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      HIV virological failure and drug resistance among injecting drug users receiving first-line ART in China

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          Abstract

          Objective

          To explore HIV virological failure and drug resistance among injecting drug users (IDUs) receiving first-line antiretroviral treatment (ART) in China.

          Design

          A series of cross-sectional surveys from 2003 to 2012 from the Chinese National HIV Drug Resistance (HIVDR) Surveillance and Monitoring Network.

          Setting

          China.

          Participants

          Data were analysed by the Chinese National (HIVDR) Surveillance and Monitoring Network from 2003 to 2012. Demographic, ART and laboratory data (CD4+ cell count, viral load and drug resistance) were included. Factors associated with virological failure were identified by logistic regression analysis.

          Results

          929 of the 8556 individuals in the Chinese HIVDR database were IDUs receiving first-line ART. For these 929 IDUs, the median duration of treatment was 14 months (IQR 6.0–17.8). 193 of the 929 IDUs (20.8%) experienced virological failure (HIV viral load ≥1000 copies/mL). The prevalence of HIVDR among patients with virological failure was 38.9% (68/175). The proportion of patients with drug resistance to non-nucleoside reverse transcriptase inhibitor (NNRTIs), nucleoside reverse transcriptase inhibitor (NRTIs) and protease inhibitors (PIs) was 52.9%, 76.5% and 4.4%, respectively. Factors independently associated with virological failure include: ethnic minorities, junior high school education or less, farmers, self-reported missing doses in the past month, CD4 cell count at survey from 200 to 349 cells/mm 3 or from 0 to 199 cells/mm 3, and residence of Guangxi and Yunnan provinces.

          Conclusions

          The proportion of virological failure was high among IDUs receiving first-line ART in China. However, better treatment outcomes were observed in Guangxi and Yunnan, which indicates the importance of ART education and adherence to intervention, especially for patients who are farmers, minorities or have a poor educational background.

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          Most cited references28

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

          Asian HIV epidemics are concentrated among particular behavioural groups, but large variations exist in epidemic types, timing, and geographical spread between countries and within countries, especially in China. We aimed to understand the complexity of HIV epidemics in China by systematically analysing prevalence trends by data source, region, population group, and time period. We collected HIV prevalence data from official national sentinel surveillance sites at the provincial level from Jan 1, 1995, to Dec 31, 2010. We also searched PubMed, VIP Chinese Journal Database (VIP), China National Knowledge Infrastructure, and Wanfang Data from Jan 1, 1990, to Dec 31, 2012, for independent studies of HIV prevalence. We integrated both sets of data, and used an intraclass correlation coefficient test to assess the similarity of geographical pattern of HIV disease burden across 31 Chinese provinces in 2010. We investigated prevalence trends (and 95% CIs) to infer corresponding incidence by region, population group, and year. Of 6850 articles identified by the search strategy, 821 studies (384,583 drug users, 52,356 injecting drug users, 186,288 female sex workers, and 87,834 men who have sex with men) met the inclusion criteria. Official surveillance data and findings from independent studies showed a very similar geographical distribution and magnitude of HIV epidemics across China. We noted that HIV epidemics among injecting drug users are decreasing in all regions outside southwest China and have stabilised at a high level in northwest China. Compared with injecting drug users, HIV prevalence in female sex workers is much lower and has stabilised at low levels in all regions except in the southwest. In 2010, national HIV prevalence was 9·08% (95% CI 8·04-10·52) in injecting drug users and 0·36% (0·12-0·71) in female sex workers, whereas incidence in both populations stabilised at rates of 0·57 (0·43-0·72) and 0·02 (0·01-0·04) per 100 person-years, respectively. By comparison, HIV prevalence in men who have sex with men increased from 1·77% (1·26-2·57) in 2000, to 5·98% (4·43-8·18) in 2010, with a national incidence of 0·98 (0·70-1·25) per 100 person-years in 2010. We recorded strong associations between HIV prevalence among at-risk populations in each province, supporting the existence of overlap in risk behaviours and mixing among these populations. HIV epidemics in China remain concentrated in injecting drug users, female sex workers, and men who have sex with men. HIV prevalence is especially high in southwest China. Sex between men has clearly become the main route of HIV transmission. Copyright © 2013 Elsevier Ltd. All rights reserved.
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            Five-year outcomes of the China National Free Antiretroviral Treatment Program.

            China's National Free Antiretroviral Treatment Program began in 2002 and, by August 2008, included more than 52 000 patients. To report 5-year outcomes on adult mortality and immunologic treatment failure rates and risk factors. Open cohort analysis of a prospectively collected, observational database. China. All patients in the national treatment database from June 2002 to August 2008. Patients were excluded if they had not started triple therapy or had missing treatment regimen information. Antiretroviral therapy according to Chinese national treatment guidelines. Mortality rate and immunologic treatment failure rate, according to World Health Organization criteria. Of 52 191 patients, 48 785 were included. Median age was 38 years, 58% were men, 53% were infected through plasma or blood, and the median baseline CD4 cell count was 0.118x10(9) cells/L. Mortality was greatest during the first 3 months of treatment (22.6 deaths per 100 person-years) but decreased to a steady rate of 4 to 5 deaths per 100 person-years after 6 months and maintained this rate over the subsequent 4.5 years. The strongest mortality risk factors were a baseline CD4 cell count less than 0.050x10(9) cells/L (adjusted hazard ratio [HR] compared with a count>or=0.200x10(9) cells/L, 3.3 [95% CI, 2.9 to 3.8]) and having 4 to 5 baseline symptom categories (adjusted HR compared with no baseline symptom categories, 3.4 [CI, 2.9 to 4.0]). Treatment failure was determined among 31 070 patients with 1 or more follow-up CD4 cell counts. Overall, treatment failed for 25% of patients (12.0 treatment failures per 100 person-years), with the cumulative treatment failure rate increasing to 50% at 5 years. Immunologic treatment failure does not necessarily correlate well with virologic treatment failure. The National Free Antiretroviral Treatment Program reduced mortality among adult patients in China with AIDS to rates similar to those of other low- or middle-income countries. A cumulative immunologic treatment failure rate of 50% after 5 years, due to the limited availability of second-line regimens, is of great concern.
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              Substance use and mental health correlates of nonadherence to antiretroviral medications in a sample of patients with human immunodeficiency virus infection.

              Mental health and substance use problems are common among patients infected with human immunodeficiency virus (HIV) and may impede adherence to antiretroviral regimens. This study investigated associations of antiretroviral medication nonadherence with specific types of psychiatric disorders and drug use, and varying levels of alcohol use. Data were drawn from a survey of a national probability sample of 2267 (representing 181,557) adults enrolled in the HIV Cost and Services Utilization Study. This study focused on 1910 patients who reported their antiretroviral medication adherence during the past week. Patients with depression (odds ratio [OR] = 1.7; 95% confidence interval [CI]: 1.3 to 2.3), generalized anxiety disorder (OR = 2.4; 95% CI: 1.2 to 5.0), or panic disorder (OR = 2.0; 95% CI: 1.4 to 3.0) were more likely to be nonadherent than those without a psychiatric disorder. Nonadherence was also associated with use of cocaine (OR = 2.2; 95% CI: 1.2 to 3.8), marijuana (OR = 1.7; 95% CI: 1.2 to 2.3), amphetamines (OR = 2.3; 95% CI: 1.2 to 4.2), or sedatives (OR = 1.6; 95% CI: 1.0 to 2.4) in the previous month. Compared with patients who did not drink, those who were moderate (OR = 1.6; 95% CI: 1.3 to 2.0), heavy (OR = 1.7; 95% CI: 1.3 to 2.3), or frequent heavy (OR = 2.7; 95% CI: 1.7 to 4.5) drinkers were more likely to be nonadherent. These associations could not be explained by demographic, clinical, and treatment factors. These findings suggest the need for screening and treatment for mental health and substance use problems among HIV-positive patients to improve adherence to antiretroviral medications.
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                Author and article information

                Journal
                BMJ Open
                BMJ Open
                bmjopen
                bmjopen
                BMJ Open
                BMJ Publishing Group (BMA House, Tavistock Square, London, WC1H 9JR )
                2044-6055
                2014
                15 October 2014
                : 4
                : 10
                : e005886
                Affiliations
                [1 ]State Key Laboratory for Infectious Disease Prevention and Control, National Center for AIDS/STD Control and Prevention, Chinese Center for Disease Control and Prevention, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases , Beijing, China
                [2 ]Guangxi Center for Disease Control and Prevention , Nanning, Guangxi, China
                [3 ]Yunnan Center for Disease Control and Prevention , Kunming, Yunnan, China
                [4 ]Xinjiang Autonomous Region Center for Disease Control and Prevention , Urumqi, Xinjiang, China
                [5 ]University of North Texas Health Science Center Graduate School of Biomedical Sciences , Fort Worth, Texas, USA
                Author notes
                [Correspondence to ] Hui Xing; xingh@ 123456chinaaids.cn

                XL, SL, YM, YD and WK contributed equally to this work.

                Article
                bmjopen-2014-005886
                10.1136/bmjopen-2014-005886
                4202012
                25319999
                2d32dd08-1bd5-4cb0-9193-6f1bb0e852a9
                Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions

                This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/

                History
                : 10 June 2014
                : 29 July 2014
                : 18 August 2014
                Categories
                HIV/AIDS
                Research
                1506
                1842
                1724

                Medicine
                Medicine

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