Unmatched Case-Control Study on Late Presentation of HIV Infection in Santiago, Cape Verde (2004-2011)

Access to free antiretroviral therapy (ART) in Sub-Saharan Africa has been steadily increasing over the past decade. However, the success of large-scale ART programmes depends on timely diagnosis and early initiation of HIV care. 

This study characterizes late presenters to HIV care in Santiago (Cape Verde) between 2004 and 2011, and identifies factors associated with late presentation for care. We defined late presentation as persons presenting to HIV care with a CD4 count below 350 cells/mm³. An unmatched case-control study was conducted using socio-demographic and behavioural data of 368 individuals (191 cases and 177 controls) collected through an interviewer-administered questionnaire, comparing HIV patients late and early presented to care. Logistic regression was performed to estimate odds ratio and 95% confidence intervals. 

Results show that 51.9% were late presenters for HIV. No differences were found in gender distribution, marital status, or access to health services between cases and controls. Participants who undertook an HIV test by doctor indication were more likely to present late compared with those who tested for HIV by their own initiative. Also, individuals taking less time to initiate ART are more likely to present late. 

This study highlights the need to better understand reasons for late presentation to HIV care in Cape Verde. People in older age groups should be targeted in future approaches focused on late presenters to HIV care.

Full article at:   http://goo.gl/ixv7Pb

By:  Moreira AL1, Fronteira I2, Augusto GF3, Martins MR4.

• 1Ministry of Health, Palácio do Governo, Várzea-Praia C.P. 47, Santiago-Cape Verde. antonio.moreira@ms.gov.cv.
• 2Global Health and Tropical Medicine (GHTM), Institute of Hygiene and Tropical Medicine-NOVA University of Lisbon (IHMT-UNL), Rua da Junqueira 100, Lisbon 1349-008, Portugal. ifronteira@ihmt.unl.pt.
• 3Global Health and Tropical Medicine (GHTM), Institute of Hygiene and Tropical Medicine-NOVA University of Lisbon (IHMT-UNL), Rua da Junqueira 100, Lisbon 1349-008, Portugal. figueiredo.augusto@ihmt.unl.pt.
• 4Global Health and Tropical Medicine (GHTM), Institute of Hygiene and Tropical Medicine-NOVA University of Lisbon (IHMT-UNL), Rua da Junqueira 100, Lisbon 1349-008, Portugal. mrfom@ihmt.unl.pt. 
• Int J Environ Res Public Health. 2016 Mar 15;13(3). pii: E320. doi: 10.3390/ijerph13030320.

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Suboptimal HIV Testing Uptake among Men Who Engage in Commercial Sex Work with Men in Asia

PURPOSE:

Men who have sex with men and are sex workers (MSMSW) are disproportionately affected by the growing and emerging HIV epidemic. As sex work and same-sex behavior are heavily stigmatized and often illegal in most Asian countries, HIV research focusing on MSMSW has been limited. The goal of this analysis is to examine HIV testing practices and identify correlates of HIV testing among MSMSW in Asia.

METHODS:

The Asia Internet MSM Sex Survey, an online cross-sectional survey of 10,861 men who have sex with men (MSM), was conducted in 2010. Data on sociodemographic characteristics, HIV testing behaviors, and sexual behaviors were collected. Five hundred seventy-four HIV-negative/unknown respondents reported receiving payment for sex with men at least once in the past 6 months and were included for analysis. Multivariable logistic regression was conducted to identify independent correlates of HIV testing in the past year.

RESULTS:

About half (48.6%) of the participants have been tested for HIV at least once within the past year, and 30.5% have never been tested. We also found that MSMSW participants who engaged in risky behaviors were less likely to be tested.

CONCLUSION:

While one might expect a high HIV testing rate among MSMSW due to the risks associated with engaging in sex work, we found that HIV testing uptake is suboptimal among MSMSW in Asia. These results suggest that targeted HIV prevention and testing promotion among MSMSW are needed.

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By:  Jin H1, Friedman MR2, Lim SH3, Guadamuz TE4, Wei C5.

• 1 Center for Public Health Research , San Francisco Department of Public Health, San Francisco, California.
• 2 Department of Infectious Diseases and Microbiology, University of Pittsburgh Graduate School of Public Health , Pittsburgh, Pennsylvania.
• 3 Center of Excellence for Research in AIDS, University of Malaya , Kuala Lumpur, Malaysia .
• 4 Department of Society and Health, Faculty of Social Sciences and Humanities, Mahidol University , Nakorn Pathom, Thailand .
• 5 Department of Epidemiology and Biostatistics, University of California , San Francisco, San Francisco, California. 
• LGBT Health. 2016 Mar 16.

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Korean Patients Presenting with Advanced Human Immunodeficiency Virus Disease: Epidemiological Features by Age Group

We explored factors influencing presentation with advanced human immunodeficiency virus (HIV) disease by age group. Data were derived from a city-wide cross-sectional survey of 759 HIV-infected adults living in Seoul, Korea. The significance of each observed factor was assessed via multivariate logistic regression. 

Of subjects aged 20-34 years, lower educational level had a positive influence on presentation with advanced HIV disease; those recently diagnosed with HIV were more likely to be presented with advanced HIV disease. Of the subjects aged 35-49 years, those w ith advanced HIV disease were more likely to have been diagnosed during health check-ups or via clinical manifestations. Of the subjects aged ≥ 50 years, presentation with advanced HIV disease was significantly more common in older subjects and less common among individuals diagnosed with HIV in 2000-2006. 

In conclusion, a lower educational level in younger subjects and more advanced age in older subjects positively influence the presentation of advanced HIV disease.

Full article at:   http://goo.gl/wa5zKL

By:  Cho Ryok Kang,1,7 Ji Hwan Bang,1,2 Sung-Il Cho,1,3 Kui Nam Kim,4 Hee-jin Lee,4 Bo Yeong Ryu,1,7 Soo Kyung Cho,1,7 Young Hwa Lee,1,3 Myoung-don Oh,1,5 and Jong-Koo Lee1,6

¹Seoul Center for Infectious Disease Control, Seoul, Korea.

²Division of Infectious Diseases, Seoul Metropolitan Government-Seoul National University Boramae Medical Center, Seoul, Korea.

³Department of Epidemiology, Seoul National University Graduate School of Public Health, Seoul, Korea.

⁴Division of Life & Health, Seoul Metropolitan Government, Seoul, Korea.

⁵Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea.

⁶Department of Family Medicine, Seoul National University College of Medicine, Seoul, Korea.

⁷Institute of Endemic Diseases, Seoul National University College of Medicine, Seoul, Korea.

Corresponding author.

Address for Correspondence: Ji Hwan Bang, MD. Division of Infectious Diseases, Seoul Metropolitan Government-Seoul National University Boramae Medical Center 20 Boramaero 5-gil, Dongjak-gu, Seoul 07061, Korea. Tel: +82.2-870-3209, Fax: +82.2-831-2826, Email:moc.liamg@hcribdnuor

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Factors Associated with the First Antiretroviral Therapy Modification in Older HIV-1 Positive Patients

Background

Rates of first antiretroviral therapy (cART) modifications are high in most observational studies. The age-related differences in treatment duration and characteristics of first cART modifications remain underinvestigated. With increasing proportion of older patients in HIV population it is important to better understand age-related treatment effects.

Methods

Patients were included into this analysis, if being cART naïve at the first visit at the clinic. Follow-up time was measured from the first visit date until first cART modification or 28 February 2013. First cART modification was defined as any change in the third drug component i.e. protease inhibitor (PI), non-nucleoside reverse transcriptase inhibitor (NNRTI), integrase inhibitor or fusion inhibitor. Cox proportional hazard models were used to identify factors related to first cART modification in three age groups: <30, 30–50 and >50.

Results

In total 2027 patients with 14,965 person-years of follow-up (PYFU) were included. The oldest group included 136 patients with 1901, middle group 1202 with 8416 PYFU and youngest group consisted of 689 patients with 4648 PYFU. Median follow-up time was 5.8 (IQR 3.4–9.4) years, median time on first cART was 4.4 (IQR 2.1–8.5) years. 72.4 % of patients started PI-based and 26.1 % NNRTI-based regimen. In total 1268 (62.5 %) patients had cART modification (non-adherence 30.8 %, toxicity 29.6 %). Durability of first cART was the best in patients over 50 y.o. (log-rank test, p = 0.001). Factors associated with discontinuation in this group were late presentation (HR 0.45, [95 % CI 0.23–0.90], p = 0.02) and PI use (HR 2.17, [95 % CI 1.18–4.0], p = 0.01).

Conclusions

Rates of first cART modifications or discontinuation were comparable in all groups; however older patients were significantly longer on first cART regimen.

Full article at:   http://goo.gl/rDV72Q

By:  Justyna D. Kowalska, Joanna Kubicka, Ewa Siwak, Piotr Pulik, Ewa Firląg-Burkacka, Andrzej Horban, and The Polish Observational Cohort of HIV/AIDS Patients (POLCA) Study Group

Hospital for Infectious Diseases, HIV Out-Patient Clinic, Warsaw, Poland

Department for Adult’s Infectious Diseases, Medical University of Warsaw, Warsaw, Poland

Justyna D. Kowalska, Email: moc.liamg@akslawokdj.

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#TestMeEast: A Campaign to Increase HIV Testing in Hospitals & to Reduce Late Diagnosis

Late diagnosis occurs in almost half of those diagnosed in the UK (HIV Prevention England, 2013. Retrieved June 22, 2014, from HIV Prevention England: http://www.hivpreventionengland.org.uk/Campaigns-Current/National-HIV-Testing-Week). Testing occurs mainly in sexual health and antenatal clinics despite recommendations to test more broadly 

We report the findings of an HIV-testing week campaign to offer testing to those who have blood tests as part of routine care within outpatient clinics and emergency departments of six London hospitals. The campaign target was to test 500 patients a day during the 2013 National HIV Testing Week (NHTW). Clinic staff and medical students were trained to offer routine HIV testing. Linkage to care was arranged for those who tested HIV-positive. 

During NHTW we tested 2402 of the planned 2500 test target. 2402/4317 (55.6% 95% CI 54.1-57.1%) of those who had routine blood tests were tested for HIV. There were eight HIV-positive tests; three were new diagnoses (all linked to care). The campaign hashtag #TestMeEast achieved a total Twitter "reach" of 238, 860 and the campaign had widespread news coverage. Our campaign showed that staff and students could be trained and mobilised to do thousands of routine HIV tests during a campaign.

Purchase full article at:   http://goo.gl/BVVLLG

By:   Bath R1, O'Connell R1, Lascar M1, Ferrand R2, Strachan S3, Matin N1, Bassnet I1, Orkin C1,4.

• 1 Barts Health NHS Trust , London , UK.
• 2 London School of Hygiene and Tropical Medicine , London , UK.
• 3 Positively UK , London , UK.
• 4 HIV Medicine, Infection and Immunity , Royal London Hospital , London , UK. 

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Late Antiretroviral Therapy (ART) Initiation Is Associated with Long-Term Persistence of Systemic Inflammation and Metabolic Abnormalities

Objectives

HIV-induced immunodeficiency is associated with metabolic abnormalities and systemic inflammation. We investigated the effect of antiretroviral therapy (ART) on restoration of insulin sensitivity, markers of immune activation and inflammation.

Methods

Immunological, metabolic and inflammatory status was assessed at antiretroviral therapy initiation and three years later in 208 patients from the ANRS-COPANA cohort. Patients were compared according to their pre-ART CD4⁺ cell count (group 1: ≤ 200/mm³, n = 66 vs. group 2: > 200/mm³, n = 142).

Results

Median CD4⁺ cell count increased in both groups after 3 years of successful ART but remained significantly lower in group 1 than in group 2 (404 vs 572 cells/mm³). Triglyceride and insulin levels were higher or tended to be higher in group 1 than in group 2 at ART initiation (median: 1.32 vs 0.97 mmol/l, p = 0.04 and 7.6 vs 6.8 IU, p = 0.09, respectively) and remained higher after three years of ART (1.42 vs 1.16 mmol/L, p = 0.0009 and 8.9 vs 7.2 IU, p = 0.01). After adjustment for individual characteristics and antiretroviral therapy regimens (protease inhibitor (PI), zidovudine), insulin levels remained significantly higher in patients with low baseline CD4⁺cell count. Baseline IL-6, sCD14 and sTNFR2 levels were higher in group 1 than in group 2. Most biomarkers of immune activation/inflammation declined during ART, but IL-6 and hsCRP levels remained higher in patients with low baseline CD4⁺ cell count than in the other patients (median are respectively 1.4 vs 1.1 pg/ml, p = 0.03 and 2.1 vs 1.3 mg/ml, p = 0.07).

Conclusion

After three years of successful ART, low pretreatment CD4⁺ T cell count remained associated with elevated insulin, triglyceride, IL-6 and hsCRP levels. These persistent metabolic and inflammatory abnormalities could contribute to an increased risk of cardiovascular and metabolic disease.

Below:  Distribution of inflammatory markers according to CD4 T cell count at ART initiation

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By:  

Mathilde Ghislain, Laurence Meyer, Cécile Goujard

Inserm UMRS1018, CESP, Epidemiology of HIV and STI, Le Kremlin-Bicêtre, France

Jean-Philippe Bastard, Jacqueline Capeau, Soraya Fellahi

Tenon Hospital, AP-HP, Department of Biochemistry and Hormonology, Paris, France

Jean-Philippe Bastard, Jacqueline Capeau, Soraya Fellahi, Corinne Vigouroux

Inserm UMRS 938, Centre de Recherche Saint-Antoine, Paris, France

Jean-Philippe Bastard, Jacqueline Capeau, Soraya Fellahi, Corinne Vigouroux

Sorbonne Universities, UPMC, Institute of Cardiometabolism and Nutrition (ICAN), Paris, France

Laurence Meyer, Cécile Goujard

Paris-Sud university, Le Kremlin-Bicêtre, France

Laurence Meyer

Bicêtre Hospital, AP-HP, Department of Public Health, Le Kremlin-Bicêtre, France

Laurence Gérard

Saint-Louis Hospital, AP-HP, Department of Clinic Immunopathology, Paris, France

Thierry May

Teaching hospital of Nancy, Brabois Hospitals, Department of Infectious and Tropical Diseases, Vandoeuvre les Nancy, France

Anne Simon

Pitié-Salpétrière Hospital, AP-HP, Department of Internal Medicine and Clinical Immunology, Paris, France

Corinne Vigouroux

Saint-Antoine Hospital, AP-HP, Common Laboratory of Biology and Molecular Genetics, Paris, France

Cécile Goujard

Bicêtre Hospital, AP-HP, Department of Internal Medicine, Le Kremlin-Bicêtre, France

ANRS-COPANA Cohort Study Group

Inserm-ANRS, Paris, France

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Determinants of Late Presentation to HIV/AIDS Care in Southern Tigray Zone, Northern Ethiopia

Background

Late diagnosis and presentation to human immune deficiency virus (HIV)/acquired immune deficiency syndrome care reduce the benefits of antiretroviral therapy and increase the risk of HIV transmission.

Objectives

This study was conducted to identify determinants of late presentation to HIV care among people living with HIV in Southern Tigray, Northern Ethiopia.

Methods

An institution based un-matched case–control (1:2 ratios) supported with qualitative data was conducted in Southern Tigray Zone from March 1 to April 30, 2014. Individuals with HIV enrolled from six randomly selected health facilities were included in the study. Cases were people living with HIV who had cluster of differentiation four count <350 cells/μl or World Health Organization stages 3 or 4. A total of 442 study participants were included by systematic sampling techniques. Bivariable and multivariable binary logistic regression model was used to identify associated factors. Odds ratio with 95 % CI was computed to assess the strength of the associations.

Result

Age categories, 25–29 years and 35–39 years, having two and more lifetime sexual partners, poor social support, second (next to lowest) wealth quintile, fear of stigma, fear of losing job, and reported severe illness were identified to be the risk factors for late presentation.

Conclusion

Low socio-economic status and social support, fear of stigma were potential risk factors for late presentation. Efforts towards promoting early care seeking should target on these factors in the study area and other similar settings.

Table 3

FGD results extracted from HIV positive individuals works on mothers supporting groups concerning barriers to early HIV/AIDS care, Southern Tigray Zone, April 2014

Barriers to HIV/AIDS care	HIV/AIDS positive individuals working on Mother Supporting Group
Fear of stigma	“… I was worried that people will talk about me if they hear I tested positive”… Male-32 “When I became aware of my HIV status my challenge was fear of health professionals and seeing other individuals I know while attending the ART clinic”, Female-27.
Fear of losing income source/former job	“People seem supportive towards HIV positives at first, but the pain is that they gradually change their feeling and treat you as ‘too weak’ to accomplish your duty …HIV positives will be shifted to lower status/position”, Male-55 “Although they are HIV positive, numerous commercial sex workers in the town continue their commercial sex work”, Female-27
Use of non-medical treatment	“…then she ate a dried Wild boar’s meat and Wild boar’s bile”, Female-30 “…he told me a very bitter plant called ‘Oure’ or ‘Eret’ is medicine for HIV and he had been drinking it until he ended up dying”, Female-30 “I went to a local traditional healer called ‘TonqualIi’ or magician and spent around 3000 Ethiopian Birr then he told to my wife wash my body using sheep’s blood and dung added together ….”, Male-38 “There was one HIV-positive neighbor with symptoms of diarrhea, she bought drugs from the pharmacy, was relieved of her symptoms for some time and then went to other pharmacy a few days later….”, Female-30 “My husband and were severely diseased and confined to bed for around 6 months. He had been telling that his illness was due to other diseases like malaria, and he has been getting medicines from drug stores”, Female-34
Low families driving force for initiation care	“We should let peoples think for the next generation…If my children are healthy…..”, Male -32 … “My child is negative”, Female-27, “My wife and children are negative”, Males-32, 55
Inadequacy of social support (spouse, friends and religious leaders)	“… I show him my ART drugs that I am taking and he became persuaded to take his treatment too”, Female-55 “I become angry and decided not to take any treatment for 1 year. Later on my friends were taking HIV treatment and they encouraged me to take treatment.” Male-28 “Males say that we are healthy even though we have the HIV and nothing bad is going on us, but, females become ill and suffer from headache and they come to ART clinics saying I tested positive for HIV …”, Female-27 “….later on my wife went to the health center and tested positive after that she encouraged me to be tested …”, Male-38 “…..I then persuaded my husband to be tested for HIV and avoided taking other drugs from outside the treatment center’’, Female-34 “My brother shouts at me, you should be tested and know the cause for your illness today; I will help every expense that follows …..”, Female-35 “…she was severely ill and her family said that they didn’t want to take care of the dead”, Female-27
Inadequate knowledge	“The HIV testing sites that are conducted in the shade in town are always crowded with people being tested, especially males. But they don’t come to care once they have tested positive [F-55] and they can only be accessed after they become diseased, arriving on a stretcher or by ambulance, or when found during house-to-house tracing by volunteer HIV support groups. …”, Female-34

Full article at:  http://goo.gl/tRVDU0

By:  Yalemzewod Assefa Gelaw

Email author, 

Goitom Halefom Senbete, 

Akelew Awoke Adane and 

Kefyalew Addis Alene

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Advanced HIV Disease at Enrolment in HIV Care: Trends and Associated Factors over a Ten Year Period in Cambodia

Background

Early HIV diagnosis and enrolment in care is needed to achieve early antiretroviral treatment (ART) initiation. Studies on HIV disease stage at enrolment in care from Asian countries are limited. We evaluated trends in and factors associated with late HIV disease presentation over a ten-year period in the largest ART center in Cambodia.

Methods

We conducted a retrospective analysis of program data including all ARV-naïve adults (> 18 years old) enrolling into HIV care from March 2003-December 2013 in a non-governmental hospital in Phnom Penh, Cambodia. We calculated the proportion presenting with advanced stage HIV disease (WHO clinical stage IV or CD4 cell count <100 cells/μL) and the probability of ART initiation by six months after enrolment. Factors associated with late presentation were determined using multivariate logistic regression.

Results

From 2003–2013, a total of 5642 HIV-infected patients enrolled in HIV care. The proportion of late presenters decreased from 67% in 2003 to 44% in 2009 and 41% in 2013; a temporary increase to 52% occurred in 2011 coinciding with logistical/budgetary constraints at the national program level. Median CD4 counts increased from 32 cells/μL (IQR 11–127) in 2003 to 239 cells/μL (IQR 63–291) in 2013. Older age and male sex were associated with late presentation across the ten-year period. The probability of ART initiation by six months after enrolment increased from 22.6% in 2003–2006 to 79.9% in 2011–2013.

Conclusion

Although a gradual improvement was observed over time, a large proportion of patients still enroll late, particularly older or male patients. Interventions to achieve early HIV testing and efficient linkage to care are warranted.

Below:  Evolution in the proportion of individuals enrolling with advanced HIV disease (CD4 cell count < 100 cells/μL or WHO clinical stage IV), Phnom Penh, Cambodia (2003–2013)

Below:  Evolution in the proportion of individuals enrolling with WHO clinical stage IV, Phnom Penh, Cambodia (2003–2013)

Below:  Evolution in the median CD4 count at enrolment into HIV care, Phnom Penh, Cambodia (2003–2013)

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By:  

Reaksmey Pe, Bopha Chim, Sopheak Thai, Johan van Griensven

Sihanouk Hospital Center of HOPE, Phnom Penh, Cambodia

Lutgarde Lynen, Johan van Griensven

Institute of Tropical Medicine, Antwerp, Belgium

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HIV Indicator Condition-Guided Testing to Reduce the Number of Undiagnosed Patients & Prevent Late Presentation in a High-Prevalence Area: A Case–Control Study in Primary Care

Recent guidelines advocate accelerated provider-initiated HIV testing by general practitioners (GPs). We aimed to identify the number of patient consultations in six general practices in the South-East of Amsterdam, and the incidence of HIV indicator conditions reported in their medical files prior to diagnosis.

A cross-sectional search in an electronic general practice database. We used a case–control design to identify those conditions most associated with an HIV-positive status.

We included 102 HIV cases diagnosed from 2002 to 2012, and matched them with 299 controls. In the year prior to HIV diagnosis, 61.8% of cases visited their GP at least once, compared with 38.8% of controls. In the 5 years prior to HIV diagnosis, 58.8% of HIV cases had exhibited an HIV indicator condition, compared with 7.4% of controls. The most common HIV-related conditions were syphilis and gonorrhoea. The most common HIV-related symptoms were weight loss, lymphadenopathy and peripheral neuropathy. During this period, average HIV prevalence among people aged 15–59 years increased from 0.4% to 0.9%.

This study revealed many opportunities for HIV indicator condition-guided testing in primary care. As yet, however, HIV indicator conditions are not exploited as triggers for early HIV testing.

Below:  Trends in prevalence of HIV in six general practices in a South-Eastern district of Amsterdam, the Netherlands, 2002–2012

Full article at: http://goo.gl/S5rjFl

By: Ivo K Joore¹, Derk L Arts¹, Marjan JP Kruijer¹, Eric P Moll van Charante¹,Suzanne E Geerlings², Jan M Prins², Jan EAM van Bergen¹,³,⁴

¹ Department of General Practice, Division of Clinical Methods and Public Health, Academic Medical Center, Amsterdam, The Netherlands

² Department of Internal Medicine, Division of Infectious Diseases, Academic Medical Center, Amsterdam, The Netherlands

³ STI AIDS Netherlands (Soa Aids Nederland), Amsterdam, The Netherlands

⁴ Epidemiology & Surveillance Unit, Centre for Infectious Disease Control, National Institute of Public Health and the Environment (RIVM), Bilthoven, The Netherlands

  

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Gender Difference in Advanced HIV Disease & Late Presentation According to European Consensus Definitions

Effectiveness of highly active antiretroviral therapy is limited for a large proportion of individuals living with HIV presenting for medical care at an advanced stage. Controversial results of gender differences in risk of late HIV diagnosis were reported among existing literatures. Therefore, we conducted this meta-analysis to synthesize a summary of gender differences in risk of advanced HIV disease (AHD) and late presentation (LP) according to European consensus definitions. 

Totally, 32 studies were included based on predetermined selection criteria. The pooled adjusted odds ratios of males presenting with AHD and LP compared with females were 1.73 (95% confidence interval [CI], 1.59-1.89) and 1.38 (95% CI, 1.18-1.62) with significant heterogeneity observed (I(2) = 78.50%, and I(2) = 85.60%, respectively). 

Subgroup analysis revealed that time lag, study location, number of patients, proportion of females, study design, number of adjusted variables might be potential source of heterogeneity. Sensitivity analysis showed robustness of the results. No publication bias was observed in studies on AHD or LP. 

The current meta-analysis indicated that males are at higher risk of AHD or LP compared with females. More attention should be paid to males to make sure early testing, diagnosis, and treatment, and ultimately improve individual and population health.

Via: http://goo.gl/iWFoJ6  Full article at:  http://goo.gl/aSZ8rW

By: Jiang H1, Yin J1, Fan Y1, Liu J1, Zhang Z1, Liu L1, Nie S1.

• 1Department of Epidemiology and Biostatistics, School of Public Health, Tongji Medical College, Huazhong University of Science and Technology, 430030 Wuhan, Hubei, P.R. China. 

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