https://orcid.org/0000-0002-3554-7693
Abstract
Background
Partner notification and testing could expand HIV testing and link infections to care. We performed a meta-analysis on HIV testing rate and prevalence among couples of people diagnosed with HIV in China.
Methods
Six electronic databases (PubMed, Cochrane Library, Embase, Web of Science, the China National Knowledge Internet, and WanFang) and abstracts of five HIV/sexually transmitted infections conferences were searched up to February 1, 2020. Meta-analysis was conducted using a random-effects model to assess HIV testing rate and prevalence among couples of Chinese people diagnosed with HIV.
Results
Of 3,657 records retrieved, 42 studies were identified. Among them, three studies were conducted among pregnant women and 10 among men who have sex with men. The pooled uptake rate of couples HIV testing among Chinese people diagnosed with HIV was 65% (95% confidence interval, 57% -73%; 23 studies). The pooled HIV prevalence among couples who had an HIV test was 28% [24%-32%] (38 studies). Subgroup analyses showed that the pooled couples HIV testing uptake rates among pregnant women and men who have sex with men were 76% [66%-86%] (3 studies) and 49% [30%-68%] (8 studies), and the pooled HIV prevalence in two populations was 53% [27%-78%] (3 studies) and 14% [10%-17%] (10 studies), respectively.
Conclusions
Nearly two-thirds of couples of people diagnosed with HIV have had an HIV test, of whom 28% were positive. Couples of MSM with a positive HIV diagnosis had a lower testing rate, which indicates more effective strategies need to be carried out to improve couples HIV testing among Chinese MSM.
Figures
Citation: Zhang C, Qian H-Z, Chen X, Bussell S, Shen Y, Wang H, et al. (2021) HIV testing and seroprevalence among couples of people diagnosed with HIV in China: A meta-analysis. PLoS ONE 16(3): e0247754. https://doi.org/10.1371/journal.pone.0247754
Editor: Qigui Yu, Indiana University School of Medicine, UNITED STATES
Received: May 11, 2020; Accepted: February 12, 2021; Published: March 19, 2021
Copyright: © 2021 Zhang et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Data Availability: All relevant data are within the manuscript and its Supporting information files.
Funding: This study was funded by Central South University Innovation-driven project (XL; 2018CX036; http://www.csu.edu.cn/) and National Natural Science Foundation of China (XL; 72074226; https://isisn.nsfc.gov.cn/egrantweb/). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
Competing interests: The authors have declared that no competing interests exist.
Introduction
Historically, intravenous drug use played a major role in HIV transmission in China; however, currently, sexual intercourse is the main mode of HIV transmission [1, 2]. Only 68% of people living with HIV (PLWH) are aware of their positive status [3], which is well below from the 90% awareness target by 2020 as set by the Joint United Nations Programme on HIV and AIDS [4]. This suggests that there is still a significant gap of HIV testing in China.
Couples HIV Testing (CHT) is an approach to have couples tested for HIV and promote HIV testing [5]. This strategy can increase their knowledge of their serostatus and encourage disclosure among people who are in an ongoing sexual relationship [6, 7]. Studies show that CHT is a feasible strategy that can expand HIV testing and further, prevent HIV transmission by increasing condom use among discordant couples [8, 9]. In addition, encouraging CHT among people who have been diagnosed with HIV (PDWH) can identify additional HIV-infected individuals and direct them to early antiretroviral therapy (ART) [10].
The World Health Organization (WHO) released guidelines for the testing and counseling of couples in 2012 and strongly recommended CHT as an essential strategy to promote HIV testing and reach more PLWH [7]. In the 13th Five-Year Plan, which mapped out the tasks to build a healthy China, the Chinese government encouraged CHT among PDWH [11]. We conducted a meta-analysis examining CHT uptake rate and HIV prevalence among Chinese PDWH in order to provide a useful summary of evidence on CHT practice and outcomes.
Materials and methods
This meta-analysis was reported according to the PRISMA guidelines (S1 Table) [12].
Inclusion criteria
We defined CHT as 1) HIV testing of sexual partners (whether married or not) reported by participants; and 2) testing recorded by the Chinese Centers for Disease Control (CDC) staff. The target population was defined as Chinese PDWH who had documented records of CHT.
Studies were eligible if they reported data on at least one of the following outcomes: the proportion of CHT among Chinese PDWH, and the HIV prevalence among CHT for Chinese PDWH. CHT uptake rate was calculated using the following formula: (number of PDWH couples who had HIV testing) / (number of PDWH). HIV prevalence among CHT was calculated using the following formula: (number of infected couples)/(number of couples who had HIV testing). Randomized controlled trials (RCTs), quasi-experimental studies, and observational (cross-sectional, cohort, and case-control) studies were eligible for inclusion. For experimental trials and cohort studies, baseline data were used for the meta-analysis. Studies were excluded if they were qualitative, a review, or a duplicate report.
Search strategy
We searched six electronic databases (PubMed, Embase, Web of Science, Cochrane Library, the China National Knowledge Internet, and WanFang) and abstracts from the International AIDS Society (IAS), HIV Diagnostics Conference (HDC), Canadian Association of HIV Research (CAHR), Infectious Diseases Society of America (IDSA), and the International Congress of Behavioral Medicine (ICBM) for publications up to February 1, 2020. Our search terms included (China OR Chinese) AND ((“couple HIV testing” OR “couples HIV testing” OR “partner HIV testing” OR “partner testing” OR “couple testing” OR “couples testing”) OR ((test OR testing) AND ("couple" OR "couples" OR "partner" OR "partners"))) AND "HIV Infections"[MeSH] OR "HIV infections" OR "HIV infection" OR "Acquired Immunodeficiency Syndrome"[MeSH] OR "Acquired Immunodeficiency Syndrome" OR "Acquired Immunodeficiency Syndromes" OR AIDS OR HIV). The search was limited to human studies, and English and Chinese language publications. We included abstracts if full texts could not be accessed, and we contacted the authors for original data if needed. Gray literature was screened using Google Scholar. In addition, the reference lists of included studies and previously published reviews were searched for additional potentially eligible studies. The literature search and study selection procedures are described in Fig 1.
Data screening and extraction
Two reviewers (C.Z. and Y.S.) independently screened the titles and abstracts of the articles referring to Chinese PDWH and CHT, and then screened full texts for eligibility. Discrepancies (about 5%) were resolved by discussions with a third reviewer (X.L.). A standard data extraction form was used to extract the variables (including author, year, province, study design, study period, sample size, population, type of union, outcome measurement, CHT uptake, and HIV prevalence among CHT) from the identified studies.
Quality assessment
We performed a quality assessment of the included studies using the Joanna Briggs Institute Critical Appraisal Checklist for cross-sectional studies [13]. RCTs, quasi-experimental studies, cohort studies, and case-control studies were also evaluated using the cross-sectional study checklist, as data was only extracted from the baseline phase. The checklist has eight items, so the total score for each study ranged from 0 to 8, and it was categorized as low quality ≤ 3, moderate = 4–6, and high quality ≥ 7. The quality assessment was conducted by two independent reviewers (C.Z. and Y.S.), and the disagreements were resolved by discussion with a third reviewer (X.L.).
Statistical analysis
STATA 12.0 was used to summarize the results. A meta-analysis was conducted using the DerSimonian-Laird random-effect model to produce pooled proportions and 95% confidence intervals (95% CI) [14, 15]. Heterogeneity was assessed using I2 statistics. In addition, subgroup analyses were performed to explore the source of heterogeneity by the study population and the type of couples. In this study, we classified couples into two types: couples that were defined as people in an ongoing sexual relationship and spouses that were defined as people who have a legal marital relationship. Egger’s tests and funnel plot visual inspection were performed to detect publication bias [16]. A sensitivity analysis was performed to detect the impact of each study on the pooled estimate using the leave-one-out approach, which is a repeating procedure of removing one study from the analysis each time. There are two ways to determine that one study impacts the pooled estimate significantly: the estimate after removing this study is across the upper or lower CI limit lines of the pooled estimate; the upper or lower CI limit lines after removing this study are across the pooled estimate line.
Results
Description of included studies
A total of 3,657 records were retrieved, of which 3,647 were from database searching and 10 from other sources. After removing duplicates, 2,918 records were identified and 2,803 records were excluded by reviewing the title or abstract. The eligibility of the remaining 115 records was assessed by reviewing the full-text articles, and 73 studies were excluded. Finally, 42 studies were included in the meta-analysis (Fig 1).
These included studies were conducted between 1989 and 2019 and published during 2009–2019, which are presented in Table 1 [17–58]. Thirty-eight studies were published in Chinese [17–51, 54, 55, 58] and four in English [52, 53, 56, 57]. Geographically, the 42 included studies covered 20 provinces (58.8%) of all 34 provinces in China, with 13 studies conducted in Yunnan Province [17, 18, 21–23, 27, 31, 35, 38, 39, 51, 56, 58] and 7 studies in Guangxi Province [19, 34, 36, 41, 42, 44, 51]. The sample size varied from 28 to 48,931. Most studies were cross-sectional (83.3%, 35/42) [17, 19–22, 25–30, 32–45, 47–55, 58]. The majority of studies were conducted among general PDWH (27/42, 64.3%) [18, 20, 22, 26, 27, 29, 32–52, 54], 11 (23.8%) among men who have sex with men (MSM) [19, 23–25, 28, 30, 31, 52, 55–57], 3 (7.1%) among pregnant women [17, 21, 58], and one (2.4%) among blood transfusion recipients [53]. In most studies (85.7%) [19, 20, 22–33, 35–47, 49–56, 58], the outcomes of CHT uptake and HIV infection were recorded by a CDC staff member when PDWH couples underwent HIV testing in a CDC. Reported outcome variables included uptake of CHT (23 studies) [17–21, 24, 25, 27–31, 33, 34, 39, 40, 44, 46–48, 55, 57, 58] and HIV prevalence among CHT (38 studies) [17, 20–43, 45, 47–58]. The quality of each study was evaluated in detail (S2 Table). Most studies were assessed as high quality (38/42, 90.5%) [17–34, 36–38, 41–43, 45–58].
Uptake of CHT
The pooled proportion for the uptake of CHT among Chinese PDWH was 65% (95% CI: 57%–73%). Significant heterogeneity was observed between individual studies included in the analysis (I2 = 99.6%, P < 0.001) (Fig 2).
HIV prevalence among PDWH couples
Among Chinese PDWH couples, the pooled HIV prevalence was 28% (95%CI: 24%–32%) (Fig 3). Significant heterogeneity, observed between individual studies, was included in the analysis (I2 = 99.1%, P < 0.001).
Subgroup analysis
The subgroup analyses are shown in Table 2. The pooled uptake rate of CHT among pregnant women (76%, 95%CI: 66%–86%) was higher than that of MSM (49%, 95%CI: 30%–68%). Of the eight studies among MSM participants, three reported that their sexual partners were their spouses (legally married women). The uptake rate of CHT among PDWH couples (49%, 95%CI: 27%–70%) was similar to that among spouses (50%, 95%CI: 17%–83%). The CHT uptake rate in Yunnan province (69%, 95%CI: 59%–80%) was slightly higher than that in Guangxi province (65%, 95%CI: 49%–81%) (Table 2).
Subgroup analysis of HIV seroprevalence among CHT showed that the pooled prevalence among couples with HIV-infected pregnant women (53%, 95%CI: 27%–78%) was higher than that among couples of MSM (14%,95%CI: 10%–17%). Of the studies among MSM participants, two studies reported that their sexual partners were specifically their spouses. If these two studies were excluded, the pooled HIV prevalence was 13% (95% CI: 2%–24%) with moderate heterogeneity (I2 = 40.7%, P = 0.106) (Table 2). The pooled HIV prevalence in Guangxi province (35%, 95%CI: 32%–39%) was slightly higher than that in Yunnan province (33%, 95%CI: 25%–42%), with moderate heterogeneity (I2 = 49.2%, P = 0.116).
Publication bias
For the meta-analyses of CHT uptake rate and HIV prevalence among partners of PDWH, both Egger’s (t = -1.74, P = 0.097; t = 0.91, P = 0.369) tests found no statistically significant difference, which indicates that there was no publication bias. However, results from the funnel plot of CHT uptake rate among PDWH couples showed that there might be missing studies at the bottom right of the graph (Fig 4), while results from the funnel plot of HIV prevalence among PDWH couples indicated that there might be missing studies from the bottom left of the graph (Fig 5).
Discussion
This meta-analysis provided pooled estimates of the uptake rate of CHT and HIV prevalence among Chinese PDWH couples, and presented the data according to study population, type of couple, and province. The CHT uptake rate was 65% among PDWH in China and 49% among couples of HIV-infected MSM. The results suggested that there were gaps in HIV testing among discordant sexual partners. The meta-analysis showed a pooled HIV prevalence of 28% among the PDWH couples in China. Our results highlighted the long-way PDWH couples have to go in order to achieve the Chinese government’s goal to reduce HIV transmission rates between discordant spouses to below 1% by 2030 [11].
In the WHO guidelines for the “Partner Notification Policy,” partner notification relied on the PDWH themselves to notify their sexual partners and receive CHT services [59]. While, taking HIV voluntary counseling and testing is voluntary for PDWH couples across most of China [60], partner notification in the four provinces of Yunnan, Henan, Zhejiang, and Gansu is mandatory among serodiscordant spouses [60]. The WHO guidelines also recommended the promotion of CHT by advocating HIV self-testing (HIVST) among high-risk populations and PDWH couples [59]. Few studies have shown the effectiveness of improved CHT uptake through the distribution of HIVST kits to sexual partners by antenatal and postpartum women [61]. The Chinese government also encouraged the implementation of HIVST and integrated it into routine HIV testing services [11]. However, there is no evidence based on rigorously designed studies that have explored the effects of HIVST on CHT uptake among PDWH in China.
CHT uptake rate is reasonably high among pregnant women study participants (76%), where the purpose may have been the prevention of mother-to-child transmission [62]. The uptake rate was only 49% among HIV-infected MSM study participants. HIV-infected Chinese MSM may have a low rate of disclosure to their sexual partners because of the high levels of stigma and discrimination [59]. In addition, married MSM may have been concerned about the negative consequences of disclosing their sexual orientation to their female spouses [19]. These may have also led to a low CHT uptake. The CHT uptake in Guangxi province (65%) was similar to the pooled CHT uptake rate, but slightly lower than that in Yunnan province (69%). This may be due to the mandatory CHT policy among serodiscordant spouses in Yunnan province [60].
The pooled HIV prevalence in CHT was 28%, which is much higher than that among key populations in China, including MSM, injecting drug users, and sex workers [63, 64]. It is suggested that promoting CHT could be an efficient strategy to identify new infections. HIV prevalence among couples of infected pregnant women (53%) was 3.79 times higher than that among couples of infected MSM (14%). Pregnant women are not typically regarded as a high-risk population and consistent condom use is low with their partners. A recent study showed that 69% of pregnant women and their couples reported inconsistent condom use [65]. HIV prevalence rates among couples and spouses of MSM were similar. The implication may be that the wives of MSM could also be a high-risk population for HIV infection, since up to 70% of Chinese MSM would get married with women under the “filial piety” culture belief [66]. HIV prevalence rates among CHT in Yunnan (33%) and Guangzi (35%) provinces were similar, but much higher than the pooled HIV prevalence (28%). The main reason may be that both provinces have the highest HIV prevalence in China [67].
Limitations
This meta-analysis had several limitations. First, selection bias could not be ruled out because the languages of the included studies were limited to English and Chinese. Second, information bias was likely to have existed because 14.3% of outcomes were evaluated by the participants’ self-reporting. Third, the heterogeneity across the included studies was high, which may account for publication bias and limit generalizability of the findings. The main reasons might be that samples were recruited from 20 provinces with diverse HIV prevalence and partner notification policies. In addition, some studies had small sample sizes, which might also contribute to the heterogeneity.
Conclusions
Two-thirds of Chinese couples living with HIV have had an HIV test, of which 28% were positive. Couples of MSM had a lower HIV testing rate, which indicates that more effective strategies need to be carried out to improve couples’ HIV testing among the Chinese MSM population.
Supporting information
S2 Table. Assessment of methodological quality of cross-sectional studies.
https://doi.org/10.1371/journal.pone.0247754.s002
(DOC)
References
- 1.
UNAIDS. Global HIV & AIDS statistics-2019 fact sheet; 2019 [Cited 2020 February 26]. https://www.unaids.org/en/resources/fact-sheet
- 2.
UNAIDS. UNAIDS Data 2019; 2019 [Cited 2020 February 26]. https://www.unaids.org/en/resources/documents/2019/2019-UNAIDS-data
- 3.
General Office of the State Council of China. Notification on the prevention and treatment of AIDS in China; 2017 [Cited 2020 February 26]. http://www.gov.cn/zhengce/content/2017-02/05/content_5165514.htm
- 4.
UNAIDS. 90-90-90—An ambitious treatment target to help end the AIDS epidemic; 2017 [Cited 2020 February 26]. https://www.unaids.org/en/resources/documents/2017/90-90-90.
- 5.
WHO. Guidance on couples HIV testing and counselling including antiretroviral therapy for treatment and prevention in serodiscordant couples: recommendations for a public health approach. Geneva: World Health Organization; 2012.
- 6. Hailemariam TG, Nathan S, Seifu CN, Rawstorne P. Uptake of couples HIV testing and counselling among heterosexual couples in Sub-Saharan Africa: a systematic review and meta-analysis. AIDS care. 2020;32(2):137–47. pmid:31116028
- 7. Loubiere S, Peretti-Watel P, Boyer S, Blanche J, Abega SC, Spire B. HIV disclosure and unsafe sex among HIV-infected women in Cameroon: results from the ANRS-EVAL study. Soc Sci Med. 2009;69(6):885–91. pmid:19560244
- 8. Allen S, Karita E, Chomba E, Roth DL, Telfair J, Zulu I, et al. Promotion of couples’ voluntary counselling and testing for HIV through influential networks in two African capital cities. BMC Public Health. 2007;7:349. pmid:18072974
- 9. Allen S, Meinzen-Derr J, Kautzman M, Zulu I, Trask S, Fideli U, et al. Sexual behavior of HIV discordant couples after HIV counseling and testing. AIDS. 2003;17(5):733–40. pmid:12646797
- 10. Anglemyer A, Rutherford GW, Horvath T, Baggaley RC, Egger M, Siegfried N. Antiretroviral therapy for prevention of HIV transmission in HIV-discordant couples. Cochrane Database Syst Rev. 2013(4):CD009153. pmid:23633367
- 11.
General Office of the State Council of China. The "13th Five-year Plan" on HIV prevention and control in China; 2017 [Cited 2020 February 26]. http://www.gov.cn/zhengce/content/2017-02/05/content_5165514.htm
- 12. Moher D, Liberati A, Tetzlaff J, Altman DG. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. PLoS Med. 2009;6(7):e1000097. pmid:19621072
- 13.
The Joanna Briggs Institute. Joanna Briggs Institute Reviewers’ Manual: 2016 edition. Australia: The Joanna Briggs Institute; 2016.
- 14. Barendregt JJ, Doi SA, Lee YY, Norman RE, Vos T. Meta-analysis of prevalence. J Epidemiol Community Health. 2013;67(11):974–8. pmid:23963506
- 15. Nyaga VN, Arbyn M, Aerts M. Metaprop: a Stata command to perform meta-analysis of binomial data. Arch Public Health. 2014;72(1):39. pmid:25810908
- 16. Egger M, Davey Smith G, Schneider M, Minder C. Bias in meta-analysis detected by a simple, graphical test. BMJ. 1997;315(7109):629–34. pmid:9310563
- 17. Zheng M, Guo G, Zheng J, Zhang Y, Zhou D, Zhou L. Analysis of HIV testing and associate factors among 5086 spouses of HIV infected pregnant women in Yunnan Province. Soft Science of Health. 2019;33(06):93–7. [In Chinese]
- 18. Yu H, Han Y, Shi Y, Huo JL, Zhang XB, Yang YC, et al. Case-control study of the correlation of partner notification and HVI testing with seroconversion of spouses among human immunodeficiency virus sero-discordant couples. Chin J AIDS STD. 2017;23(10):898–900+8.
- 19. Lan G, Liang N. High risk behaviors of MSM group living with HIV/AIDS and influencing factors of partners to receive HIV testing. J Applied Prev Med. 2017;23(05):355–8. [In Chinese]
- 20. Zhao W, Wang Y, Chen Y, Liu Y. Analysis on HIV testing and HIV infected situation among HIV infected spouses in Jiangdu District, Yangzhou. Henan J Prev Med. 2017;28(01):34–5+7.
- 21. Wang X, Wang A, Wang F, Qiao YP, Wang Q, Dou LX, et al. Partner’s HIV testing and influence factors of HIV infected maternities in some high prevalence areas of China. Chin J AIDS STD. 2015;21(06):493–6+522.
- 22. Bai X, Liu H, Wang D, Ma Y, Luo QY, Zheng L, et al. Analysis on influencing factors of HIV testing and rate of HIV infections among couples of people who living with HIV. J Dermatology and Venereology. 2016;38(03):193–5. [In Chinese]
- 23.
Li Q. Feasibility study on mobilizing sex partners of HIV-positive men for HIV testing. Thesis, Kunming Medical University; 2016. https://kns.cnki.net/KCMS/detail/detail.aspx?dbcode=CMFD&dbname=CMFD201701&filename=1016295934.nh&v=MjM4MTJGeXJsVTd2S1ZGMjZHTEd4RzlqUHE1RWJQSVI4ZVgxTHV4WVM3RGgxVDNxVHJXTTFGckNVUjdxZlplUnY=
- 24.
Li J. A randomized trial of improving partner notification with assisted partner notification services among HIV positive MSM. Thesis, Chinese Medical Sciences University. 2019. https://kns.cnki.net/KCMS/detail/detail.aspx?dbcode=CMFD&dbname=CMFDTEMP&filename=1019891871.nh&v=MTE5Njg3RGgxVDNxVHJXTTFGckNVUjdxZlplUnZGeXJsVnIzQVZGMjZGN3V4SDluTHJwRWJQSVI4ZVgxTHV4WVM=
- 25. Chen L, Luo M, Wang H, Zhou X, Jiang TT, Chen WJ, et al. Characteristics of HIV testing and HIV infections status among 138 sexual partners of HIV positive MSM in Zhejiang. Chin J AIDS STD. 2019;25(05):464–7.
- 26. Xu Z, Wang Z, Li C. Analysis of HIV antibody test results in 232 HIV/AIDS and their spouses or fixed sex partners. Zhongguo Wei Sheng Jian Yan. 2013;23(05):1245–7.
- 27. Xu L, Bao W, Deng L, Qin L, Liu LM, Mao BB, et al. Factors Influencing HIV Testing of spouse/regular sexual partners of HIV/AIDS In Qujing City from 1995 to 2013. Chin J Derm Venereol. 2014;28(10):1040–2.
- 28. Wang C, Rong Y. Follow-up analysis of HIV infected men who have sex with men in Guangling district, Yangzhou from 2010 to 2016. Jiangsu J Prev Med. 2018;29(5):520–1. [In Chinese]
- 29. Lian Q, Zhang M, Liu M, Wu SB, Chen L. HIV detection and its influencing factors among spouses of newly registered HIV/AIDS patients in Fujian province. Chin J Public Health. 2019;35(11):1579–84.
- 30. Da Q, Peng G, Tang H, Zheng W. Marital status and spouse’s HIV detection of HIV positive men who have sex with men in Hubei. Chin Trop Med. 2019;19(06):538–41
- 31. Li Y, Zhang R, Wang Y, Li Q, Li ZQ, Wang L, et al. Feasibility of their sex partners accepting HIV antibody tests mobilized by MSM infected with HIV. Chin J AIDS STD. 2016;22(11):883–6.
- 32. Liu Y. Analysis on HIV testing and influencing factors among couples of HIV infections in Linfen City. Chinese Remedies & Clinics. 2018;18(02):282–4. [In Chinese]
- 33. Wang M, Sun Y, Li L, Chen CY, Lai XH, Chen JH, et al. Analysis of the HIV antibody test and the follow up of the spouse of 213 HIV/AIDS in Zhongshan City. Chin J AIDS STD. 2015;21(09):766–9.
- 34.
Hu L. Serostatus disclosure and associated factors among people living with HIV/AIDS (PLWHA) in Liuzhou City, China. Thesis, Anhui Medical University; 2014. https://kns.cnki.net/KCMS/detail/detail.aspx?dbcode=CMFD&dbname=CMFD201402&filename=1014320182.nh&v=MTIxMTRyblZMdkJWRjI2R3JDNkh0REVyWkViUElSOGVYMUx1eFlTN0RoMVQzcVRyV00xRnJDVVI3cWZaZVJ2Rnk=
- 35. Zhu R, Xiang X. Analysis on HIV testing among 196 couples of HIV infections. Health World. 2010;04(2):69. [In Chinese]
- 36. Zhong J, Pan Y, Chen Y. Survey on the status of HIV /AIDS patients’ spouses / fixed partners with HIV infection. J Med Pest Control. 2016;32(12):1358–60.
- 37. Chen H, Ma G, Chen D. HIV infection and influencing factors in spouses of HIV/AIDS. Prev Med. 2018;30(7):658–61,66.
- 38. Duan S, Xiang L, Huang S, Wu QB, Liu WH, Li ZR, et al. Analysis on voluntary couples HIV testing of HIV infected patients. Chin J AIDS STD. 2004(01):62. [In Chinese]
- 39. Xi J, Sun X, Su J, Hou WJ, Zhang JX. Situational investigation in HIV status among partners of people with HIV/AIDS. Soft Science of Health. 2009;23(02):232–3.
- 40. Xu P, Liu K, Lv F. Analysis on status quo of spousal notification of HIV infectors. Chinese Journal of Health Policy. 2011(10):55–9.
- 41. Zhu Q, Liu W, Zhu J, Zheng WB. Survey on people lived with HIV / AIDS and their spouses. J Prev Med Inf. 2014;30(9):700–3.
- 42. Chen J, Liao J, Nong H, Liang X. Change trend and influencing factors of HIV infection among the spouses of HIV/AIDS patients in Baise. The Journal of Practical Medicine. 2018;34(15):2548–51.
- 43. Chen L, Zhang M, Lin X, Yan YS. HIV infection among couples and regular sexual partners of HIV / AIDS patients in Fujian province. Chin J Public Health. 2015;31(12):1536–8.
- 44. Nong L, He B, Tang H, Cen P, Lin Q, Li SS, et al. Referral service model and its effect evaluation among HIV/AIDS patients in Nanning city, Guangxi. Pract Prey Med. 2019;26(8):919–23.
- 45. Yang Q, Hu Q, Zhang S. Analysis on HIV infections and influencing factors among couples of HIV infections in Jiangxi Province. Applied Prev Med. 2018;24(4):273–5. [In Chinese]
- 46. Yang R, Yan Y, Gong X. Evaluation on the implementation of HIV/AIDS self-health management program in Ganzhou city, Jiangxi province. Guo Ji Bing Du Xue Za Zhi. 2019;26(5):341–4.
- 47. Wang C, Zhang R. Survey of infectious status of HIV in couples in Caoxian County. CHINA TROPICAL Med. 2008;8(12):2201,13.
- 48. Zhang Y, Yin F, Zhong P, He N. Practice and correlates of partner notification of HlV infection status among 307 HIV-Infected individuals of Shanghai. Chin J Prev Med. 2015;49(11):956–61.
- 49. Zeng G, Chen H, Li C, Zhang JH, A LLQ, Ku YH, et al. Survey on HIV-infection of spouses of HIV infected persons in Liangshan, Sichuan province. Disease Surveillance. 2010;25(6):461–3.
- 50. Zhang M, Wang Y, Lu Y, Ma L, He Z, Rui BL, et al. Survey of HIV Infection among HIV Positive Couples in Urumqi. Medical Information. 2013(17):58–9.
- 51. Li J, Tang H, Han J, Xu J, Shen ZY, Lai WH, et al. HIV transmission in newly reported HIV infected couples before diagnoses in five provinces. China, 2011–2014. Chin J Epidemiol. 2016;37(11):1497–502.
- 52. Lian Y, Zhao Y, Wang J, Cynthia S, Kerong W, Xia W, et al. A health communication intervention to integrate partner testing with antiretroviral therapy service among men who have sex with men in China: an observational cohort study. BMC Public Health. 2018;18.
- 53. Chen S, Lu X, Bai G, Zhang YQ, Li BJ, Wang W, et al. Twenty-seven year surveillance of blood transfusion recipients infected with HIV-1 in Hebei Province, China. Plos One. 2018;13(8). pmid:30110373
- 54. Lin H, Fei J, Wu Q, Qiu DH, Gao MY, He N. Risk behavioral networks of newly reported HIVinfections in Taizhou prefecture, Zhejiang province. Chin J Epidemiol. 2010;31(11):1227–30.
- 55. Li J, Han J, Xu J, Tang HL, Mao YR. Status of marriage and HIV transmission between couples in newly reported HIV cases before diagnosis was made, among men who have sex with men in China, 2014. Chin J Epidemiol. 2017;38(6):750–3.
- 56. Fu X, Qi J, Hu Y, Pan XH, Li YF, Liu H, et al. Partner notification in cooperation with community-based organizations among HIV-positive men who have sex with men in two Chinese cities. Int J STD AIDS. 2016;27(10):821–31. pmid:27140946
- 57. Mi G, Wu Z, Wang X, Shi CX, Yu F, Li T, et al. Effects of a quasi-randomized web-based Intervention on risk behaviors and treatment seeking among HIV-positive men who have sex with men in Chengdu, China. Curr HIV Res. 2015;13(6):490–6. pmid:26105555
- 58. Qiu XR, Zhou CD, Du J. Transmission mode of HIV /AIDS and spouse infection among 28 HIV positive pregnant women. Maternal and Child Health Care of China. 2009;24(31):4365–6.
- 59.
WHO. Guidelines on HIV Self-Testing and Partner Notification: Supplement to Consolidated Guidelines on HIV Testing Services. Geneva: World Health Organization; 2016.
- 60. He HJ, Xu P, Xin QQ, Zeng J, Zhang LL, Sun DY, et al. Study on spousal notification in HIV discordant couples and associated factors in four provinces of China. Chin J Epidemiol. 2015;36(6):565–8.
- 61. Masters SH, Agot K, Obonyo B, Napierala MS, Maman S, Thirumurthy H. Promoting Partner Testing and Couples Testing through Secondary Distribution of HIV Self-Tests: A Randomized Clinical Trial. PLoS Med. 2016;13(11):e1002166. pmid:27824882
- 62. Farquhar C, Kiarie JN, Richardson BA, Kabura MN, John FN, Nduati RW, et al. Antenatal couple counseling increases uptake of interventions to prevent HIV-1 transmission. J Acquir Immune Defic Syndr. 2004;37(5):1620–6. pmid:15577420
- 63. Zhang Z, Li J, Chen LJ, Xu XH, W YL, Xu YY, et al. Characteristics of heterosexual behaviors and associated factors in men who have sex with men in Taizhou, Zhejiang,2018. Disease Surveillance. 2019;34(11):1017–21.
- 64. Hao Y, Cui Y, Sun XH, Guo W, Xia G, Ding ZW, et al. A retrospective study of HIV /AIDS situation: a ten-year implementation of “four frees and one care”policy in China. Chinese journal of disease control & prevention. 2014;18(5):369–74.
- 65. Hatcher AM, Darbes L, Kwena Z, Musoke PL, Rogers AJ, Owino G, et al. Pathways for HIV Prevention Behaviors Following a Home-Based Couples Intervention for Pregnant Women and Male Partners in Kenya. AIDS Behav. 2020;24(7):2091–2100. pmid:31894444
- 66. Zhang BC, Li XF, Shi TX, Yang LG, Zhang JD. Preliminary estimates of the gay/bisexual population and HIV prevalence in China. Chin J AIDS STD. 2002;(04):197–9.
- 67. Ding QY, Yang Z, Zhou QY. Spatial changes of AIDS epidemic and population mobility in China. Tropical Geography. 2017; 37(4):538–546.
