To describe the current situation of CD4, viral load of HIV and some risk behaviors of couples with one new detected infected HIV person was managed at outpatient clinic at Dienbien and Cantho provinces (2013 - 2014).
Journal of military pharmaco-medicine no8-2019 STATUS OF CD4 CELLS, HIV VIRAL LOAD AND RISK BEHAVIORS OF COUPLES HAVE ONE PEOPLE INFECTED WITH HIV/AIDS AT DIENBIEN AND CANTHO (2013 - 2014) Doan Van Viet1; Nguyen Thanh Long2; Nguyen Van Hung3 SUMMARY Objectives: To describe the current situation of CD4, viral load of HIV and some risk behaviors of couples with one new detected infected HIV person was managed at outpatient clinic at Dienbien and Cantho provinces (2013 - 2014) Subjects and method: Cross-sectional study was used; direct interviews with the couples on their some risk behaviors of tranmitted HIV; blood tests of CD4 cells and HIV viral load A total of 133 couples with one new detected infected HIV person (Dienbien: 98 pairs; Cantho 36 pairs) participated in this study Results: About CD4 cells and viral load of HIV-infected people: the proportion of CD4 level at dengerous (< 100 cells/µL could have meningitis at any time) and at very high risk (100 - < 350 cells/µL) of the subjects were 20.9% and 26.1%, respectively The proportion of CD4 level at risk of opportunistic infections (< 500 cells/µL) of the subjects was 64.9%; the proportion of HIV viral load level at very high risk (1,000 - 100,000 copies/mL, easily transmitted through sex) and at very dengerous (≥ 100,000 copies/mL, very dangerous to contact people) of the subjects were 52.0% and 40.2%, respectively; total was 92.2%; the total proportion of risk to transmit HIV to other (HIV viral load level ≥ 20 copies/mL) was 95.3% Risk behaviors of couples: there were 6.7% of HIV-infected people who injected drugs within the past months; 77.6% of spouses of HIV-infected people believed that HIV-infected people still inject drugs within the past months 24.6% of couples had one HIV-infected person having sex with each other within the past months, of which 87.9% used condoms in sexual relations Conclusion: Proportion of HIVinfected containing CD4 cell at dangerous level and very high risk level was 20.9% and 26.2%, respectively and having viral load at very high risk level and very dangerous level to contacts was 92.2% Over the past months: 24.6% of couples having sex with each other (87.9% using condom) and 77.6% of HIV negative spouses suppose HIV-infected individuals have still injected drugs * Keywords: HIV-infected people; CD4 cells; Viral load; Risk behavior; Couples Hoankiem District Health Center Central Propaganda and Training Commission Vietnam Military Medical University Corresponding author: Doan Van Viet (drviet67@gmail.com) Dtae received: 30/08/2019 Date accepted: 10/10/2019 131 Journal of military pharmaco-medicine no8-2019 INTRODUCTION The HIV epidemic in Vietnam is still concentrated in the main infectious groups and the main mode of infection is through injecting drug Recent estimates showed that sexually transmitted infections start to account for a significant proportion and often occur mainly among groups between injecting drug users with their sexual partners, between female sex workers with their clients, between clients of sex workers with their wives and homosexual group including men and women having sex with their partners High-risk behaviors such as unsafe sex still prevail Integrated monitoring of behavior and biological indicators (IBBS) [1] and evaluation of methadone replacement therapy (MMT) in recent years have shown that the proportion of people injecting drugs is low and not frequent, of using condom when having sex with female sex workers in the injecting drug group last months was only between 22% and 63% As for the sex workers themselves, the rate of using condoms when having sex with their clients last month was only from 31% to 81% The figures in Vietnam showed that there were a significant number of couples having sex with HIV Results of a survey on 2,597 HIV-infected people in 22 provinces/cities indicated that 46% of the partners of HIV-infected men are currently negative or not aware of their HIV status, while this rate was 15% for the female partner/partner of HIV-infected women About 40% of married HIV-infected people are currently being treated at Bachmai Hospital's outpatient clinic in the group of couples who have HIV infection [2] 132 Dienbien and Cantho now belong to a group of key provinces affected by the HIV epidemic in Vietnam Dienbien is a northern mountainous province with a border with Laos, where HIV epidemic is on the rise and has a great impact on the injecting drug users and their sexual partners The HIV prevalence rate of injecting drug users in 2009 in Dienbien was 56% [3] The HIV infection detection rate of pregnant mothers according to key surveillance results was 1.5% in 2010, and was the highest in the country Cantho is the southern province of the Mekong Delta with a combination of HIV infection patterns, with a significant number of HIV-infected sex workers HIV prevalence among injecting drug users in the province in 2009 was 32%, while this rate among female sex workers was 16% [4] In both provinces, injecting HIV infection is still the main mode of infection However, until now, there have been no studies in two provinces to find out, and characterize risk behaviors among HIV-infected couples Therefore, we conducted a study aimed at: Describing the actual situation of CD4 cells, viral load of HIV and some risk behaviors of the couples with one new detected infected-HIV person under management at outpatient clinics in Dienbien and Cantho provinces (2013 - 2014) SUBJECTS AND METHODS Subjects, location and time of study * Subjects: Couples, in which, one of them visit an outpatient clinic in Dienbien, Cantho to seek HIV counseling and testing and are confirmed to be HIV positive Journal of military pharmaco-medicine no8-2019 * Criteria for selecting research subjects: Existing couples have regular sex (including homosexual or heterosexual); 18 years old and older, living in Dienbien and Cantho during the study period; one of them was confirmed positive, the other was negative; they both accepted to participate in the study (meaning that they both consulted couples, who have HIV (+) to accept ART immediately) * Time and location of study: This study was conducted from 2013 to 2104 at Dienbien province and Cantho city Methods * Study design: The cross-sectional study * Sampling and sample size: Appling the formula for descriptive research [5]: n = Z2(1-α/2) p (1 − p) d2 Inside: n: Minimum sample size; α: Significance levels (α = 0.05); z: Reliability taken at the probability threshold, α = 0.05, Z(1-α / 2) = 1.96; p: Percentage of HIV-infected people participating in HIV counseling and testing (estimated) was determined that their spouse was currently negative or their HIV status was unknown, taking p = 0.50 (1 - p = 0.50); d: Absolute error, expected d = 5% (d = 0.09) Replace the values in the formula to calculate n = 118 pairs Estimate the rejection rate in the study by about 10% to maintain the accuracy of the results, the calculated sample body was 130 pairs Actually investigated 133 couples The Respondent Driven Sampling (RDS) was used First, based on the list of HIV-infected people that the research team knew or were introduced by peer educators, three couples with HIV-negative "seeds" was selected as the first study participants After the interview, each pair of participants (who will become selectors) would receive 03 invitation cards to invite other HIV-infected couples that they knew to participate in the study If HIV-infected couples in the community received an invitation card and wish to participate, they could take an invitation card and went to HIV counseling and testing facility to research The selection process used three such votes to continue until enough sample size stops * Methods and techniques for data collection: - Direct interview subjects of this study included both husband and wife, in which, there was a HIV-positive person and a HIV-negative person - Test: Determining the HIV infection status based on the national guidelines, blood samples were tested by rapid test and then confirmed by EIA test and Murex HIV Ag/Ab test CD4 cells were tested at AIDS Centers in Dienbien and Cantho HIV viral load were tested at Bachmai Hospital in Hanoi (with samples obtained from Dienbien) and at Pasteur Institute in Hochiminh City (with samples obtained from Cantho) * Data processing methods: Data was entered with Epidata 3.1 software and was analyzed with SPSS software 11.5 Using descriptive statistical tests to analyze results Using frequency tables describe frequencies and rates according to research variables 133 Journal of military pharmaco-medicine no8-2019 * Research ethics: The study was approved at the Ethics Council of the Hanoi University of Public Health before formal implementation The consent of the study was recorded by both subjects in the HIV-positive couple RESULTS Current situation of CD4 cells and viral load of HIV/AIDS in HIV-infected subjects Table 1: Decomposition of CD4 cells in HIV-infected subjects Dienbien (n = 98) Decomposition of CD4 cells (CD4/µL) Cantho (n = 35) Total (n = 133) Number % Number % Number % Dangerous level (< 100/µL) 16 16.3 12 34.3 28 21.1 Very high risk (100 - < 350/µL) 28 28.6 20.0 35 26.3 High risk (350 - < 500/µL) 19 19.4 14.3 24 18.0 No or little risk (≥ 500/µL) 35 35.7 11 31.4 46 34.6 98 100.0 35 100.0 133 100.0 63 64.3 24 68.6 87 65.4 Total Total risk level (< 500/µL) - The proportion of CD4 cells at dangerous levels (< 100 cells/µL) and at very high risk (100 - < 350 cells/µL) can threaten meningitis at any time, in general of the two provinces was 21.1% and 26.3% (Dienbien: 16.3% and 28.6%; Cantho: 34.3% and 20.0%) - The total number of people at risk of opportunistic infections (CD4 < 500 cells/µL) of the two provinces was 65.4% (Dienbien: 64.3%; Cantho: 68.6%) The difference of blood levels of CD4 cells in HIV-infected people between Dienbien and Cantho provinces was not statistically significant (Chi2 test, p > 0.05) Table 2: Number of CD4 cells in HIV-infected subjects Target Dienbien (n = 98) Cantho (n = 35) Total (n = 133) Min 1 Max 1,231 1,308 1,308 375 348 374 SD 251.6 342.6 277.1 SE 25.4 57.9 24.1 Medium 387.3 378.3 384.9 336.9 - 437.8 260.6 - 495.9 337.4 - 432.5 Median 95%CI of medium HIV-infected people had the lowest number of CD4 cells/µL of only - cells (almost lost CD4 cells); the highest from 1,231 - 1,308 cells/µL Median values fluctuate from 348 to 375 cells/µL The average number of CD4 cells in HIV-infected people in Dienbien and Cantho, respectively: 336.9 (95%CI: 336.9 - 437.8) and 378.3 (95%CI: 134 Journal of military pharmaco-medicine no8-2019 260.6 - 495,9) The average difference in CD4 cells in HIV-infected people between the two provinces was not statistically significant (p > 0.05) Table 3: Classification of HIV viral load in HIV-infected subjects Dienbien (n = 98) Classification of HIV viral load (copy/mL) Cantho (n = 29) Total (n = 127) Number % Number % Number % Very good (< 20) 3.1 3.4 3.1 Good (20 - < 200) 2.0 - 1.6 High risk (200 - < ,1000) 4.1 - 3.1 Very high risk (1000 - < 100,000) 52 53.1 14 48.3 66 52.0 Very dangerous level (≥ 100,000) 37 37.7 14 48.3 51 40.2 98 100.0 29 100.0 127 100.0 Good level (< 200) 5.1 3.4 4.7 Risk level (≥ 200) 93 95.0 28 96.6 121 95.3 Total The rate of viral load was under the detection level, very good (< 20 copies/mL) and at a good level (20 - < 200 copies/mL; the level of non-sexually transmitted) accounted for a very low rate, in the two provinces 4.7% (Dienbien: 5.1%; Cantho: 3.4%) The majority of HIV-infected people had very high viral load (1,000 < 100,000 copies/mL; easy sexually transmitted) and very dangerous levels (≥ 100,000 copies/mL; very dangerous for people contact), of the two provinces was 92.2% (Dienbien: 90.8%; Cantho: 96.6%) The total number of people who were at risk of HIV transmission to surrounding people (the amount of HIV virus at ≥ 200 copies/mL) was very high, of the two provinces was 95.3% (Dienbien: 94,9%; Cantho: 96.6%) Table 4: HIV viral load (HIV/mL) in HIV-infected subjects Targets Dienbien (n = 95) Cantho (n = 28) Total (n = 123) Min 50 1,170 50 Max 5,850,000 341,0000 5,850,000 63,400 93,300 67,700 SD 886,453.9 734,267.4 840,707.4 SE 90,948.3 138,763.5 76,825.2 Medium 336,409.4 418,241.8 355,037.9 155,829.5 - 516,989.2 133,522.6 - 702,960.9 202,954.7 - 507,121.0 Median 95%CI of medium Among those with HIV viral load exceeding the threshold (Dienbien: 95 people; Cantho: 28 people) showed that: the lowest viral load was from 50 - 1,170 copies/mL 135 Journal of military pharmaco-medicine no8-2019 and the highest was 3,410,000 - 5,850,000 copies/mL Median values were in the range of 63,400 - 93,300 copies/mL The average of viral load on HIV-infected subjects in Dienbien: 336,409.4 (95%CI: 155,829.5 - 516,989.2), Cantho: 418,241.8 (95%CI: 133,522.6 - 702,960.9) Some risk behaviors of couples with HIV infection Table 5: Actual situation of drug injection behavior of HIV-infected people in the past months Dienbien (n = 98) Cantho (n = 36) Total (n = 134) Number % Number % Number % No 91 92.9 34 94.4 125 93.3 Yes 7.1 5.6 6.7 Do not use new needles and syringes for the last time 85.7 100.0 88.9 Sharing needles and syringes with wife/husband in the past months 100.0 50.0 88.9 Sharing needles and syringes with others in the past months 100.0 50.0 88.9 Drug injection behavior Inside The rate of injecting drug in the last months of the HIV-infected people in the provinces was 6.7% (Dienbien: 7.1%; Cantho: 5.6%) The difference in injection rates between the two provinces was not statistically significant (Chi2 test, p > 0.05) There were 6/7 people in Dienbien and 2/2 people in Cantho did not use new needles and syringes the last time; 7/7 people in Dienbien and 1/2 people in Cantho shared needles with spouses and with others within the past months Table 6: Prediction of spouses on drug injection status of HIV-infected people in the past months Drug injection status of HIV-infected people Dienbien (n = 98) Cantho (n = 36) Total (n = 134) Number % Number % Number % Yes 68 69.4 36 100.0 104 77.6 No 5.1 - 3.7 No answer 3.1 - 2.2 Unknown 22 22.4 - 22 16.5 98 100.0 36 100.0 134 100.0 Total Spouses of HIV-infected people believed that HIV-infected people who were still injecting drugs in the last months were 77.6% (Dienbien: 69.4%; Cantho: 100%) In Dienbien, 22.4% of spouses of HIV-infected people did not know whether people with HIV continue to inject drugs 136 Journal of military pharmaco-medicine no8-2019 Table 7: Sexual behavior in the past months of HIV-infected spouses Sexual behavior Cantho (n = 36) Total (n = 134) Number % Number % Number % 19 19.4 14 38.9 33 24.6 - - - - - - Using condoms 15 78.9 14 100.0 29 87.9 No answer 21.1 - - 12.1 84 85.7 35 97.2 119 88.8 Having sex with spouse Did not use condoms Inside Dienbien (n = 98) Having sex with others The rate of couples having one HIV-infected person had sex with each other in the past months was 24.6% (Dienbien: 19.4%; Cantho: 38.9%) In sex behavior, couples who used condoms, two provinces were 87.9% (Cantho: 100%; Dienbien: 78.9%) Table 8: The fact that couples of HIV-infected people had access to support services for detoxification, health care and HIV prevention Types of services Dienbien (n = 98) Cantho (n = 36) Total (n = 134) Number % Number % Number % Exchange of needles and syringes - - - Peers 9.2 - 6.7 Methadone - - - STIs services - 5.6 1.5 Prevention of tuberculosis - 8.3 2.2 Health facilities 79 80.6 25 69.4 104 77.6 Other (VTC, OPV ) 15 15.3 22.2 23 17.2 Wife/husband of HIV-infected people in the two provinces mainly accessed and used medical examination and treatment and health care services in general health facilities (commune/ward health stations, clinics ) in Dienbien 80.6% and Cantho 69.4% DISCUSSION * About CD4 cells in HIV-infected people: In 2013, the CD4 index was a good indicator of whether HIV destroyed the immune system of an HIV-infected person and it indicated the risk of infection and the time to start treatment And in 2013, people with HIV with a CD4 count below 350 cells/µL were indicated for ART In our study, the prevalence of CD4 cells was dangerous and at a very high risk, which could threaten meningitis at any time, in the two provinces of 21.1% and 26.3, respectively (Dienbien: 16.3% and 28.6%; Cantho: 34.3% and 20.0%) The total number of subjects at risk of opportunistic infections (CD4 < 500 cells/µL) 137 Journal of military pharmaco-medicine no8-2019 in the two provinces was 65.4% The CD4 average number of HIV-positive people averaged 384.9 and 47.0% CD4 was below 350 Thus, nearly half of those who were positive spouses were at risk of threatening health complications and had indicated ARV treatment However, WHO has recommended HIV prevention by using ARV treatment for HIV-infected people should start sooner regardless of the CD4 count of HIV-infected people would have a positive impact on minimizing the possibility of HIV infection from HIV-infected people to their negative spouses/partners [6] * About HIV viral load of HIV-infected people: Rakai's team chaired by Thomas Quinn followed 415 couples who did not co-infected with HIV in Uganda for 30 months to assess the impact of some biological risk factors, and behavior including viral load in heterosexual transmission Research had shown that the risk of transmission to uninfected partners varies significantly based on different viral load levels The average level of serum HIV-1 RNA was significantly higher in patients with HIV transmission (90,254 copies/mL) compared to patients who did not transmit the virus (38,029 copies/mL) No HIV transmission occurred from HIV patients with viral load < 1,500 copies/mL Of the 90 cases of infection, 23% were transmitted from infected partners with viral load at around 400 to 9,999 copies/mL, 40% had an amount of 10,000 to 49,999 copies/mL, 37% had a load of about > 50,000 copies/mL Based on this analysis, more than 75% of cases had a viral load of more than 10,000 copies/mL [7] The results of our 138 study showed that the majority of HIVinfected people had very high risk of viral load (1,000 - < 100,000 copies/mL) easily transmitted through sexual contact and very dangerous level (≥ 100,000 copies/mL), very dangerous for contacts, general of provinces was 92.2% (Dienbien: 90.9%; Cantho: 96.6%) The total number of people at risk of HIV infection in surrounding people accounted for 95.3% of the two provinces * Regarding the risk behaviors of HIV-positive couples/husbands: Research results showed that 6.7% of injecting drug users in the last months of the two provinces were 6.7% (Dienbien: 7.1%; Cantho: 5.6%) However, spouses of HIV-infected people believed that HIVinfected people were still injecting drugs within the past months, in general, the two provinces were 77.6% (Dienbien: 69.4%; Cantho: 100%) Although the two injecting drug rates of HIV-infected people of the two respondents were very different, they all reflected the fact that HIV-infected people using injecting drugs were at risk of HIV/AIDS infection to the community was unavoidable Sexual behavior without condoms with regular partners was a high risk of HIV infection The research results showed that the proportion of couples with one HIV-infected person having sex with each other in the past months, in general of the two provinces was 24.6% (Dienbien: 19.4%; Cantho: 38.9%) In sex behavior, couples who used condoms, in two provinces were 87.9% (Cantho: 100%; Dienbien: 78.9%) Thus, the risk of HIV infection from infected people to spouses was still negative and high in Dienbien Therefore, Journal of military pharmaco-medicine no8-2019 there was a need to raise awareness for HIV-infected people as well as those at high risk of HIV infection on the regular use of condoms when had sex with a spouse or partner CONCLUSION Proportion of HIV-infected containing CD4 cell at dangerous level and very high risk level (21.1% and 26.3%) was at risk, chance of opportunistic infection (65.4%), respectively and having viral load at very high risk level and very dangerous level to contacts (92.2%); total risk of infection HIV for surrounding people accounts for a very high rate (95.3%) Over the past months: 24.6% of couples having sex with each other (including 87.9% of couples using condom) and 77.6% of HIV negative spouses suppose HIV-infected individuals have still injected drugs REFERENCES National Institute of Hygiene and Epidemiology Results of the HIV/STI Integrated Biological and Behavioral Surveillance (IBBS) in Vietnam Round III - 2013 and the trend through 03 rounds of the article look up 2014 Vietnam Authority of HIV/AIDS Control Antiretroviral therapy for HIV infection prevention in serodifferent couples in Vietnam Project of Vietnam Ministry of Health and WHO on "Suppressive ART for HIV transmission in serodifferent couples, version 13.0" 2012 Dienbien Center of HIV/AIDS Control Report on results of HIV/AIDS prevention and control in 2015 and key directions and tasks in 2016 2015 Cantho Center of HIV/AIDS Control Report No 21/BC-AIDS on the results of HIV/AIDS prevention and control in 2015 and key directions and tasks in 2016 2015 Hanoi Medical University Epidemiology and statistics applied in scientific research Medical Publishing House 1999, p.32 WHO Antiretroviral Treatment as Prevention (TasP) of HIV and TB 2012 Quinn T.C et al Viral load and heterosexual transmission of human immunodeficiency virus type Rakai Project Study Group N Engl J Med 2000, 342 (13), pp.921-929 139 ... out, and characterize risk behaviors among HIV- infected couples Therefore, we conducted a study aimed at: Describing the actual situation of CD4 cells, viral load of HIV and some risk behaviors of. .. About CD4 cells in HIV- infected people: In 2013, the CD4 index was a good indicator of whether HIV destroyed the immune system of an HIV- infected person and it indicated the risk of infection and. .. 6/7 people in Dienbien and 2/2 people in Cantho did not use new needles and syringes the last time; 7/7 people in Dienbien and 1/2 people in Cantho shared needles with spouses and with others within