Low Virologic Failure and Drug Resistance among HIV-Infected Patients Receiving Hospital-Based ART While Care and Outreach through Community in Guangxi, China
Identifieur interne : 000077 ( Pmc/Corpus ); précédent : 000076; suivant : 000078Low Virologic Failure and Drug Resistance among HIV-Infected Patients Receiving Hospital-Based ART While Care and Outreach through Community in Guangxi, China
Auteurs : Shujia Liang ; Zhiyong Shen ; Jing Yan ; Fuxiong Liang ; Zhenzhu Tang ; Wei Liu ; Wei Kan ; Lingjie Liao ; Xuebing Leng ; Yuhua Ruan ; Hui Xing ; Yiming ShaoSource :
- Frontiers in Public Health [ 2296-2565 ] ; 2015.
Abstract
To investigate human immunodeficiency virus (HIV) virologic suppression and drug resistance among HIV-infected patients receiving first-line antiretroviral treatment (ART) in hospitals while community care and outreach through local health workers in Guangxi, China.
This was a series of cross-sectional surveys from 2004 to 2012 in Guangxi, supported by the Chinese National HIVDR Surveillance and Monitoring Network Working Group.
Guangxi, China.
Demographic, ART, and laboratory data (CD4+ cell count, viral load, and drug resistance) were analyzed. Factors associated with virologic suppression were identified by logistic regression analysis.
A total of 780 patients were included in this study. The median treatment duration was 20.6 months (IQR 6.6–35.9). Of 780 study participants, 95.4% of patients (744/780) had HIV virologic suppression. Among these, of the 143 patients who were infected through drug injection, only 10 (7.0%) experienced virologic failure, and the overall prevalence of HIV drug resistance was 2.8% (22/789). Factors associated with virologic suppression in the final multivariate models included self-reported missing doses in the past month (compared to not missing doses in the past month, AOR = 0.2, 95% CI: 0.1–0.6) and initial ART regimen without 3TC (compared to initial ART regimen with 3TC, AOR = 0.2, 95% CI: 0.1–0.4). Moreover, the trend chi-square test showed that the proportion of virologic suppression increased over time from 2004 to 2012 (
This study first demonstrated that HIV patients infected through various transmission routes can achieve an excellent treatment outcome in hospitals at or above the county level for free first-line ART in Guangxi. It is an important of ART education and adherence to intervention for achieving better treatment outcomes.
Url:
DOI: 10.3389/fpubh.2015.00244
PubMed: 26579506
PubMed Central: 4621383
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PMC:4621383Le document en format XML
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id="aff2"><institution>State Key Laboratory of Infectious Disease Prevention and Control, National Center for AIDS/STD Control and Prevention</institution>,<addr-line>Beijing</addr-line>,<country>China</country></nlm:aff></affiliation><affiliation><nlm:aff id="aff3"><institution>State Key Laboratory for Infectious Disease Prevention and Control, Chinese Center for Disease Control and Prevention</institution>,<addr-line>Beijing</addr-line>,<country>China</country></nlm:aff></affiliation><affiliation><nlm:aff id="aff4"><institution>State Key Laboratory for Infectious Disease Prevention and Control, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases</institution>,<addr-line>Beijing</addr-line>,<country>China</country></nlm:aff></affiliation></author><author><name sortKey="Liang, Fuxiong" sort="Liang, Fuxiong" uniqKey="Liang F" first="Fuxiong" last="Liang">Fuxiong Liang</name><affiliation><nlm:aff id="aff1"><institution>Guangxi Center for Disease Control and Prevention</institution>,<addr-line>Nanning</addr-line>,<country>China</country></nlm:aff></affiliation></author><author><name sortKey="Tang, Zhenzhu" sort="Tang, Zhenzhu" uniqKey="Tang Z" first="Zhenzhu" last="Tang">Zhenzhu Tang</name><affiliation><nlm:aff id="aff1"><institution>Guangxi Center for Disease Control and Prevention</institution>,<addr-line>Nanning</addr-line>,<country>China</country></nlm:aff></affiliation></author><author><name sortKey="Liu, Wei" sort="Liu, Wei" uniqKey="Liu W" first="Wei" last="Liu">Wei Liu</name><affiliation><nlm:aff id="aff1"><institution>Guangxi Center for Disease Control and Prevention</institution>,<addr-line>Nanning</addr-line>,<country>China</country></nlm:aff></affiliation></author><author><name sortKey="Kan, Wei" sort="Kan, Wei" uniqKey="Kan W" first="Wei" last="Kan">Wei Kan</name><affiliation><nlm:aff id="aff2"><institution>State Key Laboratory of Infectious Disease Prevention and Control, National Center for AIDS/STD Control and Prevention</institution>,<addr-line>Beijing</addr-line>,<country>China</country></nlm:aff></affiliation><affiliation><nlm:aff id="aff3"><institution>State Key Laboratory for Infectious Disease Prevention and Control, Chinese Center for Disease Control and Prevention</institution>,<addr-line>Beijing</addr-line>,<country>China</country></nlm:aff></affiliation><affiliation><nlm:aff id="aff4"><institution>State Key Laboratory for Infectious Disease Prevention and Control, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases</institution>,<addr-line>Beijing</addr-line>,<country>China</country></nlm:aff></affiliation></author><author><name sortKey="Liao, Lingjie" sort="Liao, Lingjie" uniqKey="Liao L" first="Lingjie" last="Liao">Lingjie Liao</name><affiliation><nlm:aff id="aff2"><institution>State Key Laboratory of Infectious Disease Prevention and Control, National Center for AIDS/STD Control and Prevention</institution>,<addr-line>Beijing</addr-line>,<country>China</country></nlm:aff></affiliation><affiliation><nlm:aff id="aff3"><institution>State Key Laboratory for Infectious Disease Prevention and Control, Chinese Center for Disease Control and Prevention</institution>,<addr-line>Beijing</addr-line>,<country>China</country></nlm:aff></affiliation><affiliation><nlm:aff id="aff4"><institution>State Key Laboratory for Infectious Disease Prevention and Control, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases</institution>,<addr-line>Beijing</addr-line>,<country>China</country></nlm:aff></affiliation></author><author><name sortKey="Leng, Xuebing" sort="Leng, Xuebing" uniqKey="Leng X" first="Xuebing" last="Leng">Xuebing Leng</name><affiliation><nlm:aff id="aff2"><institution>State Key Laboratory of Infectious Disease Prevention and Control, National Center for AIDS/STD Control and Prevention</institution>,<addr-line>Beijing</addr-line>,<country>China</country></nlm:aff></affiliation><affiliation><nlm:aff id="aff3"><institution>State Key Laboratory for Infectious Disease Prevention and Control, Chinese Center for Disease Control and Prevention</institution>,<addr-line>Beijing</addr-line>,<country>China</country></nlm:aff></affiliation><affiliation><nlm:aff id="aff4"><institution>State Key Laboratory for Infectious Disease Prevention and Control, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases</institution>,<addr-line>Beijing</addr-line>,<country>China</country></nlm:aff></affiliation></author><author><name sortKey="Ruan, Yuhua" sort="Ruan, Yuhua" uniqKey="Ruan Y" first="Yuhua" last="Ruan">Yuhua Ruan</name><affiliation><nlm:aff id="aff2"><institution>State Key Laboratory of Infectious Disease Prevention and Control, National Center for AIDS/STD Control and Prevention</institution>,<addr-line>Beijing</addr-line>,<country>China</country></nlm:aff></affiliation><affiliation><nlm:aff id="aff3"><institution>State Key Laboratory for Infectious Disease Prevention and Control, Chinese Center for Disease Control and Prevention</institution>,<addr-line>Beijing</addr-line>,<country>China</country></nlm:aff></affiliation><affiliation><nlm:aff id="aff4"><institution>State Key Laboratory for Infectious Disease Prevention and Control, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases</institution>,<addr-line>Beijing</addr-line>,<country>China</country></nlm:aff></affiliation></author><author><name sortKey="Xing, Hui" sort="Xing, Hui" uniqKey="Xing H" first="Hui" last="Xing">Hui Xing</name><affiliation><nlm:aff id="aff2"><institution>State Key Laboratory of Infectious Disease Prevention and Control, National Center for AIDS/STD Control and Prevention</institution>,<addr-line>Beijing</addr-line>,<country>China</country></nlm:aff></affiliation><affiliation><nlm:aff id="aff3"><institution>State Key Laboratory for Infectious Disease Prevention and Control, Chinese Center for Disease Control and Prevention</institution>,<addr-line>Beijing</addr-line>,<country>China</country></nlm:aff></affiliation><affiliation><nlm:aff id="aff4"><institution>State Key Laboratory for Infectious Disease Prevention and Control, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases</institution>,<addr-line>Beijing</addr-line>,<country>China</country></nlm:aff></affiliation></author><author><name sortKey="Shao, Yiming" sort="Shao, Yiming" uniqKey="Shao Y" first="Yiming" last="Shao">Yiming Shao</name><affiliation><nlm:aff id="aff2"><institution>State Key Laboratory of Infectious Disease Prevention and Control, National Center for AIDS/STD Control and Prevention</institution>,<addr-line>Beijing</addr-line>,<country>China</country></nlm:aff></affiliation><affiliation><nlm:aff id="aff3"><institution>State Key Laboratory for Infectious Disease Prevention and Control, Chinese Center for Disease Control and Prevention</institution>,<addr-line>Beijing</addr-line>,<country>China</country></nlm:aff></affiliation><affiliation><nlm:aff id="aff4"><institution>State Key Laboratory for Infectious Disease Prevention and Control, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases</institution>,<addr-line>Beijing</addr-line>,<country>China</country></nlm:aff></affiliation></author></titleStmt><publicationStmt><idno type="wicri:source">PMC</idno><idno type="pmid">26579506</idno><idno type="pmc">4621383</idno><idno type="url">http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4621383</idno><idno type="RBID">PMC:4621383</idno><idno type="doi">10.3389/fpubh.2015.00244</idno><date when="2015">2015</date><idno type="wicri:Area/Pmc/Corpus">000077</idno><idno type="wicri:explorRef" wicri:stream="Pmc" wicri:step="Corpus" wicri:corpus="PMC">000077</idno></publicationStmt><sourceDesc><biblStruct><analytic><title xml:lang="en" level="a" type="main">Low Virologic Failure and Drug Resistance among HIV-Infected Patients Receiving Hospital-Based ART While Care and Outreach through Community in Guangxi, China</title><author><name sortKey="Liang, Shujia" sort="Liang, Shujia" uniqKey="Liang S" first="Shujia" last="Liang">Shujia Liang</name><affiliation><nlm:aff id="aff1"><institution>Guangxi Center for Disease Control and Prevention</institution>,<addr-line>Nanning</addr-line>,<country>China</country></nlm:aff></affiliation></author><author><name sortKey="Shen, Zhiyong" sort="Shen, Zhiyong" uniqKey="Shen Z" first="Zhiyong" last="Shen">Zhiyong Shen</name><affiliation><nlm:aff id="aff1"><institution>Guangxi Center for Disease Control and Prevention</institution>,<addr-line>Nanning</addr-line>,<country>China</country></nlm:aff></affiliation></author><author><name sortKey="Yan, Jing" sort="Yan, Jing" uniqKey="Yan J" first="Jing" last="Yan">Jing Yan</name><affiliation><nlm:aff id="aff2"><institution>State Key Laboratory of Infectious Disease Prevention and Control, National Center for AIDS/STD Control and Prevention</institution>,<addr-line>Beijing</addr-line>,<country>China</country></nlm:aff></affiliation><affiliation><nlm:aff id="aff3"><institution>State Key Laboratory for Infectious Disease Prevention and Control, Chinese Center for Disease Control and Prevention</institution>,<addr-line>Beijing</addr-line>,<country>China</country></nlm:aff></affiliation><affiliation><nlm:aff id="aff4"><institution>State Key Laboratory for Infectious Disease Prevention and Control, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases</institution>,<addr-line>Beijing</addr-line>,<country>China</country></nlm:aff></affiliation></author><author><name sortKey="Liang, Fuxiong" sort="Liang, Fuxiong" uniqKey="Liang F" first="Fuxiong" last="Liang">Fuxiong Liang</name><affiliation><nlm:aff id="aff1"><institution>Guangxi Center for Disease Control and Prevention</institution>,<addr-line>Nanning</addr-line>,<country>China</country></nlm:aff></affiliation></author><author><name sortKey="Tang, Zhenzhu" sort="Tang, Zhenzhu" uniqKey="Tang Z" first="Zhenzhu" last="Tang">Zhenzhu Tang</name><affiliation><nlm:aff id="aff1"><institution>Guangxi Center for Disease Control and Prevention</institution>,<addr-line>Nanning</addr-line>,<country>China</country></nlm:aff></affiliation></author><author><name sortKey="Liu, Wei" sort="Liu, Wei" uniqKey="Liu W" first="Wei" last="Liu">Wei Liu</name><affiliation><nlm:aff id="aff1"><institution>Guangxi Center for Disease Control and Prevention</institution>,<addr-line>Nanning</addr-line>,<country>China</country></nlm:aff></affiliation></author><author><name sortKey="Kan, Wei" sort="Kan, Wei" uniqKey="Kan W" first="Wei" last="Kan">Wei Kan</name><affiliation><nlm:aff id="aff2"><institution>State Key Laboratory of Infectious Disease Prevention and Control, National Center for AIDS/STD Control and Prevention</institution>,<addr-line>Beijing</addr-line>,<country>China</country></nlm:aff></affiliation><affiliation><nlm:aff id="aff3"><institution>State Key Laboratory for Infectious Disease Prevention and Control, Chinese Center for Disease Control and Prevention</institution>,<addr-line>Beijing</addr-line>,<country>China</country></nlm:aff></affiliation><affiliation><nlm:aff id="aff4"><institution>State Key Laboratory for Infectious Disease Prevention and Control, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases</institution>,<addr-line>Beijing</addr-line>,<country>China</country></nlm:aff></affiliation></author><author><name sortKey="Liao, Lingjie" sort="Liao, Lingjie" uniqKey="Liao L" first="Lingjie" last="Liao">Lingjie Liao</name><affiliation><nlm:aff id="aff2"><institution>State Key Laboratory of Infectious Disease Prevention and Control, National Center for AIDS/STD Control and Prevention</institution>,<addr-line>Beijing</addr-line>,<country>China</country></nlm:aff></affiliation><affiliation><nlm:aff id="aff3"><institution>State Key Laboratory for Infectious Disease Prevention and Control, Chinese Center for Disease Control and Prevention</institution>,<addr-line>Beijing</addr-line>,<country>China</country></nlm:aff></affiliation><affiliation><nlm:aff id="aff4"><institution>State Key Laboratory for Infectious Disease Prevention and Control, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases</institution>,<addr-line>Beijing</addr-line>,<country>China</country></nlm:aff></affiliation></author><author><name sortKey="Leng, Xuebing" sort="Leng, Xuebing" uniqKey="Leng X" first="Xuebing" last="Leng">Xuebing Leng</name><affiliation><nlm:aff id="aff2"><institution>State Key Laboratory of Infectious Disease Prevention and Control, National Center for AIDS/STD Control and Prevention</institution>,<addr-line>Beijing</addr-line>,<country>China</country></nlm:aff></affiliation><affiliation><nlm:aff id="aff3"><institution>State Key Laboratory for Infectious Disease Prevention and Control, Chinese Center for Disease Control and Prevention</institution>,<addr-line>Beijing</addr-line>,<country>China</country></nlm:aff></affiliation><affiliation><nlm:aff id="aff4"><institution>State Key Laboratory for Infectious Disease Prevention and Control, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases</institution>,<addr-line>Beijing</addr-line>,<country>China</country></nlm:aff></affiliation></author><author><name sortKey="Ruan, Yuhua" sort="Ruan, Yuhua" uniqKey="Ruan Y" first="Yuhua" last="Ruan">Yuhua Ruan</name><affiliation><nlm:aff id="aff2"><institution>State Key Laboratory of Infectious Disease Prevention and Control, National Center for AIDS/STD Control and Prevention</institution>,<addr-line>Beijing</addr-line>,<country>China</country></nlm:aff></affiliation><affiliation><nlm:aff id="aff3"><institution>State Key Laboratory for Infectious Disease Prevention and Control, Chinese Center for Disease Control and Prevention</institution>,<addr-line>Beijing</addr-line>,<country>China</country></nlm:aff></affiliation><affiliation><nlm:aff id="aff4"><institution>State Key Laboratory for Infectious Disease Prevention and Control, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases</institution>,<addr-line>Beijing</addr-line>,<country>China</country></nlm:aff></affiliation></author><author><name sortKey="Xing, Hui" sort="Xing, Hui" uniqKey="Xing H" first="Hui" last="Xing">Hui Xing</name><affiliation><nlm:aff id="aff2"><institution>State Key Laboratory of Infectious Disease Prevention and Control, National Center for AIDS/STD Control and Prevention</institution>,<addr-line>Beijing</addr-line>,<country>China</country></nlm:aff></affiliation><affiliation><nlm:aff id="aff3"><institution>State Key Laboratory for Infectious Disease Prevention and Control, Chinese Center for Disease Control and Prevention</institution>,<addr-line>Beijing</addr-line>,<country>China</country></nlm:aff></affiliation><affiliation><nlm:aff id="aff4"><institution>State Key Laboratory for Infectious Disease Prevention and Control, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases</institution>,<addr-line>Beijing</addr-line>,<country>China</country></nlm:aff></affiliation></author><author><name sortKey="Shao, Yiming" sort="Shao, Yiming" uniqKey="Shao Y" first="Yiming" last="Shao">Yiming Shao</name><affiliation><nlm:aff id="aff2"><institution>State Key Laboratory of Infectious Disease Prevention and Control, National Center for AIDS/STD Control and Prevention</institution>,<addr-line>Beijing</addr-line>,<country>China</country></nlm:aff></affiliation><affiliation><nlm:aff id="aff3"><institution>State Key Laboratory for Infectious Disease Prevention and Control, Chinese Center for Disease Control and Prevention</institution>,<addr-line>Beijing</addr-line>,<country>China</country></nlm:aff></affiliation><affiliation><nlm:aff id="aff4"><institution>State Key Laboratory for Infectious Disease Prevention and Control, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases</institution>,<addr-line>Beijing</addr-line>,<country>China</country></nlm:aff></affiliation></author></analytic><series><title level="j">Frontiers in Public Health</title><idno type="eISSN">2296-2565</idno><imprint><date when="2015">2015</date></imprint></series></biblStruct></sourceDesc></fileDesc><profileDesc><textClass></textClass></profileDesc></teiHeader><front><div type="abstract" xml:lang="en"><sec id="ST1"><title>Objectives</title><p>To investigate human immunodeficiency virus (HIV) virologic suppression and drug resistance among HIV-infected patients receiving first-line antiretroviral treatment (ART) in hospitals while community care and outreach through local health workers in Guangxi, China.</p></sec><sec id="ST2"><title>Design</title><p>This was a series of cross-sectional surveys from 2004 to 2012 in Guangxi, supported by the Chinese National HIVDR Surveillance and Monitoring Network Working Group.</p></sec><sec id="ST3"><title>Settings</title><p>Guangxi, China.</p></sec><sec id="ST4"><title>Methods</title><p>Demographic, ART, and laboratory data (CD4<sup>+</sup> cell count, viral load, and drug resistance) were analyzed. Factors associated with virologic suppression were identified by logistic regression analysis.</p></sec><sec id="ST5"><title>Results</title><p>A total of 780 patients were included in this study. The median treatment duration was 20.6 months (IQR 6.6–35.9). Of 780 study participants, 95.4% of patients (744/780) had HIV virologic suppression. Among these, of the 143 patients who were infected through drug injection, only 10 (7.0%) experienced virologic failure, and the overall prevalence of HIV drug resistance was 2.8% (22/789). Factors associated with virologic suppression in the final multivariate models included self-reported missing doses in the past month (compared to not missing doses in the past month, AOR = 0.2, 95% CI: 0.1–0.6) and initial ART regimen without 3TC (compared to initial ART regimen with 3TC, AOR = 0.2, 95% CI: 0.1–0.4). Moreover, the trend chi-square test showed that the proportion of virologic suppression increased over time from 2004 to 2012 (<italic>P</italic> = 0.002).</p></sec><sec id="ST6"><title>Conclusion</title><p>This study first demonstrated that HIV patients infected through various transmission routes can achieve an excellent treatment outcome in hospitals at or above the county level for free first-line ART in Guangxi. It is an important of ART education and adherence to intervention for achieving better treatment outcomes.</p></sec></div></front><back><div1 type="bibliography"><listBibl><biblStruct><analytic><author><name sortKey="Zhang, F" uniqKey="Zhang F">F Zhang</name></author><author><name sortKey="Dou, Z" uniqKey="Dou Z">Z Dou</name></author><author><name sortKey="Ma, Y" uniqKey="Ma Y">Y Ma</name></author><author><name sortKey="Zhao, Y" uniqKey="Zhao Y">Y Zhao</name></author><author><name sortKey="Liu, Z" uniqKey="Liu Z">Z Liu</name></author><author><name sortKey="Bulterys, M" uniqKey="Bulterys M">M Bulterys</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Borrell, C" uniqKey="Borrell C">C Borrell</name></author><author><name sortKey="Rodriguez Sanz, M" uniqKey="Rodriguez Sanz M">M Rodriguez-Sanz</name></author><author><name sortKey="Pasarin, Mi" uniqKey="Pasarin M">MI Pasarin</name></author><author><name sortKey="Brugal, Mt" uniqKey="Brugal M">MT 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<front><journal-meta><journal-id journal-id-type="nlm-ta">Front Public Health</journal-id><journal-id journal-id-type="iso-abbrev">Front Public Health</journal-id><journal-id journal-id-type="publisher-id">Front. Public Health</journal-id><journal-title-group><journal-title>Frontiers in Public Health</journal-title></journal-title-group><issn pub-type="epub">2296-2565</issn><publisher><publisher-name>Frontiers Media S.A.</publisher-name></publisher></journal-meta><article-meta><article-id pub-id-type="pmid">26579506</article-id><article-id pub-id-type="pmc">4621383</article-id><article-id pub-id-type="doi">10.3389/fpubh.2015.00244</article-id><article-categories><subj-group subj-group-type="heading"><subject>Public Health</subject><subj-group><subject>Original Research</subject></subj-group></subj-group></article-categories><title-group><article-title>Low Virologic Failure and Drug Resistance among HIV-Infected Patients Receiving Hospital-Based ART While Care and Outreach through Community in Guangxi, China</article-title></title-group><contrib-group><contrib contrib-type="author"><name><surname>Liang</surname><given-names>Shujia</given-names></name><xref ref-type="aff" rid="aff1"><sup>1</sup></xref><xref ref-type="author-notes" rid="fn001"><sup>†</sup></xref><uri xlink:type="simple" xlink:href="http://frontiersin.org/people/u/266483"></uri></contrib><contrib contrib-type="author"><name><surname>Shen</surname><given-names>Zhiyong</given-names></name><xref ref-type="aff" rid="aff1"><sup>1</sup></xref><xref ref-type="author-notes" rid="fn001"><sup>†</sup></xref></contrib><contrib contrib-type="author"><name><surname>Yan</surname><given-names>Jing</given-names></name><xref ref-type="aff" rid="aff2"><sup>2</sup></xref><xref ref-type="aff" rid="aff3"><sup>3</sup></xref><xref ref-type="aff" rid="aff4"><sup>4</sup></xref><xref ref-type="author-notes" rid="fn001"><sup>†</sup></xref><uri xlink:type="simple" xlink:href="http://frontiersin.org/people/u/266334"></uri></contrib><contrib contrib-type="author"><name><surname>Liang</surname><given-names>Fuxiong</given-names></name><xref ref-type="aff" rid="aff1"><sup>1</sup></xref></contrib><contrib contrib-type="author"><name><surname>Tang</surname><given-names>Zhenzhu</given-names></name><xref ref-type="aff" rid="aff1"><sup>1</sup></xref></contrib><contrib contrib-type="author"><name><surname>Liu</surname><given-names>Wei</given-names></name><xref ref-type="aff" rid="aff1"><sup>1</sup></xref></contrib><contrib contrib-type="author"><name><surname>Kan</surname><given-names>Wei</given-names></name><xref ref-type="aff" rid="aff2"><sup>2</sup></xref><xref ref-type="aff" rid="aff3"><sup>3</sup></xref><xref ref-type="aff" rid="aff4"><sup>4</sup></xref></contrib><contrib contrib-type="author"><name><surname>Liao</surname><given-names>Lingjie</given-names></name><xref ref-type="aff" rid="aff2"><sup>2</sup></xref><xref ref-type="aff" rid="aff3"><sup>3</sup></xref><xref ref-type="aff" rid="aff4"><sup>4</sup></xref></contrib><contrib contrib-type="author"><name><surname>Leng</surname><given-names>Xuebing</given-names></name><xref ref-type="aff" rid="aff2"><sup>2</sup></xref><xref ref-type="aff" rid="aff3"><sup>3</sup></xref><xref ref-type="aff" rid="aff4"><sup>4</sup></xref><uri xlink:type="simple" xlink:href="http://frontiersin.org/people/u/266493"></uri></contrib><contrib contrib-type="author"><name><surname>Ruan</surname><given-names>Yuhua</given-names></name><xref ref-type="aff" rid="aff2"><sup>2</sup></xref><xref ref-type="aff" rid="aff3"><sup>3</sup></xref><xref ref-type="aff" rid="aff4"><sup>4</sup></xref></contrib><contrib contrib-type="author"><name><surname>Xing</surname><given-names>Hui</given-names></name><xref ref-type="aff" rid="aff2"><sup>2</sup></xref><xref ref-type="aff" rid="aff3"><sup>3</sup></xref><xref ref-type="aff" rid="aff4"><sup>4</sup></xref><xref ref-type="corresp" rid="cor1">*</xref></contrib><contrib contrib-type="author"><name><surname>Shao</surname><given-names>Yiming</given-names></name><xref ref-type="aff" rid="aff2"><sup>2</sup></xref><xref ref-type="aff" rid="aff3"><sup>3</sup></xref><xref ref-type="aff" rid="aff4"><sup>4</sup></xref></contrib></contrib-group><aff id="aff1"><sup>1</sup><institution>Guangxi Center for Disease Control and Prevention</institution>,<addr-line>Nanning</addr-line>,<country>China</country></aff><aff id="aff2"><sup>2</sup><institution>State Key Laboratory of Infectious Disease Prevention and Control, National Center for AIDS/STD Control and Prevention</institution>,<addr-line>Beijing</addr-line>,<country>China</country></aff><aff id="aff3"><sup>3</sup><institution>State Key Laboratory for Infectious Disease Prevention and Control, Chinese Center for Disease Control and Prevention</institution>,<addr-line>Beijing</addr-line>,<country>China</country></aff><aff id="aff4"><sup>4</sup><institution>State Key Laboratory for Infectious Disease Prevention and Control, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases</institution>,<addr-line>Beijing</addr-line>,<country>China</country></aff><author-notes><fn fn-type="edited-by"><p>Edited by: Shervin Assari, University of Michigan, USA</p></fn><fn fn-type="edited-by"><p>Reviewed by: Sarah Rowland-Jones, John Radcliffe Hospital, UK; Arezoo Shajiei, University of Manchester, UK</p></fn><corresp content-type="corresp" id="cor1">*Correspondence: Hui Xing, <email>xingh@chinaaids.cn</email></corresp><fn fn-type="other" id="fn001"><p><sup>†</sup>Shujia Liang, Zhiyong Shen and Jing Yan have contributed equally to this work.</p></fn><fn fn-type="other" id="fn002"><p>Specialty section: This article was submitted to HIV and AIDS, a section of the journal Frontiers in Public Health</p></fn></author-notes><pub-date pub-type="epub"><day>27</day><month>10</month><year>2015</year></pub-date><pub-date pub-type="collection"><year>2015</year></pub-date><volume>3</volume><elocation-id>244</elocation-id><history><date date-type="received"><day>19</day><month>8</month><year>2015</year></date><date date-type="accepted"><day>12</day><month>10</month><year>2015</year></date></history><permissions><copyright-statement>Copyright © 2015 Liang, Shen, Yan, Liang, Tang, Liu, Kan, Liao, Leng, Ruan, Xing and Shao.</copyright-statement><copyright-year>2015</copyright-year><copyright-holder>Liang, Shen, Yan, Liang, Tang, Liu, Kan, Liao, Leng, Ruan, Xing and Shao</copyright-holder><license xlink:href="http://creativecommons.org/licenses/by/4.0/"><license-p>This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) or licensor are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.</license-p></license></permissions><abstract abstract-type="executive-summary"><sec id="ST1"><title>Objectives</title><p>To investigate human immunodeficiency virus (HIV) virologic suppression and drug resistance among HIV-infected patients receiving first-line antiretroviral treatment (ART) in hospitals while community care and outreach through local health workers in Guangxi, China.</p></sec><sec id="ST2"><title>Design</title><p>This was a series of cross-sectional surveys from 2004 to 2012 in Guangxi, supported by the Chinese National HIVDR Surveillance and Monitoring Network Working Group.</p></sec><sec id="ST3"><title>Settings</title><p>Guangxi, China.</p></sec><sec id="ST4"><title>Methods</title><p>Demographic, ART, and laboratory data (CD4<sup>+</sup> cell count, viral load, and drug resistance) were analyzed. Factors associated with virologic suppression were identified by logistic regression analysis.</p></sec><sec id="ST5"><title>Results</title><p>A total of 780 patients were included in this study. The median treatment duration was 20.6 months (IQR 6.6–35.9). Of 780 study participants, 95.4% of patients (744/780) had HIV virologic suppression. Among these, of the 143 patients who were infected through drug injection, only 10 (7.0%) experienced virologic failure, and the overall prevalence of HIV drug resistance was 2.8% (22/789). Factors associated with virologic suppression in the final multivariate models included self-reported missing doses in the past month (compared to not missing doses in the past month, AOR = 0.2, 95% CI: 0.1–0.6) and initial ART regimen without 3TC (compared to initial ART regimen with 3TC, AOR = 0.2, 95% CI: 0.1–0.4). Moreover, the trend chi-square test showed that the proportion of virologic suppression increased over time from 2004 to 2012 (<italic>P</italic> = 0.002).</p></sec><sec id="ST6"><title>Conclusion</title><p>This study first demonstrated that HIV patients infected through various transmission routes can achieve an excellent treatment outcome in hospitals at or above the county level for free first-line ART in Guangxi. It is an important of ART education and adherence to intervention for achieving better treatment outcomes.</p></sec></abstract><kwd-group><kwd>HIV</kwd><kwd>antiretroviral treatment</kwd><kwd>virologic suppression</kwd><kwd>drug resistance</kwd><kwd>China</kwd></kwd-group><funding-group><award-group><funding-source id="cn01">National Natural Science Foundation of China<named-content content-type="fundref-id">10.13039/501100001809</named-content></funding-source><award-id rid="cn01">81471962</award-id></award-group><award-group><funding-source id="cn02">Guangxi Bagui Honor Scholar</funding-source></award-group><award-group><funding-source id="cn03">Ministry of Science and Technology of the People’s Republic of China<named-content content-type="fundref-id">10.13039/501100002855</named-content></funding-source><award-id rid="cn03">2012ZX10001-002</award-id></award-group><award-group><funding-source id="cn04">State Key Laboratory for Infectious Disease Prevention and Control</funding-source></award-group><award-group><funding-source id="cn05">International Development Research Centre<named-content content-type="fundref-id">10.13039/501100000193</named-content></funding-source><award-id rid="cn05">#104519-010</award-id></award-group></funding-group><counts><fig-count count="0"></fig-count><table-count count="3"></table-count><equation-count count="0"></equation-count><ref-count count="30"></ref-count><page-count count="6"></page-count><word-count count="4487"></word-count></counts></article-meta></front><body><sec sec-type="introduction" id="S1"><title>Introduction</title><p>Highly active antiretroviral therapy (HAART) has led to a dramatic increase in sustained suppression of human immunodeficiency virus (HIV) replication. Since HAART was developed in the early 1990s, there has been a rapid improvement in prognosis of patients infected with HIV and reduction in AIDS-related mortality (<xref rid="B1" ref-type="bibr">1</xref>, <xref rid="B2" ref-type="bibr">2</xref>). In resource-rich countries, because of the use of optimal regimens and a complete monitoring system for virologic failure and drug resistance, levels of drug resistance decreased over time (<xref rid="B3" ref-type="bibr">3</xref>, <xref rid="B4" ref-type="bibr">4</xref>). As a result of the scale-up of the “3 by 5” project in low-income and middle-income countries, an increasing number of patients received antiretroviral treatment (ART) from 2003. However, the emergence of HIV drug resistance (HIVDR) was a big challenge to the rapid development of HAART (<xref rid="B5" ref-type="bibr">5</xref>, <xref rid="B6" ref-type="bibr">6</xref>).</p><p>The China’s National Free Antiretroviral Treatment Program (NFATP) began in 2002 and rapidly scaled-up. In 2008, China’s NFATP changed the threshold of initiating free ART access to more patients (<xref rid="B7" ref-type="bibr">7</xref>). By the end of 2013, among the 436,817 people living with HIV in China, the total number receiving free ART had increased to 278,080 (<xref rid="B8" ref-type="bibr">8</xref>). In China, ART has significantly reduced mortality among HIV patients (<xref rid="B9" ref-type="bibr">9</xref>–<xref rid="B11" ref-type="bibr">11</xref>) and HIV transmission among serodiscordant couples in the Chinese national observational cohort study (<xref rid="B12" ref-type="bibr">12</xref>). However, meta-analysis study results showed that the pooled prevalence of HIVDR was 11.1% during 0–12 months and increased to 22.92% at 61–72 months in Chinese HIV-Infected Patients Receiving First-Line HAART (<xref rid="B13" ref-type="bibr">13</xref>). Guangxi Zhuang Autonomous Region located on the southern coast of the China, and neighboring Vietnam in the South and Yunnan Province in the west, is the major drug trafficking route linking Guangxi with Yunnan and Vietnam. The reported cases of HIV/AIDS in Guangxi accounted for 10% of the reported numbers in China. The first HIV infection among local IDUs was observed in 1996 in Guangxi, and HIV infection through drug injection accounted for 69% of the cumulative reported cases of HIV in Guangxi in 2003 (<xref rid="B14" ref-type="bibr">14</xref>). However, in 2013, 93% of reported HIV cases in Guangxi were infected through heterosexual intercourse (<xref rid="B15" ref-type="bibr">15</xref>). Guangxi Zhuang Autonomous Region has the highest number of reported HIV cases in China (<xref rid="B15" ref-type="bibr">15</xref>). Because of the capacity in county hospital-based care and management for free ART in Guangxi, the aim of this study was to evaluate virologic failure and drug resistance and associated factors among HIV-infected patients receiving first-line ART.</p></sec><sec sec-type="materials|methods" id="S2"><title>Materials and Methods</title><sec id="S2-1"><title>Study Design and Study Participants</title><p>We conducted a series of cross-sectional surveys of HIVDR in adult patients at regional representative ART clinics in Guangxi from 2004 to 2012. This protocol of Chinese National HIVDR Surveillance was adopted from the WHO recommended cross-sectional survey on acquired HIVDR in adult patients receiving ART, which has been described elsewhere (<xref rid="B16" ref-type="bibr">16</xref>–<xref rid="B19" ref-type="bibr">19</xref>). First-line ART regimens before 2008 consisted of [azidothymidine (AZT) or stavudine (D4T)] + [didanosine (DDI) or lamivudine (3TC)] + [nevirapine (NVP) or efavirenz (EFV)]. The second edition of the National Free ART Guideline in 2008 was revised to consist of [tenofovir (TDF) or azidothymidine (AZT)] + lamivudine (3TC) + [efavirenz (EFV) or nevirapine (NVP)] (<xref rid="B7" ref-type="bibr">7</xref>). The NFATP criterion for treatment was (1) CD4 cell count <200/mm<sup>3</sup> before 2008, and <350/mm<sup>3</sup> since 2008, (2) total lymphocyte count <1200/mm<sup>3</sup> before 2008, and/or (3) WHO stage III or IV disease (<xref rid="B7" ref-type="bibr">7</xref>, <xref rid="B20" ref-type="bibr">20</xref>). The study eligibility criteria were HIV patients, 18 years or older, having received first-line ART, willingness and consent to participate in the study. Patients who received second-line ART were excluded.</p></sec><sec id="S2-2"><title>Data Collection</title><p>The data were collected with an interviewer-administered questionnaire. Each participant provided informed consent before participation in the study. Each subject was assigned a confidential identification number to label questionnaires and blood specimens. The questionnaire was administered by trained local staff in a private room. The questionnaire information included demographic data, HAART treatment, and self-reported adherence measures. Demographic variables included sex, ethnicity, education level, occupation, marital status, and HIV transmission route. HAART treatment variables included initial regimen, the duration of HAART, and end of HAART regimen. Self-reported adherence variables included missed ART doses in the past month. The institutional review board (IRB) of the National Center on HIV/STD Control and Prevention (NCAIDS), China CDC approved this study.</p></sec><sec id="S2-3"><title>Laboratory Analysis</title><p>Blood specimens were provided by all subjects to determine CD4<sup>+</sup> T-lymphocyte count (CD4 count), HIV viral load (VL), and HIVDR mutations. The CD4 count was determined by flow cytometry within 24 h after collection in the provincial CDC. The Plasma HIV RNA was quantified with real-time NASBA (NucliSense Easy Q, bioMerieux, France) or COBAS (Roche Applied Biosystems, Germany) according to the manufacturer recommendations. In samples with a viral load ≥1000 copies/ml, HIVDR was determined by using an in-house polymerase chain reaction (PCR) (<xref rid="B16" ref-type="bibr">16</xref>, <xref rid="B21" ref-type="bibr">21</xref>). The Stanford HIV Drug Resistance Database (<uri xlink:type="simple" xlink:href="http://hivdb.stanford.edu/">http://hivdb.stanford.edu/</uri>) was used to analyze drug resistance mutation and viral subtype determination. Low-, intermediate-, and high-level drug resistance were defined as HIVDR (<xref rid="B22" ref-type="bibr">22</xref>, <xref rid="B23" ref-type="bibr">23</xref>).</p></sec><sec id="S2-4"><title>Data Analysis</title><p>Questionnaire and laboratory data were double entered and compared with Epidata 3.1 (The Epidata Association Odense, Denmark), and then were analyzed by Statistical Analysis System (SAS 9.2, SAS Institute Inc., Cary, NC, USA). Demographic variables were described with descriptive statistics. Factors associated with virologic failure (viral load ≥1000 copies/ml) were identified by univariate and multivariate logistic regression models. Variables with <italic>P</italic> < 0.05 were retained in multivariate logistic regression models using stepwise selection and results were presented with adjusted odds ratio (AOR) and 95% CIs. Hypothesis testing was two-sided with α = 0.05.</p></sec></sec><sec id="S3"><title>Results</title><sec id="S3-5"><title>Demographic Characteristics</title><p>Seven hundred eighty patients were included in this study. Among these, 221 patients were investigated in 2004–2006, 114 patients were investigated in 2006–2007, and then 291 patients were surveyed in 2007–2009, whereas 154 patients were included in 2011–2012. The demographic characteristics of the subjects are shown in Table <xref ref-type="table" rid="T1">1</xref>. Among the patients, the mean age was 39.2 ± 12.2 years, 61.9% were male, 87.1% belonged to the Han ethnic group, 21.9% had an education level of high school or higher, 76.9% were primarily farmers, and 23.2% were married. Reported transmission routes were 75.3% sexual transmission, 18.3% injection drug use, 1.4% blood transmission, and 5.0% other.</p><table-wrap id="T1" position="float"><label>Table 1</label><caption><p><bold>Characteristics of HIV patients receiving first-line ART in Guangxi</bold>.</p></caption><table frame="hsides" rules="groups"><thead><tr><th align="left" rowspan="1" colspan="1">Characteristics</th><th align="center" rowspan="1" colspan="1">Number</th><th align="center" rowspan="1" colspan="1">Percentage</th></tr></thead><tbody><tr><td align="left" rowspan="1" colspan="1">Total</td><td align="center" rowspan="1" colspan="1">780</td><td align="center" rowspan="1" colspan="1"></td></tr><tr><td align="left" rowspan="1" colspan="1"> Age (years): mean ± SD</td><td align="center" rowspan="1" colspan="1">39.2 ± 12.2</td><td align="center" rowspan="1" colspan="1"></td></tr><tr><td align="left" rowspan="1" colspan="1">Sex</td><td align="center" rowspan="1" colspan="1"></td><td align="center" rowspan="1" colspan="1"></td></tr><tr><td align="left" rowspan="1" colspan="1"> Male</td><td align="center" rowspan="1" colspan="1">483</td><td align="center" rowspan="1" colspan="1">61.9</td></tr><tr><td align="left" rowspan="1" colspan="1"> Female</td><td align="center" rowspan="1" colspan="1">297</td><td align="center" rowspan="1" colspan="1">38.1</td></tr><tr><td align="left" rowspan="1" colspan="1">Ethnicity</td><td align="center" rowspan="1" colspan="1"></td><td align="center" rowspan="1" colspan="1"></td></tr><tr><td align="left" rowspan="1" colspan="1"> Han</td><td align="center" rowspan="1" colspan="1">679</td><td align="center" rowspan="1" colspan="1">87.1</td></tr><tr><td align="left" rowspan="1" colspan="1"> Minorities</td><td align="center" rowspan="1" colspan="1">101</td><td align="center" rowspan="1" colspan="1">12.9</td></tr><tr><td align="left" rowspan="1" colspan="1">Education</td><td align="center" rowspan="1" colspan="1"></td><td align="center" rowspan="1" colspan="1"></td></tr><tr><td align="left" rowspan="1" colspan="1"> Illiterate</td><td align="center" rowspan="1" colspan="1">33</td><td align="center" rowspan="1" colspan="1">4.2</td></tr><tr><td align="left" rowspan="1" colspan="1"> Primary school</td><td align="center" rowspan="1" colspan="1">236</td><td align="center" rowspan="1" colspan="1">30.3</td></tr><tr><td align="left" rowspan="1" colspan="1"> Junior high school</td><td align="center" rowspan="1" colspan="1">340</td><td align="center" rowspan="1" colspan="1">43.6</td></tr><tr><td align="left" rowspan="1" colspan="1"> High school or more</td><td align="center" rowspan="1" colspan="1">171</td><td align="center" rowspan="1" colspan="1">21.9</td></tr><tr><td align="left" rowspan="1" colspan="1">Occupation</td><td align="center" rowspan="1" colspan="1"></td><td align="center" rowspan="1" colspan="1"></td></tr><tr><td align="left" rowspan="1" colspan="1"> Others</td><td align="center" rowspan="1" colspan="1">180</td><td align="center" rowspan="1" colspan="1">23.1</td></tr><tr><td align="left" rowspan="1" colspan="1"> Farmer</td><td align="center" rowspan="1" colspan="1">600</td><td align="center" rowspan="1" colspan="1">76.9</td></tr><tr><td align="left" rowspan="1" colspan="1">Married</td><td align="center" rowspan="1" colspan="1"></td><td align="center" rowspan="1" colspan="1"></td></tr><tr><td align="left" rowspan="1" colspan="1"> Yes</td><td align="center" rowspan="1" colspan="1">181</td><td align="center" rowspan="1" colspan="1">23.2</td></tr><tr><td align="left" rowspan="1" colspan="1"> No</td><td align="center" rowspan="1" colspan="1">599</td><td align="center" rowspan="1" colspan="1">76.8</td></tr><tr><td align="left" rowspan="1" colspan="1">HIV transmission route</td><td align="center" rowspan="1" colspan="1"></td><td align="center" rowspan="1" colspan="1"></td></tr><tr><td align="left" rowspan="1" colspan="1"> Sexual intercourse</td><td align="center" rowspan="1" colspan="1">587</td><td align="center" rowspan="1" colspan="1">75.3</td></tr><tr><td align="left" rowspan="1" colspan="1"> Drug injection</td><td align="center" rowspan="1" colspan="1">143</td><td align="center" rowspan="1" colspan="1">18.3</td></tr><tr><td align="left" rowspan="1" colspan="1"> Blood transfusion</td><td align="center" rowspan="1" colspan="1">11</td><td align="center" rowspan="1" colspan="1">1.4</td></tr><tr><td align="left" rowspan="1" colspan="1"> Others</td><td align="center" rowspan="1" colspan="1">39</td><td align="center" rowspan="1" colspan="1">5.0</td></tr><tr><td align="left" rowspan="1" colspan="1">CD4 count before ART (cells/mm<sup>3</sup>)</td><td align="center" rowspan="1" colspan="1"></td><td align="center" rowspan="1" colspan="1"></td></tr><tr><td align="left" rowspan="1" colspan="1"> ≥350</td><td align="center" rowspan="1" colspan="1">10</td><td align="center" rowspan="1" colspan="1">1.3</td></tr><tr><td align="left" rowspan="1" colspan="1"> 349–200</td><td align="center" rowspan="1" colspan="1">116</td><td align="center" rowspan="1" colspan="1">14.9</td></tr><tr><td align="left" rowspan="1" colspan="1"> 199–100</td><td align="center" rowspan="1" colspan="1">142</td><td align="center" rowspan="1" colspan="1">18.2</td></tr><tr><td align="left" rowspan="1" colspan="1"> <100</td><td align="center" rowspan="1" colspan="1">512</td><td align="center" rowspan="1" colspan="1">65.6</td></tr><tr><td align="left" rowspan="1" colspan="1">Missed doses in the past month</td><td align="center" rowspan="1" colspan="1"></td><td align="center" rowspan="1" colspan="1"></td></tr><tr><td align="left" rowspan="1" colspan="1"> No</td><td align="center" rowspan="1" colspan="1">757</td><td align="center" rowspan="1" colspan="1">97.9</td></tr><tr><td align="left" rowspan="1" colspan="1"> Yes</td><td align="center" rowspan="1" colspan="1">23</td><td align="center" rowspan="1" colspan="1">2.1</td></tr><tr><td align="left" rowspan="1" colspan="1">Duration of ART (months): median, IQR</td><td align="center" rowspan="1" colspan="1">20.6</td><td align="center" rowspan="1" colspan="1">6.6–35.9</td></tr><tr><td align="left" rowspan="1" colspan="1">Initial ART regimen</td><td align="center" rowspan="1" colspan="1"></td><td align="center" rowspan="1" colspan="1"></td></tr><tr><td align="left" rowspan="1" colspan="1"> AZT + 3TC + EFV</td><td align="center" rowspan="1" colspan="1">95</td><td align="center" rowspan="1" colspan="1">12.2</td></tr><tr><td align="left" rowspan="1" colspan="1"> AZT + 3TC + NVP</td><td align="center" rowspan="1" colspan="1">250</td><td align="center" rowspan="1" colspan="1">32.1</td></tr><tr><td align="left" rowspan="1" colspan="1"> D4T + 3TC + EFV</td><td align="center" rowspan="1" colspan="1">40</td><td align="center" rowspan="1" colspan="1">5.1</td></tr><tr><td align="left" rowspan="1" colspan="1"> D4T + 3TC + NVP</td><td align="center" rowspan="1" colspan="1">271</td><td align="center" rowspan="1" colspan="1">34.7</td></tr><tr><td align="left" rowspan="1" colspan="1"> DDI-based regimens</td><td align="center" rowspan="1" colspan="1">124</td><td align="center" rowspan="1" colspan="1">15.9</td></tr></tbody></table></table-wrap></sec><sec id="S3-6"><title>HAART Regimens and Virologic Profiles</title><p>Initial HAART regimens used were AZT + 3TC + EFV (12.2%), AZT + 3TC + NVP (32.1%), D4T + 3TC + EFV (5.1%), D4T + 3TC + NVP (34.7%), and DDI-based regimens (15.9%). The median of the duration of ART was 20.6 months. At the time of the survey, 36 (4.6%) patients had a viral load ≥1000 copies/ml. Among these subjects, 35 were successfully genotyped. CRF01_AE was the most common HIV viral subtype (31/35, 88.5%). Of these, 22 had detectable HIVDR mutations.</p></sec><sec id="S3-7"><title>HIV Drug Resistance Mutations</title><p>Among the 35 subjects successfully genotyped with viral load ≥1000 copies/ml, 22 patients were identified with HIVDR mutations, and the overall prevalence of HIVDR was 2.8% (22/789) among HIV-infected patients receiving first-line ART. Approximately 54.5% (12/22) of patients were resistant to non-nucleoside reverse transcriptase inhibitor (NNRTIs) drugs, 90.9% (20/22) of patients were resistant to nucleoside reverse transcriptase inhibitor (NRTIs) drugs, and 4.5% (1/22) of patients had drug resistance to protease inhibitors (PIs). In addition, 45.5% (10/22) of patients were identified as multi-drug resistance to NNRTIs and NRTIs. The most frequent NNRTIs mutations occurred at position 101 in the RT (reverse transcriptase) region, NRTIs mutations occurred at position 184 in the RT region, and PI mutations occurred at position 84 in the PR (protease) region (Table <xref ref-type="table" rid="T2">2</xref>).</p><table-wrap id="T2" position="float"><label>Table 2</label><caption><p><bold>HIV drug resistance mutations among HIV patients receiving first-line ART in Guangxi</bold>.</p></caption><table frame="hsides" rules="groups"><thead><tr><th align="left" rowspan="1" colspan="1">Antiretroviral drug</th><th align="center" rowspan="1" colspan="1"><italic>N</italic> (%)</th><th align="left" rowspan="1" colspan="1">HIV drug resistance mutations, <italic>N</italic> (%)</th></tr></thead><tbody><tr><td align="left" rowspan="1" colspan="1">Total</td><td align="center" rowspan="1" colspan="1">22 (100.0)</td><td align="left" rowspan="1" colspan="1"></td></tr><tr><td align="left" rowspan="1" colspan="1">Non-nucleoside reverse transcriptase inhibitors (NNRTI, any)</td><td align="center" rowspan="1" colspan="1">12 (54.5)</td><td align="left" rowspan="1" colspan="1">K101E/EK/H/P, 4 (18.2)</td></tr><tr><td align="left" rowspan="1" colspan="1">Efavirenz (EFV)<xref ref-type="table-fn" rid="tfnT2_1"><sup>a</sup></xref></td><td align="center" rowspan="1" colspan="1">12 (54.5)</td><td align="left" rowspan="1" colspan="1">K103N/KN/S, 3 (13.6)</td></tr><tr><td align="left" rowspan="1" colspan="1">Nevirapine (NVP)<xref ref-type="table-fn" rid="tfnT2_1"><sup>a</sup></xref></td><td align="center" rowspan="1" colspan="1">12 (54.5)</td><td align="left" rowspan="1" colspan="1">V106L/I, 2 (9.1)</td></tr><tr><td align="left" rowspan="1" colspan="1">Delavirdine (DLV)</td><td align="center" rowspan="1" colspan="1">11 (50.0)</td><td align="left" rowspan="1" colspan="1">G190A, 2 (9.1)</td></tr><tr><td align="left" rowspan="1" colspan="1">Etravirine (ETV)</td><td align="center" rowspan="1" colspan="1">2 (9.1)</td><td align="left" rowspan="1" colspan="1">Y181C/I, 2 (9.1)</td></tr><tr><td align="left" rowspan="1" colspan="1"></td><td align="center" rowspan="1" colspan="1"></td><td align="left" rowspan="1" colspan="1">E138EQ, 1 (4.5)</td></tr><tr><td align="left" rowspan="1" colspan="1"></td><td align="center" rowspan="1" colspan="1"></td><td align="left" rowspan="1" colspan="1">Y188L, 1 (4.5)</td></tr><tr><td align="left" rowspan="1" colspan="1">Nucleoside reverse transcriptase inhibitors (NRTI, any)</td><td align="center" rowspan="1" colspan="1">20 (90.9)</td><td align="left" rowspan="1" colspan="1"></td></tr><tr><td align="left" rowspan="1" colspan="1">Emtricitabine (FTC)</td><td align="center" rowspan="1" colspan="1">18 (81.8)</td><td align="left" rowspan="1" colspan="1">M184V/MV, 8 (36.4)</td></tr><tr><td align="left" rowspan="1" colspan="1">Lamivudine (3TC)<xref ref-type="table-fn" rid="tfnT2_1"><sup>a</sup></xref></td><td align="center" rowspan="1" colspan="1">18 (81.8)</td><td align="left" rowspan="1" colspan="1">T69I/IN/N, 6 (27.3)</td></tr><tr><td align="left" rowspan="1" colspan="1">Abacavir (ABC)</td><td align="center" rowspan="1" colspan="1">15 (68.2)</td><td align="left" rowspan="1" colspan="1">D67DG/DN/G/N, 4 (18.2)</td></tr><tr><td align="left" rowspan="1" colspan="1">Didanosine (DDI)<xref ref-type="table-fn" rid="tfnT2_1"><sup>a</sup></xref></td><td align="center" rowspan="1" colspan="1">17 (77.3)</td><td align="left" rowspan="1" colspan="1">L74V, 2 (9.1)</td></tr><tr><td align="left" rowspan="1" colspan="1">Stavudine (D4T)<xref ref-type="table-fn" rid="tfnT2_1"><sup>a</sup></xref></td><td align="center" rowspan="1" colspan="1">14 (63.6)</td><td align="left" rowspan="1" colspan="1">M41I/LM, 2 (9.1)</td></tr><tr><td align="left" rowspan="1" colspan="1">Tenofovir (TDF)<xref ref-type="table-fn" rid="tfnT2_1"><sup>a</sup></xref></td><td align="center" rowspan="1" colspan="1">8 (36.4)</td><td align="left" rowspan="1" colspan="1">K65R, 1 (4.5)</td></tr><tr><td align="left" rowspan="1" colspan="1">Azidothymidine (AZT)<xref ref-type="table-fn" rid="tfnT2_1"><sup>a</sup></xref></td><td align="center" rowspan="1" colspan="1">12 (54.5)</td><td align="left" rowspan="1" colspan="1">V75T, 1 (4.5)</td></tr><tr><td align="left" rowspan="1" colspan="1"></td><td align="center" rowspan="1" colspan="1"></td><td align="left" rowspan="1" colspan="1">L210M, 1 (4.5)</td></tr><tr><td align="left" rowspan="1" colspan="1"></td><td align="center" rowspan="1" colspan="1"></td><td align="left" rowspan="1" colspan="1">F116Y, 1 (4.5)</td></tr><tr><td align="left" rowspan="1" colspan="1"></td><td align="center" rowspan="1" colspan="1"></td><td align="left" rowspan="1" colspan="1">T215Y, 1 (4.5)</td></tr><tr><td align="left" rowspan="1" colspan="1"></td><td align="center" rowspan="1" colspan="1"></td><td align="left" rowspan="1" colspan="1">K70KR, 1 (4.5)</td></tr><tr><td align="left" rowspan="1" colspan="1"></td><td align="center" rowspan="1" colspan="1"></td><td align="left" rowspan="1" colspan="1">F215FIST, 1 (4.5)</td></tr><tr><td align="left" rowspan="1" colspan="1">Protease inhibitors (PI, any)</td><td align="center" rowspan="1" colspan="1">1 (4.5)</td><td align="left" rowspan="1" colspan="1"></td></tr><tr><td align="left" rowspan="1" colspan="1">Tipranavir (TPV)</td><td align="center" rowspan="1" colspan="1">1 (4.5)</td><td align="left" rowspan="1" colspan="1">I84IV, 1 (4.5)</td></tr><tr><td align="left" rowspan="1" colspan="1">Fosamprenavir (FPV)</td><td align="center" rowspan="1" colspan="1">1 (4.5)</td><td align="left" rowspan="1" colspan="1"></td></tr><tr><td align="left" rowspan="1" colspan="1">Lopinavir (LPV)<xref ref-type="table-fn" rid="tfnT2_1"><sup>a</sup></xref></td><td align="center" rowspan="1" colspan="1">0 (0.0)</td><td align="left" rowspan="1" colspan="1"></td></tr><tr><td align="left" rowspan="1" colspan="1">Nelfinavir (NFV)</td><td align="center" rowspan="1" colspan="1">1 (4.5)</td><td align="left" rowspan="1" colspan="1"></td></tr><tr><td align="left" rowspan="1" colspan="1">Atazanavir (ATV)</td><td align="center" rowspan="1" colspan="1">1 (4.5)</td><td align="left" rowspan="1" colspan="1"></td></tr><tr><td align="left" rowspan="1" colspan="1">Darunavir (DRV)</td><td align="center" rowspan="1" colspan="1">0 (0.0)</td><td align="left" rowspan="1" colspan="1"></td></tr><tr><td align="left" rowspan="1" colspan="1">Indinavir (IDV)</td><td align="center" rowspan="1" colspan="1">1 (4.5)</td><td align="left" rowspan="1" colspan="1"></td></tr><tr><td align="left" rowspan="1" colspan="1">Saquinavir (SQV)</td><td align="center" rowspan="1" colspan="1">1 (4.5)</td><td align="left" rowspan="1" colspan="1"></td></tr><tr><td align="left" rowspan="1" colspan="1">Multi-drug resistance to NNRTI and NRTI</td><td align="center" rowspan="1" colspan="1">10 (45.5)</td><td align="left" rowspan="1" colspan="1"></td></tr></tbody></table><table-wrap-foot><fn id="tfnT2_1"><p><italic><sup>a</sup>Provided through the National Free Antiretroviral Treatment Program (NFATP)</italic>.</p></fn></table-wrap-foot></table-wrap></sec><sec id="S3-8"><title>Predictors for HIV Virologic Suppression</title><p>Of 780 study participants, 744 (95.4%) had HIV virologic suppression. Univariate logistic regression models were used to examine the factors associated with HIV virologic suppression (Table <xref ref-type="table" rid="T3">3</xref>). Ethnicity, initial ART regimen, and missed doses in the past month were associated with virologic suppression. Those found to be statistically significant were included in the multivariate logistic regression model. Factors associated with virologic suppression in the final multivariate models include self-reported missing doses in the past month (compared to not missing doses in the past month, AOR = 0.2, 95% CI: 0.1–0.6) and initial ART regimen without 3TC (compared to initial ART regimen with 3TC, AOR = 0.2, 95% CI: 0.1–0.4). Moreover, the trend chi-square test showed that the proportion of virologic suppression increased over time from 2004 to 2012 (<italic>P</italic> = 0.002).</p><table-wrap id="T3" position="float"><label>Table 3</label><caption><p><bold>Factors associated with HIV viral suppression (viral load <1000 copies/ml) among HIV patients receiving first-line ART in Guangxi</bold>.</p></caption><table frame="hsides" rules="groups"><thead><tr><th align="left" rowspan="1" colspan="1">Variable</th><th align="center" rowspan="1" colspan="1">Number</th><th align="center" rowspan="1" colspan="1">Viral suppression <italic>N</italic> (%)</th><th align="center" rowspan="1" colspan="1">Crude OR (95% CI)</th><th align="center" rowspan="1" colspan="1"><italic>P</italic>-value</th><th align="center" rowspan="1" colspan="1">Adjusted OR (95% CI)</th><th align="center" rowspan="1" colspan="1"><italic>P</italic>-value</th></tr></thead><tbody><tr><td align="left" rowspan="1" colspan="1"></td><td align="center" rowspan="1" colspan="1">780</td><td align="center" rowspan="1" colspan="1">744 (95.4)</td><td align="center" rowspan="1" colspan="1"></td><td align="center" rowspan="1" colspan="1"></td><td align="center" rowspan="1" colspan="1"></td><td align="center" rowspan="1" colspan="1"></td></tr><tr><td align="left" rowspan="1" colspan="1">Age (years)</td><td align="center" rowspan="1" colspan="1"></td><td align="center" rowspan="1" colspan="1"></td><td align="center" rowspan="1" colspan="1"></td><td align="center" rowspan="1" colspan="1"></td><td align="center" rowspan="1" colspan="1"></td><td align="center" rowspan="1" colspan="1"></td></tr><tr><td align="left" rowspan="1" colspan="1"> <40</td><td align="center" rowspan="1" colspan="1">486</td><td align="center" rowspan="1" colspan="1">458 (94.2)</td><td align="center" rowspan="1" colspan="1"></td><td align="center" rowspan="1" colspan="1"></td><td align="center" rowspan="1" colspan="1"></td><td align="center" rowspan="1" colspan="1"></td></tr><tr><td align="left" rowspan="1" colspan="1"> ≥40</td><td align="center" rowspan="1" colspan="1">294</td><td align="center" rowspan="1" colspan="1">286 (97.3)</td><td align="center" rowspan="1" colspan="1">2.2 (0.9, 4.9)</td><td align="center" rowspan="1" colspan="1">0.06</td><td align="center" rowspan="1" colspan="1"></td><td align="center" rowspan="1" colspan="1"></td></tr><tr><td align="left" rowspan="1" colspan="1">Sex</td><td align="center" rowspan="1" colspan="1"></td><td align="center" rowspan="1" colspan="1"></td><td align="center" rowspan="1" colspan="1"></td><td align="center" rowspan="1" colspan="1"></td><td align="center" rowspan="1" colspan="1"></td><td align="center" rowspan="1" colspan="1"></td></tr><tr><td align="left" rowspan="1" colspan="1"> Male</td><td align="center" rowspan="1" colspan="1">483</td><td align="center" rowspan="1" colspan="1">459 (95.0)</td><td align="center" rowspan="1" colspan="1"></td><td align="center" rowspan="1" colspan="1"></td><td align="center" rowspan="1" colspan="1"></td><td align="center" rowspan="1" colspan="1"></td></tr><tr><td align="left" rowspan="1" colspan="1"> Female</td><td align="center" rowspan="1" colspan="1">297</td><td align="center" rowspan="1" colspan="1">285 (96.0)</td><td align="center" rowspan="1" colspan="1">1.2 (0.6, 2.5)</td><td align="center" rowspan="1" colspan="1">0.55</td><td align="center" rowspan="1" colspan="1"></td><td align="center" rowspan="1" colspan="1"></td></tr><tr><td align="left" rowspan="1" colspan="1">Ethnicity</td><td align="center" rowspan="1" colspan="1"></td><td align="center" rowspan="1" colspan="1"></td><td align="center" rowspan="1" colspan="1"></td><td align="center" rowspan="1" colspan="1"></td><td align="center" rowspan="1" colspan="1"></td><td align="center" rowspan="1" colspan="1"></td></tr><tr><td align="left" rowspan="1" colspan="1"> Han</td><td align="center" rowspan="1" colspan="1">679</td><td align="center" rowspan="1" colspan="1">652 (96.0)</td><td align="center" rowspan="1" colspan="1"></td><td align="center" rowspan="1" colspan="1"></td><td align="center" rowspan="1" colspan="1"></td><td align="center" rowspan="1" colspan="1"></td></tr><tr><td align="left" rowspan="1" colspan="1"> Minorities</td><td align="center" rowspan="1" colspan="1">101</td><td align="center" rowspan="1" colspan="1">92 (91.1)</td><td align="center" rowspan="1" colspan="1">0.4 (0.2, 0.9)</td><td align="center" rowspan="1" colspan="1">0.03</td><td align="center" rowspan="1" colspan="1"></td><td align="center" rowspan="1" colspan="1"></td></tr><tr><td align="left" rowspan="1" colspan="1">Education</td><td align="center" rowspan="1" colspan="1"></td><td align="center" rowspan="1" colspan="1"></td><td align="center" rowspan="1" colspan="1"></td><td align="center" rowspan="1" colspan="1"></td><td align="center" rowspan="1" colspan="1"></td><td align="center" rowspan="1" colspan="1"></td></tr><tr><td align="left" rowspan="1" colspan="1"> High school or more</td><td align="center" rowspan="1" colspan="1">269</td><td align="center" rowspan="1" colspan="1">261 (97.0)</td><td align="center" rowspan="1" colspan="1"></td><td align="center" rowspan="1" colspan="1"></td><td align="center" rowspan="1" colspan="1"></td><td align="center" rowspan="1" colspan="1"></td></tr><tr><td align="left" rowspan="1" colspan="1"> Junior high school or less</td><td align="center" rowspan="1" colspan="1">511</td><td align="center" rowspan="1" colspan="1">483 (94.5)</td><td align="center" rowspan="1" colspan="1">0.5 (0.2, 1.8)</td><td align="center" rowspan="1" colspan="1">0.12</td><td align="center" rowspan="1" colspan="1"></td><td align="center" rowspan="1" colspan="1"></td></tr><tr><td align="left" rowspan="1" colspan="1">Occupation</td><td align="center" rowspan="1" colspan="1"></td><td align="center" rowspan="1" colspan="1"></td><td align="center" rowspan="1" colspan="1"></td><td align="center" rowspan="1" colspan="1"></td><td align="center" rowspan="1" colspan="1"></td><td align="center" rowspan="1" colspan="1"></td></tr><tr><td align="left" rowspan="1" colspan="1"> Others</td><td align="center" rowspan="1" colspan="1">180</td><td align="center" rowspan="1" colspan="1">175 (97.2)</td><td align="center" rowspan="1" colspan="1"></td><td align="center" rowspan="1" colspan="1"></td><td align="center" rowspan="1" colspan="1"></td><td align="center" rowspan="1" colspan="1"></td></tr><tr><td align="left" rowspan="1" colspan="1"> Farmer</td><td align="center" rowspan="1" colspan="1">600</td><td align="center" rowspan="1" colspan="1">569 (94.8)</td><td align="center" rowspan="1" colspan="1">1.9 (0.7, 4.9)</td><td align="center" rowspan="1" colspan="1">0.19</td><td align="center" rowspan="1" colspan="1"></td><td align="center" rowspan="1" colspan="1"></td></tr><tr><td align="left" rowspan="1" colspan="1">Married</td><td align="center" rowspan="1" colspan="1"></td><td align="center" rowspan="1" colspan="1"></td><td align="center" rowspan="1" colspan="1"></td><td align="center" rowspan="1" colspan="1"></td><td align="center" rowspan="1" colspan="1"></td><td align="center" rowspan="1" colspan="1"></td></tr><tr><td align="left" rowspan="1" colspan="1"> No</td><td align="center" rowspan="1" colspan="1">181</td><td align="center" rowspan="1" colspan="1">170 (93.9)</td><td align="center" rowspan="1" colspan="1"></td><td align="center" rowspan="1" colspan="1"></td><td align="center" rowspan="1" colspan="1"></td><td align="center" rowspan="1" colspan="1"></td></tr><tr><td align="left" rowspan="1" colspan="1"> Yes</td><td align="center" rowspan="1" colspan="1">599</td><td align="center" rowspan="1" colspan="1">574 (95.8)</td><td align="center" rowspan="1" colspan="1">1.5 (0.7, 3.1)</td><td align="center" rowspan="1" colspan="1">0.29</td><td align="center" rowspan="1" colspan="1"></td><td align="center" rowspan="1" colspan="1"></td></tr><tr><td align="left" rowspan="1" colspan="1">CD4 cell counts before ART</td><td align="center" rowspan="1" colspan="1"></td><td align="center" rowspan="1" colspan="1"></td><td align="center" rowspan="1" colspan="1"></td><td align="center" rowspan="1" colspan="1"></td><td align="center" rowspan="1" colspan="1"></td><td align="center" rowspan="1" colspan="1"></td></tr><tr><td align="left" rowspan="1" colspan="1"> ≥200</td><td align="center" rowspan="1" colspan="1">126</td><td align="center" rowspan="1" colspan="1">123 (97.6)</td><td align="center" rowspan="1" colspan="1"></td><td align="center" rowspan="1" colspan="1"></td><td align="center" rowspan="1" colspan="1"></td><td align="center" rowspan="1" colspan="1"></td></tr><tr><td align="left" rowspan="1" colspan="1"> <200</td><td align="center" rowspan="1" colspan="1">654</td><td align="center" rowspan="1" colspan="1">621 (96.3)</td><td align="center" rowspan="1" colspan="1">0.5 (0.1, 1.5)</td><td align="center" rowspan="1" colspan="1">0.20</td><td align="center" rowspan="1" colspan="1"></td><td align="center" rowspan="1" colspan="1"></td></tr><tr><td align="left" rowspan="1" colspan="1">Initial ART regimen</td><td align="center" rowspan="1" colspan="1"></td><td align="center" rowspan="1" colspan="1"></td><td align="center" rowspan="1" colspan="1"></td><td align="center" rowspan="1" colspan="1"></td><td align="center" rowspan="1" colspan="1"></td><td align="center" rowspan="1" colspan="1"></td></tr><tr><td align="left" rowspan="1" colspan="1"> Regimens with 3TC</td><td align="center" rowspan="1" colspan="1">656</td><td align="center" rowspan="1" colspan="1">638 (97.3)</td><td align="center" rowspan="1" colspan="1"></td><td align="center" rowspan="1" colspan="1"></td><td align="center" rowspan="1" colspan="1"></td><td align="center" rowspan="1" colspan="1"></td></tr><tr><td align="left" rowspan="1" colspan="1"> Regimens without 3TC</td><td align="center" rowspan="1" colspan="1">124</td><td align="center" rowspan="1" colspan="1">106 (85.5)</td><td align="center" rowspan="1" colspan="1">0.2 (0.1, 0.3)</td><td align="center" rowspan="1" colspan="1"><0.0001</td><td align="center" rowspan="1" colspan="1">0.2 (0.1, 0.4)</td><td align="center" rowspan="1" colspan="1"><0.0001</td></tr><tr><td align="left" rowspan="1" colspan="1">HIV transmission route</td><td align="center" rowspan="1" colspan="1"></td><td align="center" rowspan="1" colspan="1"></td><td align="center" rowspan="1" colspan="1"></td><td align="center" rowspan="1" colspan="1"></td><td align="center" rowspan="1" colspan="1"></td><td align="center" rowspan="1" colspan="1"></td></tr><tr><td align="left" rowspan="1" colspan="1"> Drug injection</td><td align="center" rowspan="1" colspan="1">143</td><td align="center" rowspan="1" colspan="1">133 (93.0)</td><td align="center" rowspan="1" colspan="1"></td><td align="center" rowspan="1" colspan="1"></td><td align="center" rowspan="1" colspan="1"></td><td align="center" rowspan="1" colspan="1"></td></tr><tr><td align="left" rowspan="1" colspan="1"> Others</td><td align="center" rowspan="1" colspan="1">637</td><td align="center" rowspan="1" colspan="1">611 (96.0)</td><td align="center" rowspan="1" colspan="1">1.8 (0.8, 3.8)</td><td align="center" rowspan="1" colspan="1">0.14</td><td align="center" rowspan="1" colspan="1"></td><td align="center" rowspan="1" colspan="1"></td></tr><tr><td align="left" rowspan="1" colspan="1">Missed doses in the past month</td><td align="center" rowspan="1" colspan="1"></td><td align="center" rowspan="1" colspan="1"></td><td align="center" rowspan="1" colspan="1"></td><td align="center" rowspan="1" colspan="1"></td><td align="center" rowspan="1" colspan="1"></td><td align="center" rowspan="1" colspan="1"></td></tr><tr><td align="left" rowspan="1" colspan="1"> No</td><td align="center" rowspan="1" colspan="1">757</td><td align="center" rowspan="1" colspan="1">726 (95.9)</td><td align="center" rowspan="1" colspan="1"></td><td align="center" rowspan="1" colspan="1"></td><td align="center" rowspan="1" colspan="1"></td><td align="center" rowspan="1" colspan="1"></td></tr><tr><td align="left" rowspan="1" colspan="1"> Yes</td><td align="center" rowspan="1" colspan="1">23</td><td align="center" rowspan="1" colspan="1">18 (78.3)</td><td align="center" rowspan="1" colspan="1">0.2 (0.1, 0.4)</td><td align="center" rowspan="1" colspan="1"><0.001</td><td align="center" rowspan="1" colspan="1">0.2 (0.1, 0.6)</td><td align="center" rowspan="1" colspan="1">0.003</td></tr><tr><td align="left" rowspan="1" colspan="1">Time of starting ART (years)</td><td align="center" rowspan="1" colspan="1"></td><td align="center" rowspan="1" colspan="1"></td><td align="center" rowspan="1" colspan="1"></td><td align="center" rowspan="1" colspan="1"></td><td align="center" rowspan="1" colspan="1"></td><td align="center" rowspan="1" colspan="1"></td></tr><tr><td align="left" rowspan="1" colspan="1"> Before 2006</td><td align="center" rowspan="1" colspan="1">182</td><td align="center" rowspan="1" colspan="1">165 (90.7)</td><td align="center" rowspan="1" colspan="1"></td><td align="center" rowspan="1" colspan="1"></td><td align="center" rowspan="1" colspan="1"></td><td align="center" rowspan="1" colspan="1"></td></tr><tr><td align="left" rowspan="1" colspan="1"> 2006–2008</td><td align="center" rowspan="1" colspan="1">339</td><td align="center" rowspan="1" colspan="1">327 (96.5)</td><td align="center" rowspan="1" colspan="1">2.8 (1.3, 6.0)</td><td align="center" rowspan="1" colspan="1">0.008</td><td align="center" rowspan="1" colspan="1"></td><td align="center" rowspan="1" colspan="1"></td></tr><tr><td align="left" rowspan="1" colspan="1"> After 2008</td><td align="center" rowspan="1" colspan="1">259</td><td align="center" rowspan="1" colspan="1">252 (97.3)</td><td align="center" rowspan="1" colspan="1">3.7 (1.5, 9.1)</td><td align="center" rowspan="1" colspan="1">0.004</td><td align="center" rowspan="1" colspan="1"></td><td align="center" rowspan="1" colspan="1"></td></tr></tbody></table></table-wrap></sec></sec><sec sec-type="discussion" id="S4"><title>Discussion</title><p>In this study, we found significant low virologic failure (4.6%) and drug resistance (2.8%) among HIV-infected patients receiving first-line ART with the median duration of treatment of about 20-month in Guangxi, China. Also, virologic suppression increased over time. A recent systematic review and meta-analysis showed that the pooled prevalence of HIVDR was 11.1% (95% CI, 7.49–16.14%), which increased to 22.92% at 61–72 months (95% CI, 9.45–45.86%) among Chinese HIV-infected patients receiving first-line ART in China (<xref rid="B13" ref-type="bibr">13</xref>). Defining 1000 copies/ml as the same threshold of virologic failure, a systematic review conducted in Sub-Saharan Africa concluded that the rate of virologic suppression were 76 and 67% with the median duration of ART at 12- and 24-month, respectively (<xref rid="B24" ref-type="bibr">24</xref>). Based on another systematic review conducted in resource-limited settings in 2013, HIVDR at 12–23 months was 11.1% (<xref rid="B25" ref-type="bibr">25</xref>). With prolonged treatment, the rate of virologic failure and drug resistance increased over time (<xref rid="B26" ref-type="bibr">26</xref>, <xref rid="B27" ref-type="bibr">27</xref>). In the 2012 WHO drug resistance surveillance guideline, viral load suppression after 12 months of ART can be graded as poor (<70%), fair (70–85%), or excellent (>85%) (<xref rid="B28" ref-type="bibr">28</xref>). The prevalence of virologic failure and drug resistance in our study is comparable to the virologic treatment responses seen in other developed and industrialized countries (<xref rid="B4" ref-type="bibr">4</xref>). What is more, of the 143 patients who were infected by drug injection, only 10 (7.0%) experienced virologic failure, lower than other provinces in China and this result consist with previous study in China (<xref rid="B19" ref-type="bibr">19</xref>). Compared to those results, we can conclude that successful outcomes of ART can be achieved in resource-limited settings.</p><p>There are several reasons to explain low virologic failure and drug resistance among HIV-infected patients receiving first-line ART in Guangxi. First, there are three levels of AIDS hospitals providing ART for HIV patients, including provincial, prefecture, and county hospitals. One provincial hospital provides technical supports and training to each prefecture hospital, which then provides technical assistance to each county hospital. Second, although HIV patients receive treatment in hospitals at or above the county level, health staff at village clinics or township hospitals are responsible for community care and outreach, such as home visits or telephone calls for reminding of ART adherence, and making an appointment if patients did not see doctors at AIDS hospitals for ART management every 3-month follow-up. Third, all doctors and health staff for ART and care management receive comprehensive HIV/AIDS medical training. Fourth, initial ART regimen with 3TC can increase virologic suppression. Our previous studies found HIV patients who received ART at village clinics, township hospitals, or local CDCs had poor virologic outcomes, whereas treatment counseling and instruction through telephone and 3TC-based regiments were significantly associated with HIV RNA suppression (<xref rid="B16" ref-type="bibr">16</xref>, <xref rid="B29" ref-type="bibr">29</xref>, <xref rid="B30" ref-type="bibr">30</xref>).</p><p>Despite successful HIV virologic suppression in this study, patients with missed doses in the past month and initial ART regiments without 3TC were found to be at increased risk for poor virologic response. This indicates that measures should be continuously taken to train local medical staff, and educate patients and enhance adherence monitoring. Due to the poor outcome of patients that received DDI-based treatment, the NFATP’s first-line antiretroviral regimens have been changed to exclude the use of didanosine (DDI) and to include the use of lamivudine (3TC) for all new patients beginning treatment since 2008 (<xref rid="B7" ref-type="bibr">7</xref>).</p><p>The prevalence of HIVDR among patients who experienced virologic failure was 62.9% (22/35). Of 22 patients with HIVDR, the proportions of NNRTI mutations, NRTI mutations, and PI mutations were 54.5, 90.0, and 4.5%, respectively. In addition, 10 (45.5%) were identified to be resistant to multi-drugs. M184I/V was the most common NRTI mutations and other studies in China showed similar results (<xref rid="B16" ref-type="bibr">16</xref>, <xref rid="B29" ref-type="bibr">29</xref>). One PI mutation was identified in this study, because that PI was not scaled-up at that period.</p><p>The limitations can be summed up as follows. First, these results may not represent all patients in Guangxi because of the exclusion criteria and limited geographic distribution of the surveillance sites. Also, the surveys did not include all patients who have met the inclusion criteria in Guangxi, so when we draw the conclusion we should be cautious. Second, considering diverse HIV epidemic conditions in different districts in Guangxi, the difference among those districts should be considered.</p><p>In summary, this study in Guangxi demonstrates that HIV-infected patients receiving first-line treatment achieve an excellent treatment outcome and we can summarize those factors associated with virologic suppression as increasing the proper use of 3TC-based regimens and strengthening the importance of adhering to treatment.</p></sec><sec id="S5"><title>Conclusion</title><p>In this study, we found significant low virologic failure and drug resistance among HIV-infected patients receiving first-line ART with the median duration of treatment of about 20-month in Guangxi, China. Our study demonstrated that HIV-infected patients receiving first-line treatment can achieve an excellent treatment outcome in hospitals at or above the county level for free ART in Guangxi, and we can conclude that the increasing the proper use of 3TC-based regimens and the strengthening the importance of adhering to treatment are associated with virologic suppression.</p></sec><sec id="S6"><title>Author Contributions</title><p>JY and SL wrote the main manuscript text and FL, ZT, YS, and WL prepared Tables <xref ref-type="table" rid="T1">1</xref>–<xref ref-type="table" rid="T3">3</xref>. WK, XL, LL, and YR collected the data. HX and YS designed the study. All authors read and approved the final manuscript.</p></sec><sec id="S7"><title>Conflict of Interest Statement</title><p>The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.</p></sec></body><back><ack><p>Thanks to Dr. Edward C. 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