Epidemiological Evaluation And Influencing Factors Of AIDS Infection Diagnosis And Treatment In Shandong Province

BackgroundIt is an globally important public health problem for the control and prevention of AIDS.The development of highly active anti-retroviral therapy(HAART)makes AIDS a controllable and chronic infectious disease.It is important for early detection,early diagnosis and early treatment to reduce HIV new infections and stop AIDS.There are two meanings of the test-treat strategy for the control and prevention of AIDS.First,reduce infectivity of HIV/AIDS,and then reduce HIV new infections.The Joint United Nations Programme on HIV/AIDS(UNAIDS)set the "90-90-90"targets to be reached by 2020 in order to end the AIDS epidemic by 2030,that is 90%of people living with HIV will be diagnosed,90%of those diagnosed will be on antiretroviral therapy,and 90%of people on treatment will achieve viral suppression.However,there are different viewpoints on this targets.In the real-world,there is less study about this topic.Second,reduce mortality,prolong life time,and increase the number of HIV/AIDS.Failing to treatment would increase risk of HIV infection.It was begin to HIV test and HAART from 2003 in Shandong Province,China.The number of HIV/AIDS on HAART increased annually,while the number of HIV/AIDS increased rapidly also.However,there was lack of a systematic and comprehensive study on test-treat and living status of HIV/AIDS and their influencing factors on HAART in Shandong.Based on the analysis above,this study analyzes the status of infection,diagnosis and treatment in Shandong,discusses the effectiveness of test-treat strategy to reduce HIV new infections,explores influencing factors about test-treat and living status for HIV/AIDS on HAART,such that it has guiding significance as well as actual using value for AIDS control and prevention in Shandong.ObjectivesThe study aimed to understand the status and trend of infection,diagnosis,treatment and "90-90-90" targets on AIDS,discuss the effectiveness of test-treat strategy to reduce HIV new infections,explore influencing factors about follow-up,treatment and viral suppression,analyze living status of HIV/AIDS on HAART and explore its influencing factors in Shandong.Methods1.Descriptive epidemiological method was used to analyze the status of HIV/AIDS infection,diagnosis,treatment and "90-90-90" targets among all living HIV/AIDS in Shandong Province.2.To discuss respectively the effectiveness of test-treat strategy and "90-90-90"targets for reduction of HIV new infection in Shandong by risk estimate equation.3.Logistic regression model was used to explore influencing factors on HIV/AIDS care,treatment and viral suppression for newly diagnosed HIV/AIDS from 2014-2014 in Shandong.4.Based on cohort study for all treated HIV/AIDS aged 15 years old or above,AIDS-associated mortality and accumulate survival rate were calculated to describe the survival.K-M method and CIF were used to calculate cumulative incidence of AIDS-associated death respectively,and Cox proportional hazard regression model and Fine-Gray model were used to identify influencing factors of survival time respectively.Results1.From 2013 to 2017,the cumulative numbers of infection,diagnosis,treatment and viral suppression of HIV/AIDS increased annually,and "90-90-90" targets showed increasing time trend by Cochran-Armitage trend test in Shandong(P<0.05).At the end of 2017,there were 17100 cases in Shandong Province.Of the 17100 estimated HIV/AIDS,67.17%were diagnosed.Of the 11590 diagnosed HIV/AIDS,83.81%had received HAART.Of the 9713 cases on HAART,63.65%had virally suppressed.Of the 5510 cases undiagnosed,90.80%were infected by homosexual behavior.Of the 7387 cases untreated,83.51%were infected by homosexual behavior.Of the 10918 cases who hadn’t achieve viral suppression,77.41%were infected by homosexual behavior.2.Based on risk estimate equation,if "90-90-90"targets achieved,the percentage of reduction for HIV new infections from 2013-2017 were 65.19%、64.19%、61.86%、58.50%and 54.03%respectively while transmission rate was reduced by a theoretical value 96%in the strictly scientific condition,and the percentage of reduction for HIV new infections from 2013 to 2017 were 33.59%、32.62%、30.46%、27.57%and 24.09%respectively while transmission rate was reduced by a value 53%in the real world for AIDS prevention and control.3.From 2014 to 2016,there were 6253 newly diagnosed HIV/AIDS in Shandong,94.51%were linked to care in one year after diagnosis,92.59%were sustained in care for HIV/AIDS who linked to care in one year after diagnosis,88.32%were on HAART for HIV/AIDS who sustained in care,71.36%had achieved viral suppression for HIV/AIDS who were on HAART.HIV/AIDS linked to care in one year after diagnosis were more likely to receive HAART(OR=4.60,95%CI:2.88-7.34).HIV/AIDS sustained in care were more likely to receive HAART(OR=7.40,95%CI:6.05-9.05)and meet the level of VL suppression(OR=7.59,95%CI:4.23-13.49).The time mode from diagnosis to first VL testing was 343 days,and of the 4108 HIV/AIDS who had VL testing,42.38%received first VL testing one year or later after treatment initiation.The multivariate logistic regression analysis showed:① The influencing factors on linkage to care for HIV/AIDS in Shandong were education of college degree or above(vs.primary school or illiteracy,OR=3.14,95%CI:2.07-4.78),aged 45year or old at diagnosis(vs.15-24 years old,OR=0.64,95%CI:044-0.95),diagnosed by clinical institutions(vs.by VCT,OR=0.40,95%CI:0.31-0.52)or custodial institutions(vs.by VCT,OR=0.45,95%CI:0.22-0.91),lived in middle(vs.east,OR=0.64,95%CI:0.47-0.86)or west(vs.east,OR=0.47,95%CI:0.35-0.62)of Shandong,infected by heterosexual behavior(vs.by homosexual behavior,OR=0.78,95%CI:0.60-0.99)or IDU(vs.by homosexual behavior,OR=0.41,95%CI:0.18-0.92).② The influencing factors on retained in care for HIV/AIDS in Shandong were education of college degree or above(vs.primary school or illiteracy,OR=1.77,95%CI:1.15-2.71),aged 45 or above at diagnosis(vs.15-24 years old,OR=0.56,95%CI:0.37-0.85),diagnosed by clinical institutions(vs.by VCT,OR=0.53,95%CI:0.42-0.66),lived in middle(vs.east,OR=0.73,95%CI:0.56-0.96)or west(vs.east,OR=0.50,95%CI:0.38-0.65)of Shandong,and infected by IDU(vs.by homosexual behavior,OR=0.27,95%CI:0.11-0.64).CD4 cell count at diagnosis was 201-350 cells/ul(vs.≤200cells/ul,OR=3.12,95%CI:2.33-4.16),351-500 cells/ul(vs.≤200cells/ul,OR=4.06,95%CI:3.00-5.50)and 501 cells/ul or above(vs.≤200cells/ul,OR=4.76,95%CI:3.59-6.32),③ The influencing factors on receiving HAART for HIV/AIDS in Shandong were education of college degree or above(vs.primary school or illiteracy,OR=1.69,95%CI:1.12-2.54),aged 45year or old at diagnosis(vs.15-24 years old,OR=1.64,95%CI:1.11-2.42),diagnosed by custodial institutions(vs.by VCT,OR=0.13,95%CI:0.08-0.20),lived in middle(vs.east,OR=0.75,95%CI:0.61-0.93)or west(vs.east,OR=0.75,95%CI:0.59-0.94)of Shandong,infected by IDU(vs.by homosexual behavior,OR=0.31,95%CI:0.13-0.76),CD4 cell count at diagnosis was 201-350 cells/ul(vs.≤200cells/ul,OR=0.48,95%CI:0.29-0.78),351-500 cells/ul(vs.≤200cells/ul,OR=0.23,95%CI:0.15-0.37)and 501 cells/ul or above(vs.≤200cells/ul,OR=0.13,95%CI:0.08-0.20).④ The influencing factors on achieving viral suppression for HIV/AIDS in Shandong were education of college degree or above(vs.primary school or illiteracy,OR=2.00,95%CI:1.31-3.07),CD4 cell count at initiation of HAART was 201-350 cells/ul(vs.≤200cells/ul,OR=2.36,95%CI:1.77-3.15),351-500 cells/ul(vs.≤200cells/ul,OR=2.11,95%CI:1.58-2.82)and 501 cells/ul or above(vs.≤200cells/ul,OR=2.66,95%CI:1.75-4.03),treated by clinical institutions(vs.by CDCs,OR=1.29,95%CI:1.34-1.68),missing doses(OR=0.55,95%CI:0.33-0.90).The results of qualitative study showed that the main reasons for unlikely to retained in care were fearing of discrimination if infection was knew by others,and feeling good about themselves.The main reasons for unlikely to receive HAART were feeling good about themselves and no bad effect without HAART,fearing of adverse reaction of drugs,and discrimination if infection was knew by others.4.Among all the HIV/AIDS initiated HAART from 2003 to 2015 in Shandong,there were 5593 cases who met the inclusion criteria with a total follow-up time of 20382.67 person-years,and 260 cases died of AIDS-associated death.The AIDS-associated mortality was 1.28/100 person-years(95%CI:1.12-1.43).The mortality for HIV/AIDS initiated HAART in different years showed decrease in time trend(P<0.001),the same for those who initiated HAART with CD4 count cell at initiation of HAART above 200 cells/mm3(P=0.002),but not for those less than 200 cells/mm3(P=0.886).The cumulative incidence rate for AIDS-associated death was 3.08%in lyear,4.21%in 3 years,5.37%in 5 years,and 7.59 in 10 years respectively by CIF.The F-G analysis showed that the influencing factors on survival time of HIV/AIDS on HAART were education of college degree or above(vs.primary school or illiteracy,HR=0.40,95%CI:0.24-0.65),lived in west of Shandong(vs.east,HR=1.33,95%CI:1.01-1.89),diagnosed by clinical institutions(vs.by VCT,HR=1.39,95%CI:1.06-1.80),NVP in ART regime at initiation(vs.EFV,HR=1.36,95%CI:1.03-1.88),with Ⅲ/Ⅳ clinical stages at initiation(vs.Ⅰ/Ⅱ,HR=2.61,95%CI:1.94-3.53),linkage to care≥ lyear after diagnosis(vs.<1 year,HR=2.02,95%CI:1.30-3.15),CD4 cell count at diagnosis was less than 200 cells/ul(vs.>200 cells/ul,HR=3.41,95%CI:2.59-4.59),and CD4 cell count at initiation of HAART was less than 350 cells/mm3(vs.>350 cells/ul,HR=5.48,95%CI:2.32-12.72).Conclusions1.There were gaps between diagnosis,treatment and viral suppression of HIV/AIDS in Shandong Province and "90-90-90" targets,especially the rate of diagnosis and viral suppression.Most of HIV/AIDS undiagnosed,untreated or viral unsuppressed were infected by homosexual behaviors.2.HIV incidence would have been reduced with the achievement of "90-90-90"targets in Shandong Province.In the real-world,the percentage of reduction of HIV new infections were 24.09-33.59%.Besides enlarge HAART,to strengthen diagnosis and improve viral suppression to maximize decline percentage of HIV new infections in Shandong.3.Timely linked to and sustained in care can improve percentages of on HAART and achieving viral suppression.Factors related to care and HAART were educational level,CD4 cell count at diagnosis,age at diagnosis,transmission route,sample resources and address for HIV/AIDS.Factors related to viral suppression were educational level,CD4 cell count at HAART initiation,treatment agencies and missing doses on HAART.In the real-world,there was lag between clinical requirements and viral load testing because of unlinkage to care for HIV/AIDS or delay testing for laboratories.4.Factors related to survival time of treated HIV/AIDS aged 15 years old or above in Shandong were education level,address,sample resource,timeliness of care,and CD4 cell count,ART regime,and clinical stage at HAART initiation.The numbers of infection source accumulated increased for the decreasement of mortality of HIV/AIDS with CD4 cell count at HAART initiation above 200 cells/ul.In the survival analysis,the AIDS-associated death was interesting events and the classical survival methods such as Cox proportional hazard model would lead to competing risk bias for taking non-AIDS associated death as right censored data.Competing risk model was the optimal method to control competing risk bias by handling non-AIDS associated death as competing events.