• M Kumi Smith, William C Miller, Huixin Liu, Chuanyi Ning, Wensheng He, Myron S Cohen, and Ning Wang.
• University of North Carolina Chapel Hill, Chapel Hill, NC, USA. Electronic address: kumi.smith@unc.edu.
• Lancet. 2016 Oct 1; 388 Suppl 1: S65.

BackgroundSustained viral suppression through antiretroviral therapy (ART) reduces the risk of sexual HIV transmission. However, it can require routine access to reliable and effective medical care, which can be difficult to obtain in resource-constrained areas. We investigated the effects of patient load and travel distance to an HIV care clinic on transmission risk in HIV serodiscordant couples in the Henan Province, China.MethodsThe study cohort arises from a population of HIV-infected individuals in central rural China where regional blood selling scandals in the 1990s led to mass HIV transmission of up to 30 000 people though unsanitary blood collection practices. Local disease control centres in our study prefecture followed up patients with HIV and their uninfected spouses to monitor transmission events since 2006. Eligible couples had to be registered residents living in the study prefecture, older than 16 years (the age of legal consent in China), in a stable marriage (no separation or divorce), one partner confirmed to be HIV seropositive and the other seronegative, and be willing to provide written or verbal informed consent. Cox proportional hazard models were used to compare events of HIV transmission between couples living near (<50 km), medium (≥50 km), or far (>100 km) distances from their assigned HIV care clinics, as well as between those attending clinics with high (>100 patients per clinician) versus low (≤100 patients per clinician) patient loads. Ethics approval for the analysis of these data for research purposes was provided by the Institutional Review Board of the National Center for AIDS/STD Control and Prevention (NCAIDS) at the Chinese Centers for Disease Control and Prevention. This analysis relied on an agreement between the Institutional Review Boards of NCAIDS and the University of North Carolina, Chapel Hill.Findings3611 HIV-serodiscordant couples contributed a total of 21 231 person-years. Index partners received HIV care at 159 different HIV care centres distributed over three tiers of care, including village clinics (40·8%) township health centres (56·6%), and county hospitals (2·5%). 2961 (82%) of the 3611 serodiscordant couples lived within 10 km of their assigned HIV clinic, and 2654 (73%) attended clinics with patient-to-provider ratios of at least 100:1. In adjusted Cox models, attending clinics in which clinicians bore average patient loads of 100 or more increased HIV transmission risk (adjusted hazard ratio [aHR] 1·50, 95% CI 1·00-4·84), an effect amplified in village tier clinics (1·55, 1·23-6·78). Travel distance was associated with HIV transmission only after stratification; travelling medium distances to village clinics increased transmission risk (1·83, 1·04-3·21), whereas travelling longer distances to township or county-level clinics lowered transmission risk (0·10, 0·01-0·75).InterpretationHigh patient loads at HIV clinics was strongly associated with increased risk of HIV transmission in our population, particularly at village-level clinics. Increased travel distance had divergent effects based on clinic tier, suggesting unique mechanisms operating across levels of resource availability. The resource availability of long-term HIV treatment might place substantial strains on small rural clinics, for which investments in additional support staff or time-saving tools such as point-of-care laboratory testing might bring about impactful change in treatment outcomes.FundingMinistry of Science and Technology, People's Republic of China, National Institutes of Health of the USA.Copyright © 2016 Elsevier Ltd. All rights reserved.

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