Journal of Medical Virology 87:970–977 (2015)
Prevalence and Factors Associated With Late HIV Diagnosis Se-Ying Dai,1,2 Jin-Ji Liu,3 Yin-Guang Fan,2 Gui-Su Shan,3 Hong-Bo Zhang,2 Ming-Qiang Li,3** and Dong-Qing Ye2* 1
Center for Disease Control and Prevention of Anhui Province, Hefei, China Department of Epidemiology and Biostatistics, School of Public Health, Anhui Medical University, Hefei, China 3 Center for Disease Control and Prevention of Liuzhou City, Guangxi, China 2
While highly active antiretroviral therapy has been successful in delaying progression into AIDS, late HIV diagnosis remains a major contributor to the mortality and morbidity of AIDS. An epidemiological study was conducted to evaluate the prevalence and factors of late diagnosis and the characteristics of those individuals with late diagnosis in Liuzhou city. Patients with late diagnosis were defined as either those who were diagnosed with AIDS at the time of HIV diagnosis or as those who developed AIDS no more than 1 year after HIV diagnosis. Of 899 participants, 72.6% had a late diagnosis. Common characteristics of those who experienced late diagnosis included older participants, those who were unexpectedly diagnosed while seeking other medical attention, participants who believed they could not acquire HIV from their regular heterosexual partners, those who never considered getting tested for HIV, and patients with unexplained weight loss, angular cheilitis, or prolonged fever prior to HIV diagnosis. On the other hand, those participants who were diagnosed via testing at compulsory rehabilitation centers and those whose annual household income was greater than 30,000 Yuan were less likely to be diagnosed late. These results suggested that late HIV diagnosis is common in Liuzhou city, and it is essential to promote appropriate strategies to detect HIV infections earlier. Strategies that require HIV/AIDS patients to notify their spouse/sexual-partners about their HIVpositive results within one month and start provider-initiated HIV testing and counseling in medical facilities are beneficial to earlier HIV diagnosis. J. Med. Virol. 87:970–977, 2015. # 2015 Wiley Periodicals, Inc. KEY WORDS:
HIV; factors; prevalence; late diagnosis; China
C 2015 WILEY PERIODICALS, INC.
INTRODUCTION Highly active antiretroviral therapy (HAART) is important for HIV treatment, and can prevent further HIV transmission by reducing infectivity [Cohen et al., 2011] in addition to reducing the mortality and morbidity of persons infected with HIV [Michaels et al., 1998; Lima et al., 2007]. Despite the benefits of HAART, many persons infected with HIV still do not fully benefit from the therapy due to not having been diagnosed as HIV-infected or having a late diagnosis. It is estimated that over 60% of the 33.4 million persons infected with HIV globally remain unaware of their sero-status [UNAIDS and WHO, 2009]. As a result, the late diagnosis of persons infected with HIV is a global public health issue, especially in regions where the major transmission routes are injection drug use and sexual contact. Many of these patients are diagnosed with AIDS at the time of HIV diagnosis or develop AIDS no more than 1 year after HIV diagnosis, which is called “late diagnosis.” Late HIV diagnosis could bring many adverse consequences, such as it could make the persons infected with HIV miss the best opportunity for treatment, which may result in poor response or treatment failure [Egger et al., 2002], increased chance of opportunistic infection [Phillips et al., 2004], HIV-associated morbidity and mortality
Conflicts of interest: None declared. Grant sponsor: Chinese National Center for AIDS/STD Control and Prevention; Grant sponsor: The Global Fund to Fight AIDS; Grant number: CSO-2012-21. Correspondence to: Dong-Qing Ye, Department of Epidemiology and Biostatistics, School of Public Health, Anhui Medical University, No. 81 Meishan Road, Hefei, Anhui 230032, China. E-mail: [email protected], [email protected] Correspondence to: Ming-Qiang Li, Center for Disease Control and Prevention of Liuzhou City, No. 1 Tanzhong West Road, Liuzhou, Guangxi 545007, China. E-mail: [email protected] Accepted 1 August 2014 DOI 10.1002/jmv.24066 Published online 10 March 2015 in Wiley Online Library (wileyonlinelibrary.com).
Prevalence, Factors, and Late HIV Diagnosis
[Egger et al., 2002; Chadborn et al., 2005], further transmission of HIV [Cohen et al., 2011] and higher costs of medical care [Krentz et al., 2004]. Thus, it is important to diagnose HIV earlier and provide timely initiation of HAART. A large number of epidemiological studies for late HIV diagnosis have been conducted in many countries, such as the United States, Australia, France, Canada, Italy, and Spain. These studies, operating with a similar definition of late diagnosis, found that the prevalence of late diagnosis varied greatly, from 38.8% to 65% [Centers for Disease Control and Prevention, 2003, 2006; Schwarcz et al., 2006; Duffus et al., 2009; Hall et al., 2013]. The factors associated with late diagnosis included: male gender [Castilla et al., 2002; Longo et al., 2005], older age [Mugavero et al., 2007; Carnicer-Pont et al., 2009; Lemoh et al., 2009; Kivela¨ et al., 2010; Yang et al., 2010], heterosexual contact [Lemoh et al., 2009; Yang et al., 2010], male homosexual contact [Wong et al., 2003; Carnicer-Pont et al., 2009], being migrant [Sabin et al., 2004; Longo et al., 2005], being less educated [Kigozi et al., 2009], unemployment [Thanawuth and Chongsuvivatwong, 2008], lower income [Bamford et al., 2010], perceiving themselves at low risk for HIV infection [Girardi et al., 2007], and former injection drug users [Delpierre et al., 2007; CarnicerPont et al., 2009]. However, few epidemiological studies have been conducted in China, outside of Hong Kong and Taiwan. In Hong Kong and Taiwan, with a low prevalence of HIV, the rate of late diagnosis ranged from 47 to 52.1%, which could be affected by selection bias because of enrollment from the HIV/AIDS case reporting system or the referral hospital [Wong et al., 2003; Lo et al., 2011]. Also, reported risk factors of late diagnosis in these two studies were different, including male gender, Chinese ethnicity, men who do not engage in homosexual intercourse, and those participants who do not have a regular sexual partnership at the time of HIV diagnosis [Wong et al., 2003; Lo et al., 2011]. Whether these or other factors associated with late diagnosis are relevant in China is unknown, because the prevalence and factors of late diagnosis are varied in different countries and regions [Wong et al., 2003; Sabin et al., 2004; Longo et al., 2005; Delpierre et al., 2007; Carnicer-Pont et al., 2009]. Therefore, it is essential to conduct an epidemiological study to understand the prevalence and factors of late HIV diagnosis in China. Guangxi Zhuang Autonomous Region is one of the highest HIV prevalence regions of China, with injection drug use and heterosexual contact as the major transmission routes [China Ministry of Health et al., 2009]. It is reported that the HIV infection rates for clients of medical facilities has exceeded 1% in Guangxi Zhuang Autonomous Region [China Ministry of Health et al., 2009]. According to the HIV/ AIDS case reporting system of China, in 2009 Guangxi Zhuang Autonomous Region had the largest
971
number of “late HIV diagnosis,” more than 1000, defined more narrowly as having an AIDS diagnosis at the time that HIV was diagnosed (unpublished data, meeting report of Guangxi Zhuang Autonomous Region late HIV diagnosis epidemiological survey, Chinese National Center for AIDS/STD Control and Prevention). In Guangxi Zhuang Autonomous Region, the number of reported HIV/AIDS patients has grown quickly in Liuzhou city since 2007, and the HIV epidemic of Liuzhou city is the most serious [China Ministry of Health et al., 2009]. By the end of 2010, the cumulative number of HIV/ AIDS reported in Liuzhou city was 10,853, including 4,599 AIDS cases and 2,372 deaths (unpublished data, meeting report of Guangxi Zhuang Autonomous Region late HIV diagnosis epidemiological survey, Chinese National Center for AIDS/STD Control and Prevention). The status of late HIV diagnosis in Liuzhou city is unknown, and the prevalence and factors of late diagnosis are varied in different countries and regions, therefore, an epidemiological survey was conducted to gain a more accurate understanding of the prevalence and factors of late diagnosis in Liuzhou city from May to September, 2010. MATERIALS AND METHODS Study Patients and Data Collection A census method was used to identify all the eligible study individuals in Liuzhou city, Guangxi Zhuang Autonomous Region. Individuals who were newly diagnosed with HIV infection between January 1, 2009 and June 30, 2010, and aged 18 years were eligible. Late HIV diagnosis was defined as having an AIDS diagnosis at the time of HIV diagnosis or no AIDS at the time of HIV diagnoses but developed AIDS within 1 year of their HIV diagnosis, which is similar to other studies [Centers for Disease Control and Prevention, 2003, 2006; Schwarcz et al., 2006; Duffus et al., 2009; Hall et al., 2013]. An AIDS diagnosis was defined as having CD4 cell count
Prevalence and Factors Associated With Late HIV Diagnosis Se-Ying Dai,1,2 Jin-Ji Liu,3 Yin-Guang Fan,2 Gui-Su Shan,3 Hong-Bo Zhang,2 Ming-Qiang Li,3** and Dong-Qing Ye2* 1
Center for Disease Control and Prevention of Anhui Province, Hefei, China Department of Epidemiology and Biostatistics, School of Public Health, Anhui Medical University, Hefei, China 3 Center for Disease Control and Prevention of Liuzhou City, Guangxi, China 2
While highly active antiretroviral therapy has been successful in delaying progression into AIDS, late HIV diagnosis remains a major contributor to the mortality and morbidity of AIDS. An epidemiological study was conducted to evaluate the prevalence and factors of late diagnosis and the characteristics of those individuals with late diagnosis in Liuzhou city. Patients with late diagnosis were defined as either those who were diagnosed with AIDS at the time of HIV diagnosis or as those who developed AIDS no more than 1 year after HIV diagnosis. Of 899 participants, 72.6% had a late diagnosis. Common characteristics of those who experienced late diagnosis included older participants, those who were unexpectedly diagnosed while seeking other medical attention, participants who believed they could not acquire HIV from their regular heterosexual partners, those who never considered getting tested for HIV, and patients with unexplained weight loss, angular cheilitis, or prolonged fever prior to HIV diagnosis. On the other hand, those participants who were diagnosed via testing at compulsory rehabilitation centers and those whose annual household income was greater than 30,000 Yuan were less likely to be diagnosed late. These results suggested that late HIV diagnosis is common in Liuzhou city, and it is essential to promote appropriate strategies to detect HIV infections earlier. Strategies that require HIV/AIDS patients to notify their spouse/sexual-partners about their HIVpositive results within one month and start provider-initiated HIV testing and counseling in medical facilities are beneficial to earlier HIV diagnosis. J. Med. Virol. 87:970–977, 2015. # 2015 Wiley Periodicals, Inc. KEY WORDS:
HIV; factors; prevalence; late diagnosis; China
C 2015 WILEY PERIODICALS, INC.
INTRODUCTION Highly active antiretroviral therapy (HAART) is important for HIV treatment, and can prevent further HIV transmission by reducing infectivity [Cohen et al., 2011] in addition to reducing the mortality and morbidity of persons infected with HIV [Michaels et al., 1998; Lima et al., 2007]. Despite the benefits of HAART, many persons infected with HIV still do not fully benefit from the therapy due to not having been diagnosed as HIV-infected or having a late diagnosis. It is estimated that over 60% of the 33.4 million persons infected with HIV globally remain unaware of their sero-status [UNAIDS and WHO, 2009]. As a result, the late diagnosis of persons infected with HIV is a global public health issue, especially in regions where the major transmission routes are injection drug use and sexual contact. Many of these patients are diagnosed with AIDS at the time of HIV diagnosis or develop AIDS no more than 1 year after HIV diagnosis, which is called “late diagnosis.” Late HIV diagnosis could bring many adverse consequences, such as it could make the persons infected with HIV miss the best opportunity for treatment, which may result in poor response or treatment failure [Egger et al., 2002], increased chance of opportunistic infection [Phillips et al., 2004], HIV-associated morbidity and mortality
Conflicts of interest: None declared. Grant sponsor: Chinese National Center for AIDS/STD Control and Prevention; Grant sponsor: The Global Fund to Fight AIDS; Grant number: CSO-2012-21. Correspondence to: Dong-Qing Ye, Department of Epidemiology and Biostatistics, School of Public Health, Anhui Medical University, No. 81 Meishan Road, Hefei, Anhui 230032, China. E-mail: [email protected], [email protected] Correspondence to: Ming-Qiang Li, Center for Disease Control and Prevention of Liuzhou City, No. 1 Tanzhong West Road, Liuzhou, Guangxi 545007, China. E-mail: [email protected] Accepted 1 August 2014 DOI 10.1002/jmv.24066 Published online 10 March 2015 in Wiley Online Library (wileyonlinelibrary.com).
Prevalence, Factors, and Late HIV Diagnosis
[Egger et al., 2002; Chadborn et al., 2005], further transmission of HIV [Cohen et al., 2011] and higher costs of medical care [Krentz et al., 2004]. Thus, it is important to diagnose HIV earlier and provide timely initiation of HAART. A large number of epidemiological studies for late HIV diagnosis have been conducted in many countries, such as the United States, Australia, France, Canada, Italy, and Spain. These studies, operating with a similar definition of late diagnosis, found that the prevalence of late diagnosis varied greatly, from 38.8% to 65% [Centers for Disease Control and Prevention, 2003, 2006; Schwarcz et al., 2006; Duffus et al., 2009; Hall et al., 2013]. The factors associated with late diagnosis included: male gender [Castilla et al., 2002; Longo et al., 2005], older age [Mugavero et al., 2007; Carnicer-Pont et al., 2009; Lemoh et al., 2009; Kivela¨ et al., 2010; Yang et al., 2010], heterosexual contact [Lemoh et al., 2009; Yang et al., 2010], male homosexual contact [Wong et al., 2003; Carnicer-Pont et al., 2009], being migrant [Sabin et al., 2004; Longo et al., 2005], being less educated [Kigozi et al., 2009], unemployment [Thanawuth and Chongsuvivatwong, 2008], lower income [Bamford et al., 2010], perceiving themselves at low risk for HIV infection [Girardi et al., 2007], and former injection drug users [Delpierre et al., 2007; CarnicerPont et al., 2009]. However, few epidemiological studies have been conducted in China, outside of Hong Kong and Taiwan. In Hong Kong and Taiwan, with a low prevalence of HIV, the rate of late diagnosis ranged from 47 to 52.1%, which could be affected by selection bias because of enrollment from the HIV/AIDS case reporting system or the referral hospital [Wong et al., 2003; Lo et al., 2011]. Also, reported risk factors of late diagnosis in these two studies were different, including male gender, Chinese ethnicity, men who do not engage in homosexual intercourse, and those participants who do not have a regular sexual partnership at the time of HIV diagnosis [Wong et al., 2003; Lo et al., 2011]. Whether these or other factors associated with late diagnosis are relevant in China is unknown, because the prevalence and factors of late diagnosis are varied in different countries and regions [Wong et al., 2003; Sabin et al., 2004; Longo et al., 2005; Delpierre et al., 2007; Carnicer-Pont et al., 2009]. Therefore, it is essential to conduct an epidemiological study to understand the prevalence and factors of late HIV diagnosis in China. Guangxi Zhuang Autonomous Region is one of the highest HIV prevalence regions of China, with injection drug use and heterosexual contact as the major transmission routes [China Ministry of Health et al., 2009]. It is reported that the HIV infection rates for clients of medical facilities has exceeded 1% in Guangxi Zhuang Autonomous Region [China Ministry of Health et al., 2009]. According to the HIV/ AIDS case reporting system of China, in 2009 Guangxi Zhuang Autonomous Region had the largest
971
number of “late HIV diagnosis,” more than 1000, defined more narrowly as having an AIDS diagnosis at the time that HIV was diagnosed (unpublished data, meeting report of Guangxi Zhuang Autonomous Region late HIV diagnosis epidemiological survey, Chinese National Center for AIDS/STD Control and Prevention). In Guangxi Zhuang Autonomous Region, the number of reported HIV/AIDS patients has grown quickly in Liuzhou city since 2007, and the HIV epidemic of Liuzhou city is the most serious [China Ministry of Health et al., 2009]. By the end of 2010, the cumulative number of HIV/ AIDS reported in Liuzhou city was 10,853, including 4,599 AIDS cases and 2,372 deaths (unpublished data, meeting report of Guangxi Zhuang Autonomous Region late HIV diagnosis epidemiological survey, Chinese National Center for AIDS/STD Control and Prevention). The status of late HIV diagnosis in Liuzhou city is unknown, and the prevalence and factors of late diagnosis are varied in different countries and regions, therefore, an epidemiological survey was conducted to gain a more accurate understanding of the prevalence and factors of late diagnosis in Liuzhou city from May to September, 2010. MATERIALS AND METHODS Study Patients and Data Collection A census method was used to identify all the eligible study individuals in Liuzhou city, Guangxi Zhuang Autonomous Region. Individuals who were newly diagnosed with HIV infection between January 1, 2009 and June 30, 2010, and aged 18 years were eligible. Late HIV diagnosis was defined as having an AIDS diagnosis at the time of HIV diagnosis or no AIDS at the time of HIV diagnoses but developed AIDS within 1 year of their HIV diagnosis, which is similar to other studies [Centers for Disease Control and Prevention, 2003, 2006; Schwarcz et al., 2006; Duffus et al., 2009; Hall et al., 2013]. An AIDS diagnosis was defined as having CD4 cell count
