Original research article
Large-scale HIV testing in the older population in China: findings from a cross-sectional study
International Journal of STD & AIDS 2014, Vol. 25(9) 650–655 ! The Author(s) 2013 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0956462413516097 std.sagepub.com
Tiansheng Xie1,2, Guohua Wang3, Haibo Yan4, Liqun Yang3, Wei Yu4, Jun Fan1, Bing Ruan1 and Nanping Wu1,2
Summary Aiming to explore universal HIV testing, and to understand the exact HIV prevalence in the older general population, we conducted a community-based cross-sectional epidemiological investigation in two counties of Zhejiang province, China. Using census strategy and convenience sampling method, those participants who were older than 50 years and met eligibility criteria were enrolled, and HIV prevalence was presented as a crude infection rate. A total of 215,441 (64.82%) were enrolled into this study, HIV testing was added into their health exam plan and 18 were confirmed as HIV positive, giving a crude rate of 0.84/10,000. HIV prevalence was higher among men than among women in all age groups (p < 0.05). Unlike previous research, 14 cases (78%) still had a relatively high CD4 þ count; 17 cases (94%) had been infected by sexual transmission. Active large-scale HIV screening by integrating into routine health care can be an effective strategy to find people living with HIV at relative early stage of disease.
Keywords HIV, AIDS, epidemiology, seroprevalence, older people, over 50, screening, China Date received: 16 July 2013; accepted: 18 November 2013
Introduction As is known to all, sexually transmitted infections (STIs) predominantly affect the younger population who are usually more sexually active.1 HIV interventions are also focussed on the young, in whom the highest incidence and health problems are seen in China.2–4 The World Health Organization (WHO) generally reports HIV rates in adults only up to 49 years of age,5 and many national STIs and sexuality surveys concentrate mainly on the younger.6–8 To date, few studies on HIV have focused on people aged 50 years or older, and these few studies mostly focused on developed countries.9–11 Also there is an increasing amount of information on HIV among older adults in Africa.12–15 Studies in sub-Saharan Africa indicated that there are approximately 21 million adult people living with HIV/AIDS (PLWHA), among which 14.3% were 50 years.13 Older populations of HIVinfected individuals in Australia have doubled from 12–14% to 23–28% in the past decade.16 Still there have been very little written about HIV among older adults in Asia.
As the population globally is ageing, rapidly increasing numbers of people are living long, healthy, and potentially sexually active lives.17 At the same time, the success of highly active antiretroviral therapy (HAART) can prolong life, and the average age of HIV-infected people living in resource-rich settings is increasing rapidly.18–20 With longer life expectancies and improvement in the quality of life, the sexual activity of older people has largely changed. Studies have shown that older people remains sexually active: most 1 State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital of Zhejiang University, School of Medicine, Zhejiang University, Hangzhou, China 2 Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, Hangzhou, China 3 Center for Disease Prevention and Control, Tongxiang, Jiaxing, China 4 Center for Disease Prevention and Control, Shaoxing, China
Corresponding author: Nanping Wu, State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, the First Affiliated Hospital of Zhejiang University, School of Medicine, Zhejiang University, No.79 Qingchun Road, Hangzhou 310031, China. Email: [email protected]
Downloaded from std.sagepub.com at University Library Utrecht on March 13, 2015
Xie et al.
651
men aged 50–64 years and those aged 65 years and older reported recent sex (84% and 75%, respectively) in Malawi.21 A subgroup analysis of 120 older women aged 46 years and older in the UK showed that most (70%) had been recently sexually active and more than half (59%) did not use condoms.22 Notably, in Australia among the older age group, half of the men and two-thirds of the women who had casual sexual encounters failed to use condoms consistently.23 Such findings suggest that, irrespective of sexual orientation, a significant minority of older adults continue to participate in high-risk sexual behaviour. Communitybased universal HIV testing has been successfully carried out in developed or developing countries,24–26 but rarely among older populations. In the present study, by integrating into public health service, a large-scale HIV testing programme was conducted in an older population, to explore the prevalence and characteristics of HIV infection in this population, so as to provide a reference for HIV agingrelated research in similar areas worldwide.
Methods Study setting and background Zhejiang province is one of the most densely populated provinces in China, with a reported 11,357 HIV infections at the end of 2012.27 The health exam plan (HEP) was first implemented by Zhejiang province in 2005 and has been provided free of charge to all residents every 2 years since then. In the present study, the HIV antibody test was added into the HEP in the year 2012. A cross-sectional study was carried out and the data were mainly collected from the HEP. We have defined ‘older’ as including members of the population 50 years of age or older.28
Sample Zhejiang Province covers a population of 54.4 million, involving 90 counties, and in our sample system all of these counties were ordered by their reported HIV rates; based upon these they were divided into levels. Considering the comprehensive organization and coverage of HEP, we chose one county in each level; in this way two counties were chosen. Using convenience sampling methods participants covering the entire older population in the chosen two counties were enrolled, and when the participants reached more than 60% of the entire older population (similar to the census), we finished the sample collection. The population survey and testing were carried out from March to August 2012. To be eligible for the study, participants had to meet the following
requirements: be a resident of the town or have lived there for >6 months, be older than 50 years old, and provide consent to participate in the study.
Data collection The Prevention and Treatment Working Group of HIV/AIDS in the Zhejiang Major Infectious District carried out the field investigation after receiving appropriate training offered by the lead researchers in this study. The collected information consisted of demographics (gender and age) and HIV antibody status. For those who were HIV positive, epidemic information such as route of transmission, HIV risk behaviour, CD4þ cells count and marital status were also recorded.
Ethics The study was approved by the Ethics Committee of The First Affiliated Hospital at the School of Medicine of Zhejiang University. Written consent was obtained from each participant. Those who were confirmed HIV positive were enrolled into China’s HIV/AIDS followup management system and cohort study.
Blood test Blood samples were screened for HIV antibodies using an enzyme-linked immunosorbent assay technique (Beijing Wantai Ltd, China) according to the manufacturer’s instructions. If the results were positive, two additional assays (the original assay plus a second confirmatory assay) were carried out in parallel. If both results were positive or the results were not in agreement, a confirmatory test was carried out using a Western blot assay (HIV BLOT 2.2; Genelabs Diagnostics Pty. Ltd, Singapore). The CD4 þ T cells were counted by flow cytometry (Beckman Coulter Inc., Brea, CA, USA) according to a standard protocol.29 All tests were performed in State Key Laboratory for Diagnosis and Treatment of Infectious Diseases.
Data analysis All data collected by paper-and-pencil surveys were entered manually into a custom-designed database and analyzed using SPSS for Windows Version 16.0 (SPSS Inc., Chicago, IL, USA). Descriptive statistics were generated for each of the general characteristics variables. We used Chi square tests to compare the infection rate differences among the different demographic groups. All statistical tests were twosided with a significance level of p < 0.05. Those in clinical stage IV (WHO) or with CD4þ 4 years) and received HAART, while 16 of them did not know their infection status, and were newly diagnosed by this cross-sectional study. The mean CD4 þ T count was 353 145 cells/ mm3, range from 146 to 625 cells/mm3. Only 22% (4/ 18) of them were in clinical stage IV (WHO) or CD4þ
Large-scale HIV testing in the older population in China: findings from a cross-sectional study
International Journal of STD & AIDS 2014, Vol. 25(9) 650–655 ! The Author(s) 2013 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0956462413516097 std.sagepub.com
Tiansheng Xie1,2, Guohua Wang3, Haibo Yan4, Liqun Yang3, Wei Yu4, Jun Fan1, Bing Ruan1 and Nanping Wu1,2
Summary Aiming to explore universal HIV testing, and to understand the exact HIV prevalence in the older general population, we conducted a community-based cross-sectional epidemiological investigation in two counties of Zhejiang province, China. Using census strategy and convenience sampling method, those participants who were older than 50 years and met eligibility criteria were enrolled, and HIV prevalence was presented as a crude infection rate. A total of 215,441 (64.82%) were enrolled into this study, HIV testing was added into their health exam plan and 18 were confirmed as HIV positive, giving a crude rate of 0.84/10,000. HIV prevalence was higher among men than among women in all age groups (p < 0.05). Unlike previous research, 14 cases (78%) still had a relatively high CD4 þ count; 17 cases (94%) had been infected by sexual transmission. Active large-scale HIV screening by integrating into routine health care can be an effective strategy to find people living with HIV at relative early stage of disease.
Keywords HIV, AIDS, epidemiology, seroprevalence, older people, over 50, screening, China Date received: 16 July 2013; accepted: 18 November 2013
Introduction As is known to all, sexually transmitted infections (STIs) predominantly affect the younger population who are usually more sexually active.1 HIV interventions are also focussed on the young, in whom the highest incidence and health problems are seen in China.2–4 The World Health Organization (WHO) generally reports HIV rates in adults only up to 49 years of age,5 and many national STIs and sexuality surveys concentrate mainly on the younger.6–8 To date, few studies on HIV have focused on people aged 50 years or older, and these few studies mostly focused on developed countries.9–11 Also there is an increasing amount of information on HIV among older adults in Africa.12–15 Studies in sub-Saharan Africa indicated that there are approximately 21 million adult people living with HIV/AIDS (PLWHA), among which 14.3% were 50 years.13 Older populations of HIVinfected individuals in Australia have doubled from 12–14% to 23–28% in the past decade.16 Still there have been very little written about HIV among older adults in Asia.
As the population globally is ageing, rapidly increasing numbers of people are living long, healthy, and potentially sexually active lives.17 At the same time, the success of highly active antiretroviral therapy (HAART) can prolong life, and the average age of HIV-infected people living in resource-rich settings is increasing rapidly.18–20 With longer life expectancies and improvement in the quality of life, the sexual activity of older people has largely changed. Studies have shown that older people remains sexually active: most 1 State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital of Zhejiang University, School of Medicine, Zhejiang University, Hangzhou, China 2 Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, Hangzhou, China 3 Center for Disease Prevention and Control, Tongxiang, Jiaxing, China 4 Center for Disease Prevention and Control, Shaoxing, China
Corresponding author: Nanping Wu, State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, the First Affiliated Hospital of Zhejiang University, School of Medicine, Zhejiang University, No.79 Qingchun Road, Hangzhou 310031, China. Email: [email protected]
Downloaded from std.sagepub.com at University Library Utrecht on March 13, 2015
Xie et al.
651
men aged 50–64 years and those aged 65 years and older reported recent sex (84% and 75%, respectively) in Malawi.21 A subgroup analysis of 120 older women aged 46 years and older in the UK showed that most (70%) had been recently sexually active and more than half (59%) did not use condoms.22 Notably, in Australia among the older age group, half of the men and two-thirds of the women who had casual sexual encounters failed to use condoms consistently.23 Such findings suggest that, irrespective of sexual orientation, a significant minority of older adults continue to participate in high-risk sexual behaviour. Communitybased universal HIV testing has been successfully carried out in developed or developing countries,24–26 but rarely among older populations. In the present study, by integrating into public health service, a large-scale HIV testing programme was conducted in an older population, to explore the prevalence and characteristics of HIV infection in this population, so as to provide a reference for HIV agingrelated research in similar areas worldwide.
Methods Study setting and background Zhejiang province is one of the most densely populated provinces in China, with a reported 11,357 HIV infections at the end of 2012.27 The health exam plan (HEP) was first implemented by Zhejiang province in 2005 and has been provided free of charge to all residents every 2 years since then. In the present study, the HIV antibody test was added into the HEP in the year 2012. A cross-sectional study was carried out and the data were mainly collected from the HEP. We have defined ‘older’ as including members of the population 50 years of age or older.28
Sample Zhejiang Province covers a population of 54.4 million, involving 90 counties, and in our sample system all of these counties were ordered by their reported HIV rates; based upon these they were divided into levels. Considering the comprehensive organization and coverage of HEP, we chose one county in each level; in this way two counties were chosen. Using convenience sampling methods participants covering the entire older population in the chosen two counties were enrolled, and when the participants reached more than 60% of the entire older population (similar to the census), we finished the sample collection. The population survey and testing were carried out from March to August 2012. To be eligible for the study, participants had to meet the following
requirements: be a resident of the town or have lived there for >6 months, be older than 50 years old, and provide consent to participate in the study.
Data collection The Prevention and Treatment Working Group of HIV/AIDS in the Zhejiang Major Infectious District carried out the field investigation after receiving appropriate training offered by the lead researchers in this study. The collected information consisted of demographics (gender and age) and HIV antibody status. For those who were HIV positive, epidemic information such as route of transmission, HIV risk behaviour, CD4þ cells count and marital status were also recorded.
Ethics The study was approved by the Ethics Committee of The First Affiliated Hospital at the School of Medicine of Zhejiang University. Written consent was obtained from each participant. Those who were confirmed HIV positive were enrolled into China’s HIV/AIDS followup management system and cohort study.
Blood test Blood samples were screened for HIV antibodies using an enzyme-linked immunosorbent assay technique (Beijing Wantai Ltd, China) according to the manufacturer’s instructions. If the results were positive, two additional assays (the original assay plus a second confirmatory assay) were carried out in parallel. If both results were positive or the results were not in agreement, a confirmatory test was carried out using a Western blot assay (HIV BLOT 2.2; Genelabs Diagnostics Pty. Ltd, Singapore). The CD4 þ T cells were counted by flow cytometry (Beckman Coulter Inc., Brea, CA, USA) according to a standard protocol.29 All tests were performed in State Key Laboratory for Diagnosis and Treatment of Infectious Diseases.
Data analysis All data collected by paper-and-pencil surveys were entered manually into a custom-designed database and analyzed using SPSS for Windows Version 16.0 (SPSS Inc., Chicago, IL, USA). Descriptive statistics were generated for each of the general characteristics variables. We used Chi square tests to compare the infection rate differences among the different demographic groups. All statistical tests were twosided with a significance level of p < 0.05. Those in clinical stage IV (WHO) or with CD4þ 4 years) and received HAART, while 16 of them did not know their infection status, and were newly diagnosed by this cross-sectional study. The mean CD4 þ T count was 353 145 cells/ mm3, range from 146 to 625 cells/mm3. Only 22% (4/ 18) of them were in clinical stage IV (WHO) or CD4þ
