UNIVERSITY of CALIFORNIA Los Angeles Viral Load Tests Among
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UNIVERSITY OF CALIFORNIA Los Angeles Viral Load Tests among People Living with Human Immunodeficiency Virus on Antiretroviral Therapy in Wenshan Prefecture, Yunnan Province of China A dissertation submitted in partial satisfaction of the requirements for the degree Doctor of Philosophy in Epidemiology by Youran Xu 2019 © Copyright by Youran Xu 2019 ABSTRACT OF THE DISSERTATION Viral Load Tests among People Living with Human Immunodeficiency Virus on Antiretroviral Therapy in Wenshan Prefecture, Yunnan Province of China by Youran Xu Doctor of Philosophy in Epidemiology University of California, Los Angeles, 2019 Professor Roger Detels, Chair Background China has made great achievements in antiretroviral therapy (ART) among people living with HIV (PLWH), however, there is still a gap with the 90-90-90 targets, especially in rural areas. This study investigated three topics about the centralized viral load (VL) testing in Wenshan, China, including the coverage and timeliness of VL tests, the turnaround time (TAT) of VL tests, and factors associated with sustained viral suppression (SVS). ii Methods To address the three topics, three clinic-based studies were conducted respectively. First, a retrospective cohort study was conducted among 815 PLWH who initiated ART from 2015 to 2016. Second, a sequential explanatory mixed-method study was conducted: (1) 2 892 VL tests performed in 2018 were reviewed; (2) in-depth interviews were conducted among 11 healthcare providers. Third, a questionnaire survey was conducted among 264 PLWH. Results First, in Wenshan, the cumulative VL testing rates (%) at 12, 18, and 24 months after ART initiation were 58.5%, 78.1%, and 93.0%, respectively. Patients who had healthier baseline status [adjusted hazard ratio (aHR)=1.40, 95% confidence interval (95%CI)=1.18-1.65] were more likely to undergo VL tests timely. On the contrary, patients who lived far away from ART sites (aHR=0.70, 95%CI=0.59-0.83) had delayed VL tests. Second, the median VL testing TAT was 54 days (IQR: 36, 92). Factors associated with prolonged TAT mainly included the annual urban-to-rural labor migration, the shortage of healthcare professionals and lab technicians, limited VL testing instruments, and the immature reagent procurement system and testing results reporting system. Third, 61.0% (n=161) of the PLWH who participated in the survey had achieved SVS. A total of 58.3% (n=154) participants reported they had ever proactively asked about VL testing results and they were more likely to achieve SVS [adjusted odds ratio (aOR)=3.08, 95%CI=1.52-6.26)]. Other factors associated with SVS included baseline CD4 count, VL-related knowledge, support from non-governmental organizations (NGO), age, and time interval from HIV diagnosis to ART initiation. iii Conclusions To achieve the 90-90-90 targets, the VL testing in rural China should be improved by combining the efforts of PLWH, local healthcare providers, NGO staff, and healthcare policymakers at all levels of government. iv The dissertation of Youran Xu is approved. Abdelmonem A. Afifi Li Li Zuo-Feng Zhang Roger Detels, Committee Chair University of California, Los Angeles 2019 v Dedicated to my dearest parents, 徐元明 (Yuanming Xu) and 王苗珍 (Miaozhen Wang) For their unwavering support and love vi Table of contents List of Figures ............................................................................................................................... ix List of tables.................................................................................................................................. xi List of abbreviations .................................................................................................................. xiii Acknowledgment ......................................................................................................................... xv Vita ............................................................................................................................................ xviii Chapter 1. Introduction ............................................................................................................... 1 1.1 Global HIV/AIDS epidemic ............................................................................................. 1 1.2 Progress towards UNAIDS ’90-90-90’ targets ................................................................ 1 1.3 HIV/AIDS epidemic and ART response in China ........................................................... 3 1.4 VL and VL tests ............................................................................................................... 5 1.5 VL tests in LMICs ............................................................................................................ 7 1.6 VL tests in China ............................................................................................................ 11 1.7 Study location: Wenshan Prefecture, Yunnan Province ................................................ 12 1.8 Study aims ...................................................................................................................... 13 1.9 Summary of study methods ............................................................................................ 14 Reference ................................................................................................................................... 17 Chapter 2: Timeliness of viral load tests among people living with HIV on antiretroviral therapy in Wenshan, China ....................................................................................................... 27 Abstract ..................................................................................................................................... 27 Introduction ............................................................................................................................... 28 Methods ..................................................................................................................................... 30 Results ....................................................................................................................................... 34 Discussion ................................................................................................................................. 51 Reference ................................................................................................................................... 55 Chapter 3: Factors affecting the turnaround time of viral load testing in rural China: a mixed-method study in Wenshan .............................................................................................. 61 Abstract ..................................................................................................................................... 61 Introduction ............................................................................................................................... 62 Methods ..................................................................................................................................... 64 vii Results ....................................................................................................................................... 68 Discussion ................................................................................................................................. 78 Reference ................................................................................................................................... 83 Chapter 4: Is active concern for viral load testing results associated with better antiretroviral therapy response among people living with HIV? A clinic-based study in Yunnan Province, China ............................................................................................................ 88 Abstract ..................................................................................................................................... 88 Introduction ............................................................................................................................... 90 Methods ..................................................................................................................................... 92 Results ....................................................................................................................................... 97 Discussion ............................................................................................................................... 112 Reference ................................................................................................................................. 120 Chapter 5: Conclusions ............................................................................................................ 127 viii List of Figures Chapter 1 Figure 1.1 Newly diagnosed HIV cases, all-cause deaths and people living with 3 HIV (PLWH) in China, 2009-2017 Figure 1.2 The transmission routes of newly reported HIV cases in China, 4 1985-2016 Figure 1.3 Classification and process of viral load assays 7 Figure 1.4 The general processes of centralized viral load test and the 9 definition of turnaround time Figure 1.5 HIV care cascade from initial HIV screening to viral load test 10 Figure 1.6 Summary of the three sub-study topics and the main data source 15 Chapter 2 Figure 2.1 Flowchart: the development of source cohort and survey cohort 35 Figure 2.2a Cumulative rates of