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As shown in Figure 1, a total of 16, 535 individuals had 18, 237 episodes of HIV testing at 32 VCT clinics in Wuxi, China, between January 1, 2013 and December 31, 2015. Among these individuals, 61.1% were women including 3, 125 pregnant women, 61.5% were younger than 30 years, 58.8% were married, 46.8% had high school education or lower, and 78.3% were residents of Wuxi. Meanwhile, 31.4% reported previous HIV testing [14.2% for people who have commercial heterosexual behavior (PWCH), 35.5% for MSM, and 88.8% for injection drug users (IDUs)]. In male individuals, 29.0% reported male-male sexual behaviors, 22.0% reported casual non-commercial heterosexual behaviors, and 38.1% reported having commercial heterosexual behaviors at the first recorded test. In female individuals, 18.0% reported casual non-commercial sex with a man, and 20.3% reported having sold sex to a man. At first recorded HIV test, 1.5% of the individuals were diagnosed with HIV, with male individuals having higher rate than female individuals (2.9% vs. 0.7%, P < 0.05) and MSM having the highest rate among all individuals (7.7%); 2.3% of the individuals were diagnosed with syphilis (Table 1). Approximately 29.8% of the individuals attending hospital-based VCT clinics and only 5.3% of those visiting VCT clinics affiliated to community health service centers reported having ever had male-male sex (P < 0.05).
Figure 1. Flow chart of HIV testing in VCT clinics and HIV diagnosis in Wuxi, China, from 2013 to 2015. *Other services included clinical services provided in comprehensive hospitals, specialized hospitals, community health care centers, and private clinics.
Characteristics N % No. HIV+ % HIV+ Total 16, 535 100.0 252 1.5 Gender Female 10, 107 61.1 68 0.7 Male 6, 428 38.9 184 2.9 Age (year) < 30 10, 160 61.5 117 1.2 ≥ 30 6, 375 38.5 135 2.1 Marriage Not married 6, 814 41.2 123 1.8 Married 9, 721 58.8 129 1.3 Education ≤ High school 7, 744 46.8 107 1.4 > High school 8, 791 53.2 145 1.6 Residency Permanent residents in Wuxi 12, 943 78.3 198 1.5 Migrants 3, 592 21.7 54 1.5 Type of hosting institute Community health service center 6, 604 39.9 59 0.9 Hospital 3, 084 18.7 74 2.4 Center for disease control and prevention 6, 847 41.4 119 1.7 Risk category Casual non-commercial heterosexual behaviors 3, 237 19.6 15 0.5 Commercial heterosexual behaviors 4, 498 27.2 34 0.8 Male-male sexual behaviors 1, 867 11.3 143 7.7 Injection drug use 282 1.7 10 3.5 Prenatal health check 3, 025 18.3 1 0.03 Premarital health check 1, 056 6.4 2 0.2 Spouse/sexual partner tested positive 428 2.6 8 1.9 Other 2, 142 13.0 39 1.8 Previous HIV testing No 11, 349 68.6 165 1.5 Yes 5, 186 31.4 87 1.7 Syphilis Negative 15, 443 93.4 233 1.5 Positive 388 2.3 7 1.8 Unknown 704 4.3 12 1.7 Calendar year of initial test 2013 6, 058 36.6 83 1.4 2014 5, 446 32.9 81 1.5 2015 5, 031 30.4 88 1.7 Table 1. Characteristics of Individuals at First Recorded HIV Test at
A total of 11, 504 individuals had their first recorded HIV test in either 2013 or 2014. Of these, 655 (5.7%) retested HIV within 12 months (4.1% for PWCH, 17.1% for MSM, and 52.5% for IDUs). Among pregnant women, only 32 (1.0%) retested HIV within 12 months. In a multivariable analysis, repeat HIV testing within 12 months was associated with being male [adjusted odds ratio (aOR) = 1.7, 95% confidence interval (CI): 1.4-2.2], risk behaviors [commercial heterosexual behavior (aOR = 1.4, 95% CI: 1.1-1.6), male-male sexual behavior (aOR = 3.7, 95% CI: 2.7-4.9), and injection drug use (aOR = 9.9, 95% CI: 6.5-15.1)], and having taken HIV test previously prior to study baseline (aOR = 2.0, 95% CI: 1.6-2.4) (Table 2). About one-third of individuals (3, 657, 31.8%) had previous HIV testing (13.5% for PWCH, 36.9% for MSM, and 90.6% for IDUs).
Variables n Repeat Test* (%) Univariable Analysis Multivariable Analysis OR 95% CI P aOR 95% CI P Gender Female 7, 237 2.7 Ref Ref Male 4, 267 10.8 4.4 3.7-5.3 < 0.001 1.7 1.4-2.2 < 0.001 Age (year) < 30 7, 085 3.5 Ref Ref ≥ 30 4, 419 9.0 2.8 2.4-3.3 < 0.001 1.2 0.9-1.5 0.143 Marriage Not married 4, 511 4.8 Ref Ref Married 6, 993 6.3 1.3 1.1-1.6 0.001 1.1 0.9-1.3 0.678 Education ≤ High school 5, 405 6.5 Ref Ref > High school 6, 099 5.0 0.7 0.6-0.9 < 0.001 0.9 0.7-1.1 0.319 Resident Permanent residents 9, 445 5.8 Ref Migrants 2, 059 5.1 0.9 0.8-1.1 0.477 Type of hosting institute Community health service center 1, 969 6.5 Ref Ref Hospital 4, 623 5.5 0.8 0.7-1.0 0.095 1.0 0.8-1.3 0.885 Center for disease control and prevention 4, 912 5.6 0.9 0.7-1.1 0.151 1.0 0.8-1.3 0.847 Risk category Casual non-commercial heterosexual behaviors 3, 199 3.1 Ref Ref Commercial heterosexual behaviors 3, 186 4.1 1.3 1.1-1.7 0.041 1.4 1.1-1.6 0.032 Male-male sexual behaviors 1, 057 17.1 6.5 5.0-8.4 < 0.001 3.7 2.7-4.9 < 0.001 Injection drug use 286 52.5 9.2 6.8-11.6 < 0.001 9.9 6.5-15.1 < 0.001 Others 3, 776 2.5 0.8 0.6-1.1 0.164 0.8 0.6-1.1 0.114 Previous HIV testing No 7, 847 4.1 Ref Ref Yes 3, 657 9.2 2.4 2.0-2.8 < 0.001 2.0 1.6-2.4 < 0.001 Syphilis Negative 10, 980 5.6 Ref Ref Positive 205 9.3 1.7 1.1-2.8 0.025 1.2 0.7-2.0 0.585 Unknown 319 7.2 1.3 0.9-2.0 0.215 1.3 0.8-2.0 0.321 Calendar year of initial test 2013 6, 058 5.9 Ref 2014 5, 446 5.5 0.8 0.6-1.1 0.242 Note. *Repeat test was recorded if an individual retested within 12 months since their first recorded test during 2013-2014. Table 2. Factors Associated with Repeat HIV Testing among VCT Individuals in Wuxi,
Of the 16, 535 testers involved in this study, 252 (1.5%) were tested HIV-positive at their first recorded test including 1 pregnant woman. Of the 16, 283 testers who tested HIV-negative at their first recorded test, 1, 088 (6.7%) had two or more HIV testing records during 2013-2015. In this group, there were 30 HIV diagnoses in 1, 829 person-years of follow-up, with an overall incident HIV diagnosis rate of 1.6 (95% CI: 1.1-2.1) per 100 person-years [4.5 (95% CI: 3.7-5.2) for MSM, 0.8 (95% CI: 0.3-1.3) for IDU, and 0.6 (95% CI: 0.2-1.0) for PWCH]. The rates of incident HIV diagnosis were not significantly different between MSM < 30 and ≥ 30 years of age [5.0 (95% CI: 4.4-5.7) vs. 4.2 (95% CI: 3.8-4.7) per 100 person-years, χ2 = 3.312, P = 0.071]. No pregnant women had incident HIV diagnosis. Incident HIV diagnosis was associated with male gender [adjusted hazard ratio (aHR) = 8.5, 95% CI: 1.9-38.1], attending hospital-based VCT clinics (aHR = 7.8, 95% CI: 1.1-58.3), and male-male sexual behavior (aHR = 8.4, 95% CI: 1.5-46.7) (Table 3).
Variable Incidence (PY*) Univariable Analysis Multivariable Analysis HR 95% CI P Value aHR 95% CI P Value Gender Female 0.7 Ref Ref Male 3.6 4.7 1.8-12.3 0.001 8.5 1.9-38.1 0.005 Age (year) < 30 2.5 Ref Ref ≥ 30 1.2 0.5 0.3-0.9 0.011 0.6 0.3-1.3 0.192 Marriage Not married 2.5 Ref Ref Married 1.3 0.5 0.3-0.8 0.006 0.9 0.3-2.5 0.092 Education ≤ High school 0.9 Ref Ref > High school 3.4 3.8 2.0-7.1 < 0.001 1.0 0.5-2.1 0.958 Resident Permanent residents 1.7 Ref Migrants 1.5 0.9 0.5-1.6 0.812 Type of hosting institute Community health service center 0.3 Ref Ref Hospital 2.6 9.1 2.2-37.6 0.006 7.8 1.1-58.3 0.045 Center for disease control and prevention 2.0 6.8 0.9-51.9 0.064 3.7 0.5-29.6 0.206 Risk category Casual non-commercial heterosexual behaviors 0.4 Ref Ref Commercial heterosexual behaviors 0.6 1.5 0.6-4.2 0.183 3.9 0.7-22.9 0.132 Male-male sexual behaviors 4.5 10.2 2.4-42.3 0.001 8.4 1.5-46.7 0.016 Injection drug use 0.8 1.9 0.8-4.5 0.515 1.6 0.6-4.2 0.554 Others 0.5 1.4 0.2-9.8 0.746 1.5 0.2-10.9 0.685 Previous HIV testing No 1.2 Ref Ref vYes 2.0 1.7 0.9-3.5 0.059 1.0 0.5-1.9 0.964 Syphilis diagnoses at baseline Negative 1.5 Ref Positive 0.8 0.5 0.2-1.4 0.209 Unknown 1.7 1.1 0.3-4.2 0.851 Calendar year of initial test 2013 1.4 Ref 2014 2.1 1.5 0.2-11.7 0.702 2015 1.1 0.8 0.1-6.5 0.854 Note. *PY means person-year. Table 3. Factors Associated with Incident HIV Diagnosis in Individuals Presenting for
Between January 1, 2013 and December 31, 2015, a total of 1, 445 new HIV diagnoses were reported in Wuxi based on CNHCCIS. A total of 72 cases (5.0%) were excluded due to lack of baseline CD4+ T cell count. Of the remaining 1, 373, 272 (19.8%) were diagnosed in VCT clinics (Group Ⅰ) and 1, 101 (80.2%) from other clinical services (Group Ⅱ). As shown in Table 4, there was no significant difference in gender and age between Groups Ⅰ and Ⅱ (P > 0.05 for both), but the proportion of MSM in diagnosed cases was significantly higher at VCT clinics compared with that at other services (76.1% vs. 54.7%, P < 0.001). A higher proportion of earlier HIV diagnosis was detected in Group Ⅰ compared with that in Group Ⅱ (76.7% vs. 68.6%, P = 0.008). A higher proportion of individuals with a high baseline CD4+ T cell count > 500 copies/mm3 was detected in Group Ⅰ compared with that in Group Ⅱ (30.5% vs. 20.5%, P = 0.002). No significant difference was found in the interval between HIV diagnosis and baseline CD4+ T cell count measurement in the two groups (median 27 vs. 29 days, P = 0.851). A higher median baseline CD4+ T cell count was observed in Group Ⅰ compared with that in Group Ⅱ (median 407 vs. 326 copies/mm3, P = 0.003).
Characteristics HIV Diagnosis in VCT Clinics HIV Diagnosis from other Clinical Services P Value n % n % Total 272 100 1, 101 100 Gender Female 42 15.4 131 11.9 0.115 Male 230 84.6 970 88.1 Age (year) < 30 108 39.7 396 36.0 0.252 ≥ 30 164 60.3 705 64.0 Risk category Heterosexual transmission 63 23.2 476 43.2 < 0.001 Male-male sexual transmission 207 76.1 602 54.7 Drug injection 2 0.7 19 1.7 Others 0 0.0 4 0.4 Baseline CD4+ T cell count (copy/mm3) < 200 63 23.2 346 31.4 0.002 200-349 62 22.8 254 23.1 350-499 64 23.5 275 25.0 ≥ 500 83 30.5 226 20.5 Median 407 326 0.003 IQR 222-506 163-469 Days from HIV diagnosis to baseline CD4+ count measurement ≤ 30 168 61.8 652 59.2 0.851 31-90 64 23.5 305 27.7 > 90 40 14.7 144 13.1 Table 4. Characteristics and Baseline CD4+ T Cell Count in HIV-positive Individuals from