The HIV Incidence Surveillance And Prevention Effect In A Digital Prospective Cohort Based On Voluntary Counseling And Testing

Objective: It has been nearly 40 years since the first human immunodeficiency virus(HIV)infection case has been found among men who have sex with men(MSM)in 1980.By the end of 2016,there were 36.7 million people living HIV(PLHIV)globally,There was 1.8 million new HIV infection occurred in 2016.In this context,the World Health Organization(WHO)and United Nations The Joint Programme on AIDS(UNAIDS)have announced the 90-90-90 target by 2020 and the goal to end the HIV/AIDS epidemic in 2030 globally in December 2013.The 90-90-90 target includes 90% of PLHIV be aware of their infection status,90% of those diagnosed with HIV received and sustained antiretroviral treatment(ART),and 90% received ART sustained HIV viral suppression.The first 90% target is the premise and the bottleneck.Its fulfillment needs to rely on HIV high-risk groups’ participation in HIV testing.MSM in China has beard the most rapidly growing of HIV epidemic in recent years.But less than 50% of this population has ever been tested for HIV,which is far from the 90-90-90 target.Meanwhile,voluntary counseling testing(VCT),as the most major way to provide free HIV testing to high-risk populations in China,has met challenges in response to the rapid growth and transformation of HIV epidemic among MSM populations: firstly,VCT rely on the inquiry from high-risk MSM,which failed to adapt to the current behavioral characteristics of the MSM;Secondly,the traditional VCT was limited by lack of technology and resources.It failed to "take the initiative" to reach out for the high-risk MSM and provide preventive intervention resources;Finally,VCT operates under the principle of anonymity testing.This leads to failure in identification of duplicate testing result from the same MSM,thus unable to obtain the most crucial marker of HIV epidemic surveillance,the HIV incidence rate.Not to mention the lognitude intervene and prevention.With the rapid popularization of the Internet,smartphones and online social software,and the wide application of electronic technology in Biomedicine,the traditional VCT has been given the innovative opportunity to expand its ability in monitor and prevention.Methods: in the first chapter of this study,we buid the digital prospective cohort by using and integrating the current existing Internet technologies.The strategy of the digital cohort includes: using and distribute the recruitment two-dimensional code(QR code)in MSM online and offline hotspot to obtain a representative samples,using the online self-administrated survey technology to obtain demographpic and behavioral information of the participants,using both the offline VCT laboratory testing and the online HIV/AIDS Syphilis self-test reagent to obtain the HIV and syphilis status of the participants.The goal of the study is to obtain the acceptance rate of the digital cohort strategy among MSM,the disparities of behavior and HIV infection rate between online and offline recruited participants,and finally obtained the HIV prevalence and correlates from this multiple-source representative samples of the local high risk MSM.In the second chapter of this study,we prospectively follow up the digital cohort of MSM based on VCT clinics.Using the real-time identification QR code to recognize the participants and ensure the VCT confidentiality principle.Using the self-administrated epidemiological survey technology to avoid social expectations bias and accurately obtain the participants’ demographic and HIV-related high-risk behaviral characteristics,behavioral characteristics.Syphilis and HIV laboratory test were used to detect the current syphilis infection and the HIV sero coversion.Finally,to obtain the HIV incidence,the cohort retention rate and correlates among high risk MSM and its subpopulation based on this digital cohort of VCT stragetegy.In the third chapter of this study,we explore the application and effect on HIV prevention targeted at MSM population of the online VCT by the real-world study design.We design and establishe the online VCT intervention function menu,including on-line consultation,the prevention information post and distribution,the test result on-line inquery and the HIV infection risk assessment tool,etc.By the real-time online footprint of the inquiry MSM caught by the backstage,we objectively evaluate the usage of the intervention menue and its effect on reduction of HIV related high risk behavior and incidence of HIV and syphilis.Results: 1.During the study period(March 2017 to February 2018),2,371 participants were recruited,including 689(29%)recruited from offline recruitment source and 1682(71%)recruited from online recruitment source.During screening,there was 1128 qualified for the study criteria,and among which 993 MSM participants concented to accept the digital cohort strategy and enrolled to the study,which yield to an acceptance rate of 88%(993/128).MSM who accepted compared to those who do not,had a higher proportion of being younger than 24-year-old,currently being a college student,more condomless anal intercourse(CAI).The syphilis antibody positive rate is 19.3%(191/993).The HIV prevalence was 5.7%(57/993)at baseline,with no significant difference between the online and offline recruited participants(5.5% VS.5.9%).Being migrants(VS.Resident population,adjusted or(a OR)=3.7,95%ci:1.8-7.8),had HIV testing frequency≦1 times per year(vs.2 times per year,a=4.4,95%CI:1.5-12.8),self-rated HIV infection risk as high(vs.risk-free,a OR=4.4,95%CI:1.6-11.7),inconsistent condom use with male sexual partners in the past 3 months(vs.cosistent using,a OR= 5.2,95%CI:1.8-15.0,p=0.002)and never use condom(vs.cosistent using,a OR=6.5,95%CI:2.1-20.2)were significantly correlated with HIV positive at baseline(p<0.05).2.During the study period,the digital cohort had prospectively followed up 731 HIV-negative high-risk MSM,yielding a total of 202.7 person-year observation,and observed 18 cases of HIV sero-coversion,resulting in a HIV incidence of 8.9/100 person-year(PY).Among the subgroup of MSM population,we report a 5.4/100 PY HIV incidence among young MSM(age ≦ 24 years old),a 13.1/100 PY HIV incidence among middle-aged and senior MSM(age ≧ 40 years old),a 22.0/100 PY HIV incidence among migrants MSM(lived in Shenyang≦2 years,a 3.8/100 PY HIV incidence of students MSM on campus.Being the migrants for more than 3 years(vs.has always been living in Shenyang,a HR=0.3,95%CI: 0.1-0.4),using the park/bar/bath and other non-Internet as major crusing venue(vs.Internet and other online venues,a HR=3.8,95%CI:1.3-10.8),inconsistent condom use with male sexual partners in the past-3-month(vs.always used,a HR=6.2,95%CI:1.7-22.9),syphilis infection history(vs.no syphilis infection,a HR= 2.5,95%CI:0.9-6.6),current syphilis infection(VS.a HR=4.6,95%CI:1.7-12.5)were significantly correlates of HIV seroconversion(p<0.05).During the study,440 MSM participated had attented at least one follow-up,which yields in a natural cohort retention rate as 60.2%(440/731.The median observation time was 177 days.Online recruited(vs.offline recruitment,a OR=2.4,95%CI:1.5-3.9),being migrants in Shenyang for more than 3 years(vs.has always been living in Shenyang,a OR=1.8,95%CI:1.2-2.8),HIV testing frequency≧2 times per year(vs.first time testers,a OR=4.5,95%CI:2.7-7.4),had CAI in the past-3-month(vs.no CAI,ao OR=2.5,95%CI:1.8-3.5),had more than 2 regular male sexual partners in the past-3-month(vs.no such partners,a OR=1.8,95%CI:1.1-2.8),recreational drug using behavior in the past-3-month(vs.no use,a OR=1.8,95%CI:1.3-2.7),had sexual intercourse under influence of alcohol in the past-3-month(vs.no such behaviour,a OR= 1.7,95%CI:1.3-2.4),has been diagnosed with sexual transmitted infections(STIs)in the past year(vs.undiagnosed of STIs,a OR=2.7,95%CI:0.9-8.2)were positive correlated with higher retention rates(p< 0.05).3.During the study,there were 28,818 person-times usage of the online VCT intervention function menu.We provided 2,311 person-times of counseling and prevention advices.There were 49.9%(14,369/28,818)of the usage took place during the none-working hours of traditional VCT(00:00-08:00,11:01-14:00,17:01-24:00),Among the 440 MSM followed up by the digital cohort,283 of them had enabled and used at least one online VCT intervention function.By comparing change of HIV-related high-risk sexual behavior between baseline and the lastest follow-up,we found that the incidence of CAI has decreased from 56.2% at baseline to 39.9% at the lastest follow-up,which yields into a 16.3% reduction in CAI(p<0.0001).There was no statistically significant reduction observed among the none-users.The use of online VCT intervention-type functions(HR=0.2,95%CI:0.1-1.1,p=0.065)and the use of maintenance-type functions(HR=0.8,95%ci:0.7-1.0,p=0.074)are margina associated with the reduction of syphilis incidence.Conclusion: 1.The digital cohort strategy is efficient in recruiting large samples-sized,multiple-sourced and representative high-risk MSM population samples.It has crucial prospects in future application.Based on this representative sample,we obtained the HIV prevalence of the local high-risk MSM.The HIV infections were significantly correlated with infrequent HIV testing behavior and low self-percieved HIV infection risk.2.Throug the VCT based digital cohort,we observed a high rate of HIV incidence and retention among high risk MSM populations and its subpopulations.Moreover,the strategy has the advantage in cost-efficiency of the maintenance of the migrants MSM,which needs to be urgently applied in the local VCT.3.The online VCT intervention function has high frequency of use among high-risk MSM population and it expands the time and ability of traditional VCT to provide service.The use of online intervention has significantly reduced the CAI and syphilis incidence among the MSM users.