEP attendees (meaning they had attended NSEP at least once in their life-time). The unadjusted HIV prevalence was 13.9% among NSEP attendees and 16.5% among NSEP non-attendees (meaning IDUs who had never used NSEP services). After adjusting for potential confounders and taking into account the variation between counties, NSEP non-attendees were 1.67 times more likely to be HIV-positive compared to NSEP attendees (OR=1.67, CI=1.19-2.32, P=0.0031). CONCLUSIONS: Participation in needle and syringe exchange programmes was associated with a substantially lower risk of HIV infection among intravenous drug users in China. Needle and syringe exchange programmes should be expanded to include those who are needle and syringe exchange programme non-attendees.

Impact of HIV/sexually transmitted infection testing on risky sexual behaviors among men who have sex with men in Langfang, China.

BACKGROUND: Men who have sex with men (MSM) in China remain at high risk for HIV infection, the proportion of reported HIV/AIDS cases that occurred among MSM rose greatly from 2005 to 2011. HIV testing and counseling is a critical HIV prevention strategy among HIV related high-risk population, including MSM in China. This article aimed to assess the association between receiving HIV testing and high-risk sexual behaviors among MSM in Langfang, Hebei Province, China. METHODS: Between September and November 2007, 233 MSM were recruited to receive an HIV testing intervention. Face-to-face interviews were conducted before HIV testing and 3 months later HIV-related risk behaviors were assessed. Serological testing for HIV and other sexually transmitted infections (STIs) was performed. RESULTS: Of the recruited 233 MSM, 200 completed follow-up. Baseline prevalence was 7.8% for HIV, 21.0% for syphilis, 15.8% for gonorrhea, and 5.0% for chlamydia. Multivariate analysis indicated that inconsistent condom use (OR = 7.9, 95%CI: 0.9 - 66.7, P = 0.059) and bleeding during anal sex (OR = 5.9, 95%CI: 1.3 - 26.2, P = 0.019) were risk factors for HIV infection, and group sex (OR = 6.6, 95%CI: 2.2 - 19.7, P = 0.001) was a risk factor for syphilis infection at baseline. At 3 months follow-up, among STI-positive MSM, self-reported anal sex fell from 73.1% to 38.5% (P < 0.001); group sex fell from 19.2% to 5.8% (P < 0.001); and bleeding during anal sex fell from 23.1% to 5.8% (P < 0.001). Among STI-negative MSM, the frequency of one-night stands fell from 32.5% to 17.2% (P < 0.001), and oral sex rose from 57% to 78.5% (P < 0.001). STI-positive MSM were less likely to engage in anal sex compared to STI-negative MSM (χ(2) = 5.189, P = 0.023). CONCLUSIONS: HIV testing is an important intervention strategy among MSM. HIV testing services among MSM need to be scaled up, along with comprehensive, tailored interventions including condom promotion and STI treatment.

Internet-facilitated, voluntary counseling and testing (VCT) clinic-based HIV testing among men who have sex with men in China.

OBJECTIVE: To explore the feasibility of using Internet outreach to encourage men who have sex with men (MSM) to get tested for HIV at voluntary counseling and testing (VCT) clinics in Beijing and Urumqi, China. METHODS: From June to August 2007, two volunteers contacted MSM using instant messaging, online chat rooms, mobile phone, and e-mail (active recruitment). Banners with study information were put at the front pages of three major Chinese gay websites (passive recruitment). Those contacted were offered a modest financial incentive to seek HIV testing at existing VCT clinics. Those who subsequently sought HIV testing services at VCT clinics and provided informed consent completed a questionnaire and a blood draw to test for HIV and syphilis. RESULTS: A total of 3,332 MSM were contacted and 429 attended VCT clinics. One out of every 4 men that were recruited through instant messaging actually went for HIV testing, while the recruitment yields for online gay chat rooms, mobile phone contact, and email were 1∶6, 1∶10, and 1∶140, respectively. The majority of participants (80%, 317/399) reported being motivated to seek HIV testing out of concern for their health, and only 3% (11/399) reported being motivated by the financial incentive. Active recruitment tend to recruit MSM who are younger (X(2) = 11.400, P = 0.001), never tested for HIV (X(2) = 4.281, P = 0.039), tested less often (X(2) = 5.638, P = 0.018). CONCLUSION: Internet outreach is a promising way to encourage MSM to seek HIV testing at existing VCT clinics. Active recruitment can target MSM who are younger, never tested for HIV and tested less often.

Unprotected sex among HIV-positive treatment-seeking opioid-dependent adults in China: a cross-sectional study.

BACKGROUND: We set out to identify factors associated with unprotected sex among HIV-positive patients on methadone maintenance therapy (MMT) in China. METHODS: We conducted a cross-sectional study in 60 MMT clinics in Yunnan, Sichuan, Guizhou, Guangxi, and Xinjiang provinces, China, with a total of 2742 participants. RESULTS: The median age of participants was 35 years (range, 19-63 years), and 78.3% were male. More than half (1471/2742; 53.6%) were married, 6.4% (176/2742) had a regular sex partner, and 3.5% (95/2742) had 1 or more occasional sex partners. Among married participants, 64.6% (950/1471) had a spouse who was HIV negative or of unknown HIV status. Among them, 62.8% (597/950) reported sex in the past 30 days, and 31.0% (185/597) reported unprotected sex in the past 30 days. Multivariate logistic regression identified 3 factors associated with an increased risk of unprotected sex: receiving MMT in Guangxi (odds ratio [OR], 3.72 [2.05-6.75]; P < 0.001) or Xinjiang (OR, 2.23 [1.33-3.73]; P < 0.01), having a spouse that is a current or former drug user (OR, 1.80 [1.12-2.90]; P < 0.05), and having dropped out of MMT in the past 6 months (OR, 3.05 [1.63-5.71]; P < 0.001); it also identified 2 factors associated with a decreased risk of unprotected sex: being male (OR, 0.46 [0.26-0.79]; P < 0.01) and being aware of one's own HIV serostatus (OR, 0.16 [0.10-0.27]; P < 0.001). CONCLUSIONS: Many HIV-positive opioid-dependent individuals attending MMT continue to engage in high-risk sexual behaviors. Future efforts should focus on increasing awareness of HIV serostatus, retaining patients in MMT, and addressing the specific needs of female patients on MMT.

HIV-related high-risk behaviors among Chinese migrant construction laborers in Nantong, Jiangsu.

BACKGROUND: HIV transmission in rural areas of China is being fueled in part by migrant workers who acquire HIV outside of their hometowns. Recent surveillance statistics indicate that HIV prevalence among returning migrants has increased significantly. METHODS: We conducted a community-based cross-sectional study to assess HIV-related knowledge, attitudes and behaviors among migrant returnees in Nantong, Jiangsu Province, one of the largest exporters of migrant laborers. RESULTS: A total of 1625 subjects were enrolled with a response rate of 89%. All participants were male and of the majority Han ethnicity. The mean age was 39.0 years (SD = 6.7; range: 18 to 63), and most had a stable partner (N = 1533, 94.3%). Most correctly identified the major modes of HIV transmission (68.9%-82.0%), but fewer were able to identify ways that HIV cannot be transmitted. Nearly one-third of participants held positive attitudes toward having multiple sex partners, and nearly half believed that sex work should be legalized. Multiple logistic regression analysis indicated that risky sexual behavior (defined as sex with a casual or commercial sex partner) was associated with no stable partner; working abroad; correct condom use; age <22 at first sex; higher coital frequency; and having a positive attitude towards multiple sex partners. CONCLUSIONS: We found high levels of reported sex with a casual or commercial sex partner and low levels of consistent condom use. HIV prevention interventions among migrant workers need to focus on younger migrants, migrants without stable partners, and migrants who travel abroad for work.

HIV, syphilis infection, and risky sexual behaviors among male university students who have sex with men in Beijing, China: a cross-sectional study.

Young male university students who have sex with men are at high risk of HIV and sexually transmitted infections (STIs). We conducted a cross-sectional survey to assess the prevalence of risky sexual behaviors, HIV, and syphilis among male university students who have sex with men in Beijing, China; and to identify risk factors for unprotected anal intercourse (UAI). Among 157 study participants, HIV and syphilis prevalence were 2.5% and 7.0%, respectively. We found a high prevalence of UAI in our study population. Multiple logistic regression analysis revealed two significant predictors of UAI: believing it is not necessary to use a condom with a regular sex partner and not feeling anxious about being gay. Not using a condom during first sexual experience with a man was a marginally significant predictor of UAI. Male university students who have sex with men are especially vulnerable to HIV and STIs. Intensified education and HIV testing programs are needed to reduce risk in this population.

Estimating the number of people living with HIV/AIDS in China: 2003-09.

BACKGROUND: Before 2003, little was known about the scale of China's HIV/AIDS epidemic. In 2003, the Chinese government produced national estimates with support from the Joint United Nations Programme on HIV/AIDS, the World Health Organization and the United States Centers for Disease Control and Prevention. Subsequent national estimation exercises were carried out in 2005, 2007 and 2009. We describe these estimation processes and present the results of China's HIV/AIDS estimation exercises from 2003 to 2009. METHODS: The Workbook Method was used to generate national HIV/AIDS estimates. Data from the provincial level were used in 2003, data from the prefecture level were used in 2005 and data from the county level were used in 2007 and 2009. Data at the lowest level of aggregation were used to estimate risk group population size and HIV prevalence. Data from lower levels were combined into national estimates. RESULTS: At the end of 2003, 2005, 2007 and 2009, there were an estimated 0.84, 0.65, 0.70 and 0.74 million people living with HIV/AIDS in China, respectively, with an overall HIV prevalence of 0.05-0.06%. The number of new HIV infections decreased from 70 000 in 2005, to 50 000 in 2007, to 48 000 in 2009. Data quality improvements have increased the precision of China's HIV estimates. CONCLUSION: Repeated estimates have improved understanding of the HIV/AIDS epidemic in China. HIV estimates are a valuable tool for guiding national AIDS policies evaluating HIV prevention and control programmes.

Evolution of information-driven HIV/AIDS policies in China.

BACKGROUND: As China continues to commit to universal access to HIV/AIDS prevention, treatment and care services, its HIV/AIDS policies have become increasingly information driven. We review China's key national-level HIV/AIDS policies and discuss policy gaps and challenges ahead. METHODS: We conducted a desk review of key national-level policies that have had a major impact on China's HIV/AIDS epidemic, and examined recent epidemiological data relevant to China's HIV response. RESULTS: National-level policies that have had a major impact on China's HIV/AIDS response include: 'Four Frees and One Care'; 5-year action plans; and HIV/AIDS regulation. These landmark policies have facilitated massive scaling up of services over the past decade. For example, the number of drug users provided with methadone maintenance treatment significantly increased from 8116 in 2005 to 241 975 in 2009; almost a 30-fold increase. The 'Four Frees and One Care' policy has increased the number of people living with AIDS on anti-retroviral treatment from some 100 patients in 2003 to over 80 000 in 2009. However, stigma and discrimination remains major obstacles for people living with HIV/AIDS trying to access services. CONCLUSIONS: China's current national policies are increasingly information driven and responsive to changes in the epidemic. However, gaps remain in policy implementation, and new policies are needed to meet emerging challenges.

Development of a unified web-based national HIV/AIDS information system in China.

BACKGROUND: In the past, many data collection systems were in operation for different HIV/AIDS projects in China. We describe the creation of a unified, web-based national HIV/AIDS information system designed to streamline data collection and facilitate data use. METHODS: Integration of separate HIV/AIDS data systems was carried out in three phases. Phase 1, from January 2006 to December 2007, involved creating a set of unified data collection forms that took into account existing program needs and the reporting requirements of various international organizations. Phase 2, from January to October 2007, involved creating a web-based platform to host the integrated HIV/AIDS data collection system. Phase 3, from November to December 2007, involved pilot testing the new, integrated system prior to nationwide application. RESULTS: Eight web-based data collection subsystems based on one platform began operation on 1 January 2008. These eight subsystems cover: (i) HIV/AIDS case reporting; (ii) HIV testing and counselling; (iii) antiretroviral treatment (ART) for adults; (iv) ART for children; (v) behavioural interventions for high-risk groups; (vi) methadone maintenance treatment; (vii) sentinel and behavioural surveillance; and (viii) local county background information. The system provides real-time data to monitor HIV testing, prevention and treatment programs across the country. CONCLUSION: China's new unified, web-based HIV/AIDS information system has improved the efficiency of data collection, reporting, analysis and use, as well as data quality and security. It is a powerful tool to support policy making, program evaluation and implementation of the national HIV/AIDS program and, thus, may serve a model for other countries.

Accelerating harm reduction interventions to confront the HIV epidemic in the Western Pacific and Asia: the role of WHO (WPRO).

The epidemic of HIV/AIDS linked to injecting drug usage is one of the most explosive in recent years. After a historical epicentre in Europe, South and North America, at present it is clearly the main cause of dissemination of the epidemic in Eastern Europe and some key Asian countries. Recently, 10 African countries reported the spread of HIV through people who inject drugs (PWID), breaking one of the final geographical barriers to the globalization of the epidemic of HIV among and from PWID. Several countries of the Asia and Pacific Region have HIV epidemics that are driven by injecting drug usage. Harm reduction interventions have been implemented in many countries and potential barriers to implementation are being overcome. Harm reduction is no longer a marginal approach in the Region; instead, it is the core tool for responding to the HIV/AIDS epidemic among PWID. The development of a comprehensive response in the Region has been remarkable, including scaling up of needle and syringe programmes (NSPs), methadone maintenance treatment (MMT), and care, support and treatment for PWID. This development is being followed up by strong ongoing changes in policies and legislations. The main issue now is to enhance interventions to a level that can impact the epidemic. The World Health Organization (WHO) is one of the leading UN agencies promoting harm reduction. Since the establishment of the Global Programme on AIDS, WHO has been working towards an effective response to the HIV epidemic among PWID. WHO's work is organized into a number of components: establishing an evidence base; advocacy; development of normative standards, tools and guidelines; providing technical support to countries; ensuring access to essential medicines, diagnostics and commodities; and mobilizing resources. In this paper, we trace the course of development of the HIV/AIDS epidemic among and from PWID in the Western Pacific and Asia Region (WPRO) as well as WHO's role in supporting the response in some of the key countries: Cambodia, China, Lao PDR, Malaysia, the Philippines and Viet Nam.

HIV incidence, retention rate, and baseline predictors of HIV incidence and retention in a prospective cohort study of injection drug users in Xinjiang, China.

OBJECTIVE: To determine HIV seroincidence, study participant retention rate, and baseline predictors of HIV incidence and study retention among high-risk injection drug users (IDUs) in Xinjiang, China. METHODS: A total of 508 eligible seronegative high-risk IDUs were enrolled. Study participants were tested for HIV-1 and counseled at the baseline, 6-month, and 12-month follow-up visits. Sociodemographic and behavioral data were collected during each study visit. The HIV-1 incidence rate and the retention rate were analyzed as a function of sociodemographic, behavioral, and recruitment variables. RESULTS: At 12 months of follow-up, the HIV-1 incidence rate was 8.8 per 100 person-years (95% CI 6.3-12.0%) and the participant retention rate was 93%. Marital status at baseline was the only predictor of HIV incidence. No baseline variables were predictive of study retention. CONCLUSIONS: HIV incidence is high among IDUs in Xinjiang, China. Baseline predictors of incidence and retention were minimal. The participant retention rate in this study is promising for the undertaking of future HIV intervention studies.

Demographic characteristics and risk behaviors associated with HIV positive injecting drug users in Xinjiang, China.

OBJECTIVE: To determine the demographic characteristics and risk behaviors associated with HIV positive and negative injection drug users (IDUs) who were screened for inclusion in a prospective cohort study to estimate HIV incidence in Xinjiang, China. METHODS: Data analyses were performed on the demographic and risk assessment data collected at screening from high-risk IDUs, defined as anyone who reported injecting drugs at least three times per week in the last month or injected drugs after sharing equipment on at least three occasions in the last three months. RESULTS: HIV antibody prevalence among 781 IDUs at baseline survey was 29%. The following factors were significantly associated with an increase in risk for HIV infection: age > or =26years (OR=3.16, 95% CI [2.02;4.94]), lack of college education (OR=2.32, 95% CI [1.02;5.25]), frequency of heroin use (OR=1.23, 95% CI [1.02;1.47]) and sharing of rinse water (OR=1.47, 95% CI [1.18;1.84]). Female gender (OR=0.44, 95% CI [0.22;0.86]), being Han vs Uighur ethnicity (OR=0.18, 95% CI [0.11;0.27]), and other race vs Uighur ethnicity (OR=0.23, 95% CI [0.12;0.44]) were significantly associated with a lower risk of HIV infection. CONCLUSIONS: HIV infection among high risk IDUs in Xinjiang, China is high and is associated with older male Uighur IDUs who lack college education, frequently inject heroin, and/or share rinse water. There is a great potential for HIV transmission from IDUs to the general population. Therefore, related risk behaviors in IDUs, especially their sexual behavior, should be closely monitored.

The development of HIV/AIDS surveillance in China.

The strategy for monitoring HIV/AIDS in China has evolved with the epidemic. The national HIV/AIDS surveillance system was established in 1985 and sentinel surveillance started in 1995. Initially, 42 sentinel sites were established to monitor the epidemic among certain high-risk groups, including drug users, female sex workers, STD clinic attendees and long-distance truck drivers in epidemic areas. In the last decade the programme has been considerably expanded. Target groups now also include pregnant women, men who have sex with men (MSM), clients of female sex workers and tuberculosis (TB) patients. By the end of 2006, 393 national and 370 provincial sites report to the National Centre for AIDS/Sexually transmitted disease Control and Prevention. In 2004, a nationwide HIV testing campaign was launched among certain high risk groups, including former plasma donors and injecting drug users. Routine testing in health care settings and detention centres was introduced in 2005. Behavioural surveillance began in 2004 and there were already 159 sites in 27 provinces by the end of 2006. In addition a number of epidemiological surveys have been undertaken among various groups to augment surveillance data. The combination of these comprehensive strategies is used to monitor the HIV/AIDS epidemic and guide policy decision-making. The Chinese experience illustrates how surveillance systems need to be dynamic in order to monitor trends in HIV over time.