HIV prevalence in China: integration of surveillance data and a systematic review

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1 HIV prevalence in China: integration of surveillance data and a systematic review Lei Zhang, Eric P F Chow, Jun Jing, Xun Zhuang, Xiaoshan Li, Meiqi He, Huamin Sun, Xiaoyan Li, Marelize Gorgens, David Wilson, Lan Wang, Wei Guo, Dongming Li, Yan Cui, Lu Wang, Ning Wang, Zunyou Wu*, David P Wilson* Summary Background Asian HIV epidemics are concentrated among particular behavioural groups, but large variations exist in epidemic types, timing, and geographical spread between countries and within countries, especially in China. We aimed to understand the complexity of HIV epidemics in China by systematically analysing prevalence trends by data source, region, population group, and time period. Methods We collected HIV prevalence data from official national sentinel surveillance sites at the provincial level from Jan 1, 199, to Dec 31, 21. We also searched PubMed, VIP Chinese Journal Database (VIP), China National Knowledge Infrastructure, and Wanfang Data from Jan 1, 199, to Dec 31, 212, for independent studies of HIV prevalence. We integrated both sets of data, and used an intraclass correlation coefficient test to assess the similarity of geographical pattern of HIV disease burden across 31 Chinese provinces in 21. We investigated prevalence trends (and 9% CIs) to infer corresponding incidence by region, population group, and year. Findings Of 68 articles identified by the search strategy, 821 studies ( drug users, 2 36 injecting drug users, female sex workers, and men who have sex with men) met the inclusion criteria. Official surveillance data and findings from independent studies showed a very similar geographical distribution and magnitude of HIV epidemics across China. We noted that HIV epidemics among injecting drug users are decreasing in all regions outside southwest China and have stabilised at a high level in northwest China. Compared with injecting drug users, HIV prevalence in female sex workers is much lower and has stabilised at low levels in all regions except in the southwest. In 21, national HIV prevalence was 9 8% (9% CI ) in injecting drug users and 36% ( 12 71) in female sex workers, whereas incidence in both populations stabilised at rates of 7 ( 43 72) and 2 ( 1 4) per 1 person-years, respectively. By comparison, HIV prevalence in men who have sex with men increased from 1 77% ( ) in 2, to 98% ( ) in 21, with a national incidence of 98 ( 7 1 2) per 1 person-years in 21. We recorded strong associations between HIV prevalence among at-risk populations in each province, supporting the existence of overlap in risk behaviours and mixing among these populations. Interpretation HIV epidemics in China remain concentrated in injecting drug users, female sex workers, and men who have sex with men. HIV prevalence is especially high in southwest China. Sex between men has clearly become the main route of HIV transmission. Funding The World Bank Group, the Australian Research Council, the University of New South Wales, and Chinese Center for Disease Control and Prevention. Introduction Asia is the second most HIV-affected region worldwide, with an estimated 4 8 million people living with HIV in HIV epidemics in Asia tend to be concentrated among members of groups at high risk of acquiring or spreading HIV such as female sex workers and their clients, injecting drug users, and men who have sex with men. However, the Asian epidemic does not pertain to just one group or one mode of transmission. Distribution of transmission modes, temporal trends, and geographical spread vary between countries and within countries, especially in China where five of the country s 31 provinces account for almost all HIV diagnoses. 1 4 To respond most appropriately, the complexity of HIV epidemics in China has to be understood. Many meta-analyses have been done to investigate HIV epidemic trends and patterns of risk behaviours in these most at-risk populations. 16 However, these analyses have been based on published independent studies and have included few official surveillance data, especially at the national level. China s HIV surveillance consists of two components: 4,17,18 hospital-based or clinic-based surveillance includes the reporting of HIV diagnoses in patients seeking health care, and sentinel surveillance monitors HIV epidemic trends through venue-based sampling for particular populations deemed to be at increased risk. China has more than 18 sentinel sites (appendix shows the geographical distribution of these sites). Drug users (including injecting drug users), female sex workers, and men who have sex with men are the most at-risk populations covered by the sentinel surveillance.,17,19,2 China s web-based HIV reporting system, established in Lancet Infect Dis 213; 13: 9 63 Published Online October 7, S (13)724-7 See Comment page 912 *These authors contributed equally to the supervision of the study The Kirby Institute, University of New South Wales, Sydney, NSW, Australia (L Zhang PhD, E P F Chow MPH, D P Wilson PhD); Comprehensive AIDS Research Center, Tsinghua University, Beijing, China (Prof J Jing PhD, L Zhang); School of Public Health, Nantong University, Jiangsu Province, China (Prof X Zhuang PhD, Xs Li BMed, M He BMed, H Sun BMed, Xy Li BMed); Global HIV/AIDS Program, The World Bank Group, Washington, DC, USA (M Gorgens MPH, D Wilson PhD); and National Center for AIDS/STD Control and Prevention, Chinese Center for Disease Control and Prevention, Beijing, China (L Wang PhD, W Guo PhD, D Li PhD, Y Cui MD, L Wang PhD, Prof N Wang PhD, Prof Z Wu PhD) Correspondence to: Prof Zunyou Wu, National Centre for AIDS/STD Control and Prevention, Chinese Centre for Disease Control and Prevention, Changping District, Beijing 1226, China wuzunyou@chinaaids.cn or Dr Lei Zhang, The Kirby Institute, The University of New South Wales, Sydney, NSW 22, Australia lzhang@kirby.unsw.edu.au See Online for appendix Vol 13 November 213 9

2 2, integrates information from both surveillance systems. 4,21,22 These official surveillance data are reported in summary form in jurisdictional and national reports by the Chinese Ministry of Health. Independent of the Chinese Ministry of Health, many health and research institutions undertake studies of the Chinese HIV epidemic; publications based on these studies are not integrated into the surveillance system. We integrated official sentinel surveillance data and that from independent studies published between 199 and 21, and specifically aimed to investigate prevalence trends by data source, region, population group, and time period; assessed the potential links between HIV epidemics in the most at-risk populations; and estimated HIV incidence trends in these groups. Methods Search strategy and selection criteria We collected HIV prevalence data from sentinel surveillance sites at the provincial level, which were provided by the National Center for AIDS/STD Control and Prevention (NCAIDS), Chinese Center for Disease Control and Prevention (China CDC), for Jan 1, 199, to Dec 31, 21. No ethical approval was needed for this systematic review because all data are secondary summary data. We did a systematic review of published peer-reviewed research articles of HIV prevalence by searching PubMed, VIP Chinese Journal Database, China National Knowledge Infrastructure, and Wanfang Data, from Jan 1, 199, to Dec 31, 212. We also did a manual search on relevant reference lists of published articles. We used a combination of Medical Subject Headings headings and free text terms in our search strategy (appendix). All types of quantitative epidemiological studies (including cohort, before-andafter, and cross-sectional) were eligible in this study. We included studies if they investigated at least one of the priority populations (drug users injecting drug users, men who have sex with men, or female sex workers) in mainland China. Studies had to report the number of HIV infections, the number of participants who had been tested, study period, and province. Additionally, the HIV infection had to be clinically diagnosed and confirmed with serological tests. We excluded studies if they were a review, non-peer-reviewed local or government report, conference abstract or presentation, or master or doctoral theses; the HIV diagnoses were based on questionnaire (ie, self-reported) or a non-serological sample (ie, saliva and urine); diagnoses were done in Hong Kong Special Administrative Region, Macau Special Administrative Region, and Taiwan; and they were in the national HIV/ AIDS sentinel surveillance data. We limited the language of the studies to English and Chinese. Statistical analysis HIV prevalence from both sentinel surveillance and independent studies were compared on geographical maps of China. We compared HIV prevalence in 21 when the data from both sources were most complete. For independent studies, prevalence data in 21 for each individual province were pooled to estimate an arithmetic mean with 9% CI on the basis of a binomial distribution assumption on the data. In the absence of 21 data, the last three most recently available datapoints were used to estimate the provincial prevalence in 21. HIV epidemics in at-risk groups in a province were assumed to be homogenous. We assessed how similar the geographical pattern of HIV disease burden was across the 31 Chinese provinces reported by sentinel surveillance and independent studies by intraclass correlation coefficient tests for continuous outcomes. Intraclass correlation coefficients less than 4 suggest low reproducibility of two patterns, between 4 7 medium reproducibility, and more than 7 high reproducibility. 23 All data were elicited and collated into an integrated database. We used the software package Spectrum/Estimation and Projection Package (EPP) 211 to produce best-fitting (and 9% CIs) prevalence trajectories and corresponding estimated incidence. We used EPP to fit a four-parameter epidemiological model to the collected HIV prevalence data from sentinel sites and independent studies, and calibrated with a maximum likelihood method. Prevalence data were fitted with a variable R model, which weights individual prevalence datapoints based on their sample sizes. Studies with large sample sizes were given proportionally increased weights. We used Bayesian melding to generate multiple simulations that provided CIs for the prevalence data. Corresponding incidence were estimated for each at-risk population on the basis of the trend in the calibrated HIV prevalence curves. Role of the funding source The sponsor of the study had no role in study design, data collection, or data analysis, but did provide input into the interpretation and presentation of results. The authors had full access to all the data in the study and had the final responsibility for the decision to submit for publication. Results drug users (including 313 injecting drug users), female sex workers, and 87 2 men who have sex with men were sampled from 29, 14, and 13 national sentinel sites during this period, respectively. 68 articles were identified through our search strategy and were screened for eligibility. After exclusion criteria were applied (appendix), 821 independent published studies were chosen to provide HIV prevalence data for (appendix). These studies represent drug users screened through 48 sites that were reported in 329 independent studies, 2 36 injecting drug users screened through 16 sites reported in 87 studies, female sex workers screened through 369 sites reported in 28 studies, and men who have sex with men screened through 219 sites reported 96 Vol 13 November 213

3 Articles A Sentinel Surveillance data 2 Sentinel Surveillance data 21 Independent studies data 21 >3% % 1 2 % 1 1 % 1 1 % 1 1 % 1 1 % 1 % < 1% No data North Northwest Southwest Vol 13 November B South-central Northeast East 2 21 Figure 1: HIV prevalence among the high-risk populations in 31 Chinese provinces (A) and six geographical regions (B) Data presented are based on the 2 and 21 sentinel surveillance and 21 independent studies (A); and on the combined data from both sentinel surveillance and independent studies in 2 and 21 (B). =drug users. =injecting drug users. =men who have sex with men. =female sex workers. 97

4 HIV prevalence (%) Drug users East North Northeast Northwest South-central Southwest National HIV incidence (per 1 person-years) Injecting drug users HIV prevalence (%) HIV incidence (per 1 person-years) 1 Men who have sex with men 4 HIV prevalence (%) 1 HIV incidence (per 1 person-years) Female sex workers 4 HIV prevalence (%) Year HIV incidence (per 1 person-years) Year Figure 2: Geographical and temporal trends of estimated HIV prevalence and calculated incidence in,,, and, 2 1 The trends were calibrated and estimated with Spectrum/EPP 211 on the basis of combined data from both sentinel surveillance and independent studies. =drug users. =injecting drug users. =men who have sex with men. =female sex workers Vol 13 November 213

5 in 1 studies (appendix). The appendix shows the geographical information of the sites from these studies. Data from both official surveillance and independent studies suggest a high degree of resemblance with regards to spatial distribution and magnitude of HIV prevalence by population groups across China (intraclass correlation coefficient 7, 9% CI 4 87 for men who have sex with men; 72, 49 8 for female sex workers; 77, 89 for drug users; 84, 2 9 for injecting drug users; figure 1A). The data clearly show geographical differences in HIV epidemics across China. Southwest and northwest China are the most HIV-affected regions across the at-risk groups (figure 1B) with substantially greater prevalence in the provinces of Yunnan, Sichuan, Guangxi, Guizhou, Guangdong, and Xinjiang than in other regions of China (appendix). In China, HIV has historically been most prevalent in drug users than other HIV at-risk populations. Unsurprisingly, HIV is more prevalent among people who inject drugs than in all other drug users. We estimate that in 21, HIV prevalence in people who injected drugs was 14 61% (9% CI ) in the southwest, 13 6% ( ) in the northwest, and 6 29% ( ) in south-central China (figures 1B and 2). Trends suggest that HIV epidemics among injecting drug users are low, stable, or are falling in all regions outside the southwest (figures 1B and 2). However, the national HIV prevalence in injecting drug users is still high, and increased from 82% ( ) in 199, to 1 6% ( ) in 22, and then slightly decreased to 9 8% ( ) in 21 (figure 2). We estimate that the national incidence of HIV in injecting drug users in 21 was 7 (9% CI 43 72) per 1 person-years (figure 2), corresponding to 77 new cases per year given that the population size of injecting drug users was 1 3 million in HIV incidence has stabilised among injecting drug users across all geographical regions since 2, probably because of the large roll-out of harm-reduction programmes countrywide since Data suggest that HIV prevalence in female sex workers in China has remained low. HIV prevalence in female sex workers has remained stable or decreased in all regions, but prevalence was greater in southwest China (1 7, 9% CI in 21) than the rest of China (figures 1 and 2). The national HIV prevalence in female sex workers has decreased from 46% ( 17 9) in 2, to 36% ( 12 71) in 21. We estimate that the national incidence of HIV in female sex workers is decreasing and was 2 (9% CI 1 4) per 1 person-years in 21 (figure 2), corresponding to new cases per year given that the population size of female sex workers was million. 24 HIV epidemics among men who have sex with men started more recently than did epidemics among injecting drug users and female sex workers. This occurrence of delayed epidemics among men who have sex with men is common. 26,27 However, HIV is now spreading at an alarming rate with substantial increases in prevalence in this population across all regions of China (figures 1 Estimated HIV prevalence in in 21 (%) Estimated HIV prevalence in in 21 (%) Estimated HIV prevalence in in 21 (%) A 1 East Northeast South-central North GZ Northwest CQ GS 1 Southwest JS SH ZJ GD SC SN QH HA BJ LN FJ HB HN SX TJ JX JL NX HE AH NM HI HL GX SD B JL 1 1 C 1 1 GS HL JL Estimated HIV prevalence in in 21 (%) Spearman r= 632, p< 1 ZJ BJ NX HB FJ GD JS HN HA SN QH SD SH LN SX HI HE JX AH NM GS HL Spearman r= 32, p= Estimated HIV prevalence in in 21 (%) YN XJ Spearman r= 371, p= Estimated HIV prevalence in in 21 (%) QH SN HA CQ JS SH ZJ LN GD SX FJ BJ JX XZ HB HE HN NX NM HI TJ AH SD GZ SC XJ GX YN GZ SC TJ CQ GX YN XJ Figure 3: Correlations between HIV prevalence among the high risk populations in 21 The significance of correlations was assessed by Spearman s non-parametric correlation tests. =drug users. =injecting drug users. =men who have sex with men. =female sex workers. AH=Anhui; BJ=Beijing; CQ=Chongqing; FJ=Fujian; GD=Guangdong; GS=Gansu; GX=Guangxi; GZ=Guizhou; HA=Henan; HB=Hubei; HE=Hebei; HI=Hainan; HL=Heilongjiang; HN=Hunan; JL=Jilin; JS=Jiangsu; JX=Jiangxi, LN=Liaoning, NM=Inner Mongolia, NX=Ningxia, QH=Qinghai, SC=Sichuan, SD=Shandong, SH=Shanghai, SN=Shaanxi, SX=Shanxi, TJ=Tianjin, XJ=Xinjiang, XZ=Tibet, YN=Yunnan, ZJ=Zhejiang. Vol 13 November

6 and 2). Increases have been especially rapid in urban centres such as Chongqing and Chengdu (southwest), Shanghai (east), and Beijing and Tianjin (north) (appendix). National prevalence is estimated to have increased from 1 77% ( ) in 2, to 3 % ( ) in 2, and then to 98% ( ) in 21 (figure 2). Southwest and northwest China are the two most affected regions, where HIV prevalence reached 1 21% ( ) and 6 49% ( ), respectively, in 21 (figure 2). Notably, HIV prevalence in men who have sex with men has exceeded prevalence in injecting drug users in 2 of 31 provinces and has exceeded HIV prevalence in female sex workers in all provinces (figure 3). In four major Chinese municipalities, Beijing, Tianjin, Shanghai, and Chongqing, HIV prevalence in men who have sex with men was greater than % in 21 (HIV prevalence in men who have sex with men in Chongqing was 13 28% in 21). Similarly, estimated HIV incidence in Chinese men who have sex with men tripled from 39 ( 21 6) in 2, to 98 ( 7 1 2) per 1 person-years in 21 nationwide, corresponding to 28 8 new cases per year given a population size of million men who have sex with men. 24 Estimated incidence of HIV in men who have sex with men was stable in southwest China at 1 2 ( ) per 1 person-years, but has increased in all other regions; the greatest incidence was in the northwest at 3 1 ( ) per 1 person-years (figure 2). HIV epidemics are interrelated across the three most at-risk populations. We recorded a strong positive association between HIV prevalence by province in each of the at-risk populations (figure 3). Provinces with high HIV prevalence among injecting drug users consistently also had higher HIV prevalence in female sex workers and men who have sex with men (figures 1A and 3). These results support the existence of concurrent risk behaviours (eg, men who have sex with men or female sex workers who also use drugs) and interaction of these groups (eg, injecting drug users who are clients of sex workers), which has facilitated HIV spread among these populations with potential for spreading to the broader population (appendix). Discussion This study provides a comprehensive overview of HIV epidemic trends in China at the national level, analysed at provincial level and, for the first time, based on integrated data from official sentinel surveillance and independent studies. We note that the epidemic is in a transitional phase marked by a rapid surge of HIV transmission in men who have sex with men in China. The reason for marked increases in the spread of HIV in this group could be the increased openness of male homosexuality in China, 28,29 which might be indicative of increased prevalence of homosexual partnerships, the high probability of transmission per act of anal intercourse, and the dynamic nature of large networks of men who have sex with men. 26,27 In view of the large population size of men who have sex with men (roughly 1 times greater than the number of drug users and female sex workers 24 ), high HIV prevalence and increasing incidence rates have resulted in homosexual exposure in this population becoming the dominant route of HIV transmission in China. 3 By comparison, the stable HIV prevalence and decreasing incidence in female sex workers might be indicative of the transient nature of female sex work, the continuing efforts of the Chinese Government in promotion of 1% condom use, and the substantial scale-up of voluntary HIV testing and counselling targeting female sex workers.,31 HIV epidemics in China continue to be concentrated among female sex workers, injecting drug users, and men who have sex with men, and not in the general population. HIV prevalence in the general Chinese population remained low at 6% in 211, 1,32 but prevalence in Chinese pregnant women was 3 6% 1 and in male clients of female sex workers was 2 7%. 33 However, serodiscordant sexual partners of the most at-risk population groups remain at risk of HIV infection. In particular, the very common bisexual nature of men who have sex with men in China suggests that female partners of men who have sex with men are at high risk of HIV acquisition. 1,11,34 Because of traditional values and family expectations, an estimated 17 3% of Chinese men who have sex with men are married, 3 38 and more than 7% will be married during their lifetime. 3,39 More than a quarter of Chinese men who have sex with men reported having sex with women in the past 6 months. 11 The proportion of men who have sex with men who disclose their sexual orientation and condom use with wives is low (at 11% and 23 3%, respectively), 11 suggesting that female partners of men who have sex with men are at high risk of HIV acquisition. An increasing trend in HIV infections in the general female population could arise in the near future. However, the HIV epidemic in China is highly concentrated; although there are an estimated 3 6 million men who have sex with men in China, this number still represents a very small proportion of the population. Historically, apart from commercial plasma collection, drug consumption has been the most important factor in the spread of HIV in China, and continues to be important. Most drug users in China inject drugs (68 9%). 14 Although only 1 % of the Chinese drug user population is female, 4 43 more than a third of female injecting drug users engage in sex work. 44 Drug users are also 2 6 times more likely to have unprotected sex when under the influence of drugs. 4 An estimated 8 3% (9% CI ) of men who have sex with men have used drugs in the past 6 months. 46 Further, roughly 2% of Chinese men who have sex with men sell sex to other men; 47 3 this group is 1 92 ( ) times more likely to use drugs than are other men who have sex with men. 1 In view of these interactions, centred around overlaps through drug use within each of these core 96 Vol 13 November 213

7 population groups, drug consumption might be important in the future of HIV transmission in China and adds to the complication of HIV intervention strategies for these overlapping populations. The know your epidemic, know your response message has been effectively implemented at large scales in many contexts for strategic HIV planning. 4 This study assessed the diverse nature and scale of HIV epidemics in China. We have shown that data from official sentinel surveillance sites are similar to those from the numerous independent studies, suggesting that the sentinel sites are sufficient for the assessment of the extent and pattern of HIV spread in China. Steady progress has been made in HIV/AIDS prevention and control in China over the past 1 years. However, challenges remain in view of the spread of HIV to new areas outside southwest and northwest China. National harm reduction programmes for injecting drug users namely, needle syringe programmes and methadone maintenance treatment have been substantially scaled up since 23, and cover an estimated 3% of injecting drug users in China. These programmes have probably reduced the incidence of HIV infection in injecting drug users. By contrast, Chinese men who have sex with men tend to have very poor access to HIV prevention services with only a few national prevention programmes targeting this population in China. These programmes are embedded as components of broader HIV prevention programmes for the most at-risk populations and do not specifically address the characteristics and behavioural patterns of men who have sex with men. The epidemiological evidence suggests that the greatest priority in China s response to HIV is prevention programmes for men who have sex with men, especially in the urban centres and five provinces of China with noticeably greatest HIV burden. Mobilisation of at-risk and affected communities is also essential in the support of prevention and treatment programmes. Antiretroviral treatment is an effective measure in reduction of transmission in serodiscordant couples in China. 6 The idea of treatment as prevention is well accepted by the Chinese Government and has important implications to HIV prevention programmes in China. The need for national and regional leadership in the HIV response comes at a time when international assistance is withdrawing. China will need to increase overall government spending on HIV and prioritise provinces with high HIV disease burden, and improve allocative efficiency to invest in programmes that will reduce the numbers of new infections on the basis of epidemiological evidence. Investigation and implementation of processes to improve technical efficiency of budget allocations to the different components of the national HIV/AIDS programme will also be useful to ensure maximum benefits at the lowest cost. Resource allocation should consider the epidemiology. Although homosexual exposure among men who have sex with men has become the dominant route of HIV transmission, the proportion of spending on HIV prevention among Chinese men who have sex with men accounts for only 6% of the total US$217 million spent on HIV prevention in By comparison, the amount of money spent on prevention is 1 times bigger among domestic migrants, 2 times among female sex workers, and 3 7 among drug users. The increasing affluence of China and the recent Chinese Ministry of Finance reform on improving the government s budgeting practices are key elements to help to achieve these outcomes. HIV programming should also be coupled with well organised monitoring and assessment activities. This study has several limitations. First, the analysis was based on the assumption that HIV epidemics within individual provinces are homogeneous and the pooled prevalence estimate is representative of the overall province. However, localised epidemics in specific locations and ethnic groups might exist. Additionally, surveillance coverage often relies on representative population groups to access health services, but disadvantaged subgroups with poor accessibility would be under-represented in sampling. Second, the Spectrum/EPP 211 package provides best fitting to HIV prevalence on the basis of a predefined function of HIV infectiousness, which might oversimplify the complex pattern of risk behaviours. The method also restricts its power in projection of future trends of epidemics. Third, China has substantially scaled up its HIV surveillance, prevention, and treatment programmes over the past decade, which might lead to changes in the demographic and behavioural characteristics of the study participants, reducing the comparability of data over time. Fewer sentinel sites in early years of the surveillance system might overestimate HIV prevalence because of sampling sites with known greater disease burden, and underestimate the epidemic growth over time. Fourth, male clients might act as an important connection between female sex workers and women in the general public. However, this population was not included in this analysis. We are in an era in which HIV responses need to consider strategic prioritisation of effective and efficient allocation of budgets. Planning should start with a projection of where HIV epidemics are progressing at subnational levels. Surveillance and projections in China can be based on the nationally coordinated provincial sentinel surveillance system. The present investment amounts and their allocation among programmes then needs to be established, and the benefits attained as a result of the investment need to be assessed. Therefore, an efficient HIV response in China will need to shift funding towards programmes that can mobilise and engage men who have sex with men in effective prevention activities. Identification of which programme investments across all Vol 13 November

8 target groups will be the most cost effective or yield the greatest return on investment can be used to examine potential gains associated with varying amounts and combinations of programmatic investment. 8,9 Contributors LZ, ZW, and DPW were responsible for study design and planning; EPFC, JJ, XZ, XsL, MH, HS, and XyL did the literature search and data input for independent studies; LW, WG, DL, YC, LW, and NW collected HIV sentinel surveillance and related data. LZ and DPW did the primary data analysis and modelling, and wrote the first draft of the report. LZ, MG, DW, WG, ZW, and DPW contributed to interpretation of results. All authors read and approved the final version of the report. Conflicts of interest We declare that we have no conflicts of interest. Acknowledgments This study was funded by the World Bank Group with support from the Australian Research Council and the University of New South Wales. The Kirby Institute is funded by the Australian Government, Department of Health and Ageing. The views expressed in this report do not necessarily represent the position of the Australian Government. The Kirby Institute is affiliated with the University of New South Wales. HIV surveillance activities were supported by China national technical support and operational research for HIV/AIDS prevention, treatment and care, with the Chinese Ministry of Health (Grant number of ). The opinions expressed herein show the collective views of the coauthors and do not necessarily represent the official position of the Chinese Ministry of Health, nor the National Center for AIDS/STD Control and Prevention, Chinese Center for Diseases Control and Prevention. References 1 Ministry of Health of the People s Republic of China. 212 China AIDS Response Progress Report. 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