Epidemiological characteristics of infectious diseases have changed dramatically requiring necessitate health care workers to understand the status of these diseases, especially for AIDS and other pandemics disease [8–10]. Efforts and investments have been made globally to strengthen countries’ HIV monitoring and evaluation capacity [11]. Cross-border travelers with an HIV infection may cause local HIV transmission and are defined as a bridge population [12]. Shanghai has the largest cross-border population entering China from countries around the world. Cross-border travel is important for culture and commerce but also leads to the spread of infectious diseases. Therefore, it’s important to analyze HIV prevalence and demographic characteristics in this population. This was the first study which displayed the HIV infection rate and their characteristics among entry travelers over such a long-time span, with such a large-scale population in Shanghai.
From 2005 to 2016, there were 50830 international persons entering Shanghai who finished health examination in Shanghai International Healthcare Center. In this crossing border population, a total of 245 (0.48%) travelers were determined as HIV positive. Overall, we found that the HIV infection rate among entry travelers in Shanghai did not show an increasing tendency over these years, contributed by global HIV/AIDS prevention and control efforts, such as promoting condoms in Southeast Asian countries and implementing the Asian regional AIDS project, had received international attention and achieved good results.
After the HIV infected persons were found, the epidemic situations were reported to the CDC epidemic reporting system, and the related data were handed over to the local health department. In recent years, the Shanghai international travel healthcare center has strengthened the follow-up supervision of the entry of AIDS patients, and established foreign liaison files for foreign HIV infected persons. Health education for the HIV infected persons was carried out to provide information about disease diagnosis and treatment and conduct high risk behavior intervention. With the local disease control departments, medical institutions, foreign embassies and other information interoperability, joint cooperation, explore overseas HIV infection health counseling and treatment measures. AIDS patients who do not want to return to the country need to be treated by providing health consultation and designated medical institutions to receive paid medical treatment. Using the existing conditions, according to local conditions, the entry-exit personnel health examination site could be settled as a consulting base. We tried to make full use of newspapers, magazines, radio, television and other mass media to answer typical questions; to establish International Travel Health Advisory contact, by using of websites, cellphone app and other ways to answer questions raised by travelers on AIDS prevention and control work. With the local health administration, Family Planning Commission, Red Cross and other departments, through public welfare performances, on-site distribution brochures, free distribution of condoms and other means were undergoing.
In the last decade, we had seen a dramatic change in the demographic structure of the population of people living with HIV [13]. This study found that HIV infection of entry travelers in Shanghai also had certain demographic characteristics. From the perspective of age-specific HIV prevalence, the major age population of HIV infected travelers was 18–40 years (73.90%). Overall, an estimated of 5 million young people aged 15–24 were living with HIV in 2009 and accounted for 41% (about 890,000 cases) of new HIV infections globally [14]. HIV is disproportionately afflicting young people worldwide globally, especially in the developing countries. The similar trend persisting was founded in our study. According to the diagnostic tests, those with positive results was divided into three groups, (more than 40 years old, 31 to 40 years old, less than 30 years old), working men aged 31 to 40 had the highest incidence whereas working women had a very low incidence (near zero). The results are consistent with Wang’s research, they found that travelers aged 21–30 and 31–40 were the most commonly infected individuals among entry travelers in Yunnan Province [2].
In addition, HIV infection was more frequently detected among individuals with occupations such as businessman and entertainers. Furthermore, from a view of marriage, unmarried (single or other marital status) applicants had higher proportion of infection compared to those married group (54.70%vs18.37%). In general, people with better education and better cognitive ability have healthier behaviors and lower HIV infection rate [15]. Nevertheless, our study found that most of the infected people were highly educated. The entry travelers are divided into high-income countries, middle-income countries, and low-income countries based on the host country [7]. Our data showed that most of the positive cases were from middle- and low-income countries.
From the view of transmission, our data implied that sexual contact was the major high risk behavior,especially in those men have sex with men. In the meantime, a study in the US reported the most common HIV transmission route had changed to homosexual contact in men, while injection drug users were ranked the third[16].We also deemed that the major HIV infection route had been shifted from intravenous drug use to sexual contact in this study.
Monitoring of HIV infections in high-risk populations was particularly important for preventing the spread. This study found that those who did not use condom accounted for a large proportion in the positive cases. Inconsistent condom uses and several risk-taking behaviors were also reported among young people in United States (African-Americans aged 18–21) and Uganda [17]. Insufficient HIV-related knowledge and low self-awareness of risk might be associated with an increasing number of AIDS. Thus, promotion and acceptance of sex education, accurate and age-appropriate information on HIV appeared to be the needed in order to interrupt the spread of HIV.
Strengths and Limitations
Since this was a record-based study, some of the applicant records might be incomplete. The face to face interviews were only conducted in the HIV population, the characteristics of HIV negative population could not be obtained. Therefore, the demographic characteristics of them could not be compared. Furthermore, the sample may not be representative of the total population of entry travelers in China. At present, most foreigners in China are short-term immigration, some of them go back and forth many times, the time of staying in China is less than one year each time, and the mobility is relatively large. China's law only applies to the foreign applicants who apply for residence in China to carry out AIDS monitoring, so there is no effective monitoring measures and methods for most of the short-term immigrants.
According to the relevant provisions, entry foreigners holding HIV antibody test negative proof of overseas public hospitals could be exempted from inspection. However, in the past years of work, many cases of these population, the HIV test were found positive. At the same time, the public security, inspection and quarantine, education, human resources and social security departments had found that some foreign health inspection materials provided by foreigners were incomplete or fraudulent. This part of the population was the potential spread of AIDS population, however, the supervision of them was more difficult.
This study was one of few studies based on the certain population that have been conducted in China. Although there were limitations and incomplete information, we still believed that this study could help us understand the dynamics of HIV transmission among international travelers to some extent. The findings of this study highlighted the information gap in this area and helped us fill in a small part of it.