Epidemiological Study On Subtypes And Drug-Resistant Mutations Of HIV-1 Infected Patients In Jiangsu Province

Background and ObjectivesAIDS is now one of the public health problems concerned by all humanity.Highly Active Antiretroviral Therapy（HAART）is considered the most effective method in treating HIV/AIDS.Still,the development of viral resistance seriously restricts the efficacy of ART.It is a considerable obstacle for The Joint United Nations Programme on HIV/AIDS（UNAIDS）to fail to achieve The "90-90-90" for 2020.By the end of October 2021,there were 35,284 surviving HIV/AIDS patients in Jiangsu province,among whom 99.1% had received follow-up treatment and management.National Acquired Drug Resistance ADR（44.7%）was reported in the results of previous Chinese studies using 1000 copies/ml of Viral Load（VL）as the criteria for Virologic Failure（VF）.The highest ADR reported in Jiangsu province was 57.17%,at a medium and high level in China.In approximately 10-30% of patients who do not fully control viral replication with standard ART,plasma in these patients shows Low levels of viral replication,which is known as low-level Viremia（LLV）.According to World Health Organization（WHO）guidelines,LLV is defined as a VL between 50 and 1000 copies/ml.Studies have pointed out that the mutation rate of drug resistance in LLV patients ranges from30% to 46%,and the highest even reaches 86%.However,no matter the influencing factors or adverse outcomes of LLV,there are few relevant studies in China,and the drug resistance of this population is not clear.Currently,only VF patients are provided with free drug resistance testing in Jiangsu Province,and no relevant investigation has been carried out on LLV patients in the past.Based on a systematic review of the current drug resistance of HIV/AIDS patients in China,this study took the HIV LLV patients who were followed up in Jiangsu province in 2021 as the research objects,and the successful HIV treatment patients（VL less than 50 copies/ml）as the control group.The relevant situation of the LLV population in Jiangsu province was comprehensively interpreted from two aspects of molecular epidemiology and field investigation.Methods1.Wanfang,VIP,CNKI,Sino Med,Pub Med,and Web of Science databases were used as data sources.The literature mentioned in the review was also retrieved and supplemented by manual retrieval from January 1,2010,to January 13,2022.Data extraction and meta-analysis were conducted for the literature eligible for inclusion to comprehensively describe the current drug resistance of HIV/AIDS patients in China.2.A cross-sectional study design was used to collect peripheral venous blood from HIV-1 LLV patients who were followed up in Jiangsu province in 2021.The lizhu automatic nucleic acid extractor extracted the nucleic acid of HIV-1.The target gene（POL region）was amplified by the PCR method to investigate the molecular epidemiological characteristics of the virus in the patient.PCR products were sent to Shanghai Sangon Biotech for sequencing.After sequencing,the spliced sequences were uploaded to the website（https://comet.lih.lu/）for preliminary typing.HIV BLAST module was used for further subtype determination,and the phylogenetic tree was constructed to verify the typing results.The HIValg resistant analysis Program described the detailed drug resistance information in LLV patients,and the factors that may be related to the drug resistance difference in this population were also explored.3.A case-control study design was adopted for the LLV patients in Jiangsu Province.According to the characteristics of included subjects（region,gender,and age）,one patient was matched among successful patients with VL less than 50 copies/ml in the treatment database.The epidemiological case investigation was conducted to compare the characteristics of different treatment effect groups and explore the related factors that may affect the treatment effect.Results1.The drug resistance situation among HIV/AIDS patients in China: The metaanalysis results showed that the total drug resistance rate of PDR,NRTIs,NNRTIs,and PIs in the Chinese HIV patients was 4.57%,0.89%,2.34%,and 0.75%,respectively,lower than the 5% drug resistance threshold set by WHO.The total drug resistance rate,NRTIs,NNRTIs,and PIs resistance rates of HIV/AIDS patients who have received ART in China were 53.57%,35.94%,48.08%,and 2.35%,respectively.The highest drug resistance rate of NNRTIs was lower than that of other countries except for East Africa（42%）and Western Europe（48%）.The total drug resistance rate and NRTIs resistance rate were lower than those in Africa and the United States,and only the drug resistance rate of PIs was higher than that in some African countries.2.Characteristics of HIV-1 drug resistance in different regions and populations:When the sample source was used as a subgroup for analysis,the total drug resistance rate,NRTIs,and NNRTIs resistance rates in the combined effect of PDR and ADR resistance rates in the central region were higher than those in the southwest region and the studies involving multi-region samples.When the three major regions of the south,north,and central regions were divided,the central region was also higher than the south and north region.In the MSM group that did not receive ART,all drug resistance rates of PDR were lower than the whole population except PIs,but in the MSM group that received ART,all drug resistance rates of ADR were higher than the whole population except PIs.3.Subtype composition of HIV-1 LLV patients in Jiangsu Province: Main subtypes in the LLV patients obtained in this study are as follows: CRF01_AE（95 38.5%）,CRF07_BC（87 35.2%）,B（23,9.3%）,CRF 67₀1B（14,5.7%）,and CRF 08_BC（13,5.3%）,same as the epidemic trend in Jiangsu province.A total of 10 genotypes were found in this study,all reported in previous studies in Jiangsu Province.Except for 23 cases of Subtype B,the rest were CRFs and URFs.4.Drug resistance among HIV-1 LLV patients in Jiangsu Province and its influencing factors: Among the 247 Pol region successfully amplified,40.9% had low or above drug resistance to any of the three main drugs currently used（NRTIs,NNRTIs,and PIs）,and nearly 90% of them had drug resistance to NNRTIs.More than half of the drug-resistant patients had multiple drug resistance,mainly NRTIs and NNRTIs.Multivariate regression results showed that compared with the 50-199 copies/ml group,viral load in the range of 200 and above at follow-up detected more drug resistance（200-499 copies/ml group: OR=1.972,95%CI: 1.020-3.815;500-1000 copies/ml group:OR=2.136,95%CI: 1.070-4.267）;Compared with unmarried patients,being married or cohabiting status detected less drug resistance（OR=0.499,95%CI: 0.273-0.915）.Compared with the treatment regimen of 2 NRTIs and 1 NNRTIs,patients treated with2 NRTIs and 1 PIs detected more drug resistance（OR=3.228;95%CI: 1.583-6.582）.5.Factors influencing the treatment effect of HIV/AIDS patients in Jiangsu Province: Multiple Logistic regression analyses with treatment effect as the dependent variable showed that the likelihood of LLV was statistically different among smoking history,clinical stage at diagnosis,self-assessment compliance in the last month,and treatment regimes（P<0.10）.Non-smokers were less likely to develop LLV at followup than smokers（OR=0.579,95%CI: 0.358-0.936）;Patients with clinical stage II at diagnosis were more likely to develop LLV at follow-up than patients with stage I（OR=1.700,95%CI: 1.009-2.864）;Patients treated with 2 NRTIs and 1 PIs（OR=2.171,95%CI: 1.152-4.093）were also more likely to develop LLV at follow-up.Conclusions1.PDR in HIV/AIDS patients in China is below the warning line,and ADR is below the middle level in the world.It is suggested that the free antiviral therapy widely promoted in China has lasting effectiveness.2.The drug resistance rate in the central region is significantly higher than that in other regions in China,and high drug resistance in the MSM population cannot be ignored.Treatment regimens and resistance monitoring in different regions should be combined with the local epidemic features to make adjustments.At the same time,according to the different patients’ characteristics,especially the MSM and other highrisk drug resistance populations,the treatment regime should combine with health education and peer group to improve the treatment effect and reduce the degree of resistance.3.The subtype composition of LLV patients in Jiangsu province was generally the same as previous reports in Jiangsu province,and recombinant viruses accounted for the main proportion.It is suggested that the subtypes in the province are complex and diverse,and it is necessary to strengthen monitoring and promote behavioral intervention to avoid the emergence and prevalence of new recombinant subtypes.4.Drug resistance in LLV patients in Jiangsu Province is severe.The drug resistance profiles was different among patients with different viral load,marital status,and treatment regimens.It is necessary to include the LLV population in the scope of free drug resistance testing and refine follow-up management standards according to the characteristics of different populations.5.Patients with different smoking histories,clinical stage,and treatment regimens had different likelihoods of developing LLV at follow-up,suggesting that strengthening health education,promoting patients to improve lousy living habits,actively treating concomitant diseases,and selecting more appropriate drugs can improve the therapeutic effect and the quality of life of HIV/AIDS patients.