Epidemiological and spatial analyses of HIV/AIDS prevalence in Shandong, China from 2016 and 2022: A population-based study

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Methods Data on HIV/AIDS cases was extracted from the National HIV/AIDS comprehensive response information management system. Spatial analysis were conducted with Kulldorff’s scan statistic. Results A total of 19730 HIV/AIDS were reported in Shandong, China during 2016–2022, 69.7% of them were transmitted through homosexual behavior. The proportion of HIV/AIDS aged 50 years and older increased from 13.1–26.7%. Spatial analysis indicated that the HIV clusters were located in urbans areas with higher economic level. The cluster areas of male cases were distributed in urban areas, but the cluster areas of female cases were in the western areas with backward economy. During the COVID-19 pandemic, the number of newly reported HIV/AIDS decreased, the proportion of patients receiving CD4 + T cell test (CD4) decreased, the proportion of patients receiving antiretroviral therapy (ART) had increased in Shandong, China. Conclusions More prevention and education should be done for MSM in urban areas, and women in the western areas to curl the transmission of HIV. The rapidly increasing proportion of elderly HIV/AIDS should be focused on and responded. HIV AIDS spatial analysis epidemiological character Figures Figure 1 Figure 2 Introduction There are currently 39 million people living with HIV (PLWH) worldwide as of the end of 2022. Although the number of new infections is declining, the pace is insufficient to meet the targets set by the United Nations Political Declaration on HIV/AIDS, which aims for fewer than 350,000 new infections by 2030 [ 1 ]. In China, there have been two important outbreaks of HIV infection since the first case was reported in 1985. The first stage was dominated by HIV/AIDS infected through injecting drug, and the second was by commercial blood/plasma donors [ 2 ]. Heterosexual transmission is the main transmission route of HIV/AIDS in China nowadays [ 3 ]. Unlike injecting drug users and commercial blood/plasma donors, the population at high risk of HIV infection through sexually behavior are difficult to be found and intervened. Shandong had the second largest permanent population and third highest GDP in China in 2023 [ 4 ], but the number of reported HIV/AIDS here was less than most provinces in China [ 3 ]. The main transmission route of HIV/AIDS here was sexual behaviors, of which homosexual transmission accounted for about 70% [ 5 ]. Although Shandong Province has adopted a series of public health programs and interventions to curb transmission of HIV, the results were not satisfactory. Huang et al. [ 6 ] observed the incidence of new drug abuse of a MSM cohort in Qingdao city, one city in Shandong Province, was 6.80/100 person-years, and the proportion of unprotected anal sex and group sex after using new type drugs was 93.55% and 48.39%. The study conducted by Huang et al. [ 7 ] found that 87.5% of MSM had anal sex in the last 6 months, 30.4% of them had never used condoms, and 41.4% could not insist on using condoms every time in Qingdao city and Jinan city, Shandong Province. Wang et al. [ 8 ] found that although the HIV related knowledge awareness rate of MSM was 96.94%, 16.29% had group anal sex and 63.00% had not been tested for HIV in the last 6 months in Shandong Province. In addition, an increasing rate of female cases were transmitted through non-marital non-commercial heterosexual behaviors, for whom the general publicity interventions would not acquire satisfactory achievement [ 9 ]. Although pre-exposure prophylaxis (PrEP) and post-exposure prophylaxis (PEP) is now proposed to play a very important role in blocking sexual transmission, the utilization was limited by high cost and limited resources [ 10 ]. Many studies suggest that there is a significant difference in HIV prevalence across regions [ 11 – 13 ]. Geographical spacial analysis plays an important role in the identification of the cluster area of HIV epidemic. So identifying high-risk population and HIV clustered areas to implement targeted interventions was required, such as PrEP campaigns, HIV testing, distributing free condoms, educations to decrease the incidence of HIV. The COVID-19 outbreak was declared a pandemic by the World Health Organization on March 11, 2020 [ 14 ]. Some studies have suggested that the COVID-19 pandemic had an impact on the HIV epidemic [ 15 ]. Shi et al.[ 16 ] believed that the COVID-19 pandemic had a negative impact on the HIV healthcare system including patients' access to HIV care in Jiangsu Province, China. A study in Canada [ 17 ] found that PLWH had about two times the risk of COVID-19 hospitalization than HIV-negative individuals in crude analyses by propensity score-weighted models. Consequently, we utilized case report data to analyze the epidemiological characters and spatiotemporal trends of HIV/AIDS reported during 2016–2022 in Shandong, China and searched for HIV clustered areas, so as to take targeted efforts to close disparities in resources for prevention and control. Furthermore, by comparing difference of the reported cases number, crude death rate, and HIV care status of HIV/AIDS before and during the COVID-19 pandemic, we explored the impact of COVID-19 pandemic on the HIV epidemic. Methods Study area The study area is Shandong Province, located on the east coast of China, the Yellow River mouth area,located in eastern China (114°47.5′-122°42.3′, 34°22.9′~38°24.01′), has a resident population of approximately 1.01 billion [ 4 ]. Shandong Province borders Hebei, Henan, Anhui and Jiangsu provinces from north to south, and has 16 prefecture-level cities, which comprise 139 counties or urban districts. Data on HIV/AIDS cases in all of these areas were covered in this study. Data sources Data were obtained from the National HIV/AIDS comprehensive response information management system (CRS), excluding Hong Kong, Macao, Taiwan and foreign cases. The system was established by Chinese Center for Disease Control and Prevention in 1985 and available online since 2005 [ 18 ]. All health care facilities in China (such as hospitals, centers for Disease Control and Prevention, et al.) must report the case information to this system within 24 hours after HIV/AIDS diagnosis by the principles of HIV/AIDS diagnostics and the Chinese national HIV/AIDS test technology regulation and criteria, respectively. The information reported includes socio-demographic characteristics (age, gender, occupation, education), disease status, route of transmission, and risk behaviors, etc. All data used in this study were anonymized to protect the privacy of participants. The research protocol was approved by the Ethical Committee of Prevention Medicine of Shandong Center for Disease Control and Prevention (ethical code: SL2023-040-01). Statistical Analysis Data were processed and analyzed with SPSS 21.0 (SPSS IBM Inc., Armonk, New York). Linear-by-Linear Association (LLA) test was used to analyze the temporal trend over these years and if a variable had more than 2 categories, it was transformed into a binary variable, that is, the category to be analyzed for a trend was taken as one category, and the total of remaining categories as another category. P < 0.05 was considered statistically significant. Spatial analysis spatial cluster analysis was done with Kulldorff’s scan statistic, using the SaTScan™ software [ 19 ]. The spatial scan statistic identifies statistically significant clusters using scanning windows (circular or elliptical) of varying sizes. These windows move around the study area to identify HIV-positive individuals within a window that is more than what is expected by chance. The relative risk (RR) of positive cases for each window is calculated using the observed number of positive and negative individuals within the windows. The highest log-likelihood ratio (LLR) was calculated for each cluster to determine the most likely cluster. A Bernoulli Probability Model was used for this study because of the binomial outcome of interest (HIV-positive and -negative). We ran multiple analyses by setting the maximum spatial cluster size of 50%, 25%, 20% and 15% of the population at risk of HIV infection. The best cluster size was obtained at the maximum spatial cluster size of 25%. The statistically significant clusters with the radius of the scanning window, the number of observed and expected positives within the circle, RR, LLR and P value were saved for analysis and mapping. All analyses were run using Monte Carlo replications of 999 for defining clusters and P < 0.05 was considered significant. The significant clusters obtained by SaTScan™ were mapped using ArcMap 10.5.1 (ESRI, Redlands, CA, USA). Results Study population Approximately 19730 HIV/AIDS were reported in Shandong, China, during 2016–2022, with 2,536, 2,718, 2,853, 3,108, 2,825, 3,174 and 2,516 cases in the respective years. The subjects were predominantly male (91.4%), Han nationality (97.7%), 25–49 years old (63.0%), HIV (75.9%). A relatively higher proportion of people registered in Shandong Province (85.8%) and most of the subjects had a junior high school education (31.5%). Larger proportion of cases were single (62.1%), transmitted through homosexual behavior (69.7%). In every counties of China, CDC and hospital had setted up HIV voluntary counseling and testing (VCT) clinic providing free test. In our research, VCT (36.9%) and hospitals (49.6%) were the main resources for HIV diagnosis. 11.6% HIV/AIDS had history of STD, 27.4% were lately diagnosed, 94.8% received CD4 test, 78.7% received ART, and 4.6% died in their reporting year (Table 1 ). Among 5719 cases transmitted by heterosexual behavior, female cases were mainly transmitted through non-marital non-commercial sexual behaviors (60.7%) and sexual behaviors with their spouse (34.7%), but male cases were mainly commercial heterosexual sexual behaviors (41.9%) and non-marital non-commercial heterosexual sexual behaviors (51.6%) (Fig. 1 ). Trend analysis Among all HIV/AIDS, the proportion of cases aged 50 years and older increased from 13.1% (2016) to 26.7% (2022) ( LLA statistic = 222.872, P < 0.05); the proportion of cases of Han nationality increased from 96.6% (2016) to 97.7% (2022) ( LLA statistic = 33.018, P < 0.05); the proportion of cases registered in Shandong province increased from 84.1% (2016) to 85.8% (2022)( LLA statistic = 7.202, P < 0.05); the proportion of AIDS increased from 21.1% (2016) to 24.1% (2022)( LLA statistic = 7.202, P < 0.05); the proportion of cases transmitted through homosexual behavior increased from 67.3% (2016) to 69.7% (2022) ( LLA statistic = 58.509, P < 0.05); the proportion of cases diagnosed by hospital increased from 40.5% (2016) to 49.6% (2022) ( LLA statistic = 227.721, P < 0.05); the proportion of cases with college degree or above increased from 31.6% (2016) to 32.3% (2022) ( LLA statistic = 5.493, P < 0.05); the proportion of cases received CD4 test decreased from 95.0% (2016) to 94.8% (2022) ( LLA statistic = 9.024, P < 0.05); the proportion of cases received ART increased from 62.5% (2016) to 78.7% (2022) ( LLA statistic = 966.343, P < 0.05); the proportion of cases diagnosed later increased from 21.4% (2016) to 25.5% (2022) (Table 1 ). Table 1 Trends of epidemic characteristics for HIV/AIDS in Shandong Province from 2016 to 2022 Variables 2016 N (%) 2017 N (%) 2018 N (%) 2019 N (%) 2020 N (%) 2021 N (%) 2022 N (%) Summation N (%) Gender male 2327(91.8) 2486(91.5) 2609(91.4) 2850(91.7) 2571(91.0) 2920(92.0) 2270(90.2) 18033(91.4) female 209(8.2) 232(8.5) 244(8.6) 258(8.3) 254(9.0) 254(8.0) 246(9.8) 1697(8.6) Age of diagnosis < 15 12(0.5) 12(0.4) 11(0.4) 12(0.4) 6(0.2) 8(0.3) 11(0.4) 72(0.4) 15–24 468(18.5) 500(18.4) 519(18.2) 542(17.4) 505(17.9) 556(17.5) 368(14.6) 3458(17.5) 25–49 1724(68.0) 1829(67.3) 1850(64.8) 1932(62.2) 1706(60.4) 1932(60.9) 1464(58.2) 12437(63.0) ≥ 50* 332(13.1) 377(13.9) 473(16.6) 622(20.0) 608(21.5) 678(21.4) 673(26.7) 3763(19.1) Nationality Han nationality* 2451(96.6) 2634(96.9) 2773(97.2) 3054(98.3) 2781(98.4) 3118(98.2) 2472(98.3) 19283(97.7) Minority nationality 85(3.4) 84(3.1) 80(2.8) 54(1.7) 44(1.6) 56(1.8) 44(1.7) 447(2.3) Registered area Shandong province* 2133(84.1) 2335(85.9) 2428(85.1) 2670(85.9) 2457(87.0) 2730(86.0) 2181(86.7) 16934(85.8) The other province 403(15.9) 383(14.1) 425(14.9) 438(14.1) 368(13.0) 444(14.0) 335(13.3) 2796(14.2) Disease phases HIV 2000(78.9) 2083(76.6) 2168(76.0) 2358(75.9) 2082(73.7) 2400(75.6) 1877(74.6) 14968(75.9) AIDS* 536(21.1) 635(23.4) 685(24.0) 750(24.1) 743(26.3) 774(24.4) 639(25.4) 4762(24.1) Route of transmission Homosexual* 1707(67.3) 1811(66.6) 1926(67.5) 2125(68.4) 1958(69.3) 2399(75.6) 1816(72.2) 13742(69.7) Heterosexual 766(30.2) 847(31.2) 872(30.6) 940(30.2) 852(30.2) 760(23.9) 682(27.1) 5719(29.0) The other 63(2.5) 60(2.2) 55(1.9) 43(1.4) 15(0.5) 15(0.5) 18(0.7) 269(1.4) Resource of diagnosis Hospital* 1026(40.5) 1184(43.6) 1360(47.7) 1541(49.6) 1548(54.8) 1679(52.9) 1457(57.9) 9795(49.6) VCT 1073(42.3) 1088(40.0) 1097(38.5) 1133(36.5) 945(33.5) 1125(35.4) 813(32.3) 7274(36.9) The other 437(17.2) 446(16.4) 396(13.9) 434(14.0) 332(11.8) 370(11.7) 246(9.8) 2661(13.5) Degree of education Primary and below 254(10.0) 257(9.5) 289(10.1) 339(10.9) 356(12.6) 350(11.0) 306(12.2) 2151(10.9) Junior high school 827(32.6) 876(32.2) 896(31.4) 1024(32.9) 877(31.0) 938(29.6) 783(31.1) 6221(31.5) High school or technical secondary school 654(25.8) 747(27.5) 730(25.6) 787(25.3) 668(23.6) 785(24.7) 608(24.2) 4979(25.2) College degree or above* 801(31.6) 838(30.8) 938(32.9) 958(30.8) 924(32.7) 1101(34.7) 819(32.6) 6379(32.3) History of STD Yes 296(11.7) 356(13.1) 317(11.1) 346(11.1) 353(12.5) 343(10.8) 285(11.3) 2296(11.6) None/unknown 2240(88.3) 2362(86.9) 2536(88.9) 2762(88.9) 2472(87.5) 2831(89.2) 2231(88.7) 17434(88.4) Marital status Single 1573(62.0) 1686(62.0) 1779(62.4) 1888(60.7) 1701(60.2) 2039(64.2) 1596(63.4) 12262(62.1) Married/ had permanent sexual partner 958(37.8) 1028(37.8) 1070(37.5) 1209(38.9) 1118(39.6) 1127(35.5) 915(36.4) 7425(37.6) Unknown 5(0.2) 4(0.1) 4(0.1) 11(0.4) 6(0.2) 8(0.3) 5(0.2) 43(0.2) Late diagnosis & Yes* 516(21.4) 637(24.5) 720(26.5) 756(25.6) 739(27.5) 763(25.8) 645(27.1) 4776(25.5) No 1892(78.6) 1967(75.5) 1993(73.5) 2197(74.4) 1951(72.5) 2194(74.2) 1735(72.9) 13929(74.5) CD4 test Yes* 2408(95.0) 2604(95.8) 2713(95.1) 2953(95.0) 2690(95.2) 2957(93.2) 2380(94.6) 18705(94.8) No 128(5.0) 114(4.2) 140(4.9) 155(5.0) 135(4.8) 217(6.8) 136(5.4) 1025(5.2) ART Yes* 1584(62.5) 1810(66.6) 2198(77.0) 2480(79.8) 2427(85.9) 2837(89.4) 2198(87.4) 15534(78.7) No 952(37.5) 908(33.4) 655(23.0) 628(20.2) 398(14.1) 337(10.6) 318(12.6) 4196(21.3) Death Yes 2426(95.7) 2605(95.8) 2729(95.7) 2952(95.0) 2683(95.0) 3045(95.9) 2375(94.4) 18815(95.4) No 110(4.3) 113(4.2) 124(4.3) 156(5.0) 142(5.0) 129(4.1) 141(5.6) 915(4.6) Notes : & Late diagnosis was defined as a patient with CD4 less than 200/ µL at diagnosis, and 5.2% (1025/19730) HIV/AIDS were eliminated due to they had not test CD4; * the trend of these variables were analyzed and significant change ware observed ( P < 0.05). Spatial analysis The cumulative cases reported from 2016 to 2022 were mainly concentrated in eastern and Central areas of Shandong, including the three clusters covering Jinan, Qingdao and Yantai and one cluster appeared in the border area of Weifang, Zibo, Binzhou and Dongying cities (Fig. 2 a). The male clusters were distributed significantly different with female cases (Fig. 2 b). The cluster areas of male cases were similar to the cluster areas of the whole HIV/AIDS, while the clusters of female cases were in the western areas, including the whole Heze City, the border area of Linyi, Jining and Zaozhuang cities, Guangrao County of Dongying and Gangcheng District of Jinan City (Fig. 2 c). Discussion In Shandong Province, the proportion of HIV/AIDS transmitted through homosexual behaviors was higher than most regions of China [ 3 ]. The lower proportion of heterosexual transmitted cases maybe due to Shandong Province was the hometown of Confucius and was deeply influenced by Confucianism, people here had the conservative sexual concepts and lower acceptance of extramarital sex. On the other hand, the well-developed industry and commerce attracted immigrant population, including some MSM, from western and northern areas of China. The results showed that the proportion of HIV/AIDS over 50 years old increased year by year, which is as same as studies in other provinces of China [ 2 , 20 ]. The sexual demands of older people were often neglected in China and unprotected sexual exposures remained common, which in turn increased the risk of HIV transmission in old people [ 2 ]. Some studies [ 20 ] have suggested that older HIV/AIDS were more susceptible to comorbidity, so we must focus on the vulnerabilities of these people and provide public health programs. The occupations reported in Shandong Province were mainly farmers, housekeeping, housework and unemployed, workers and business service staffs, all these above had not regular jobs. In order to earn more money, farmers in China would like to look for a temporary job in the city. They knew less about AIDS prevention and treatment, had a high risk of infection. Their job was not fixed, and when they lost jobs or their labor force declined, they would return to countryside and became the infectious resource. Zhang et al [ 21 ] found that the ART effect of farmer cases was worse than that of non-farmer cases in Heze City, Shandong Province, all these above suggested immigrant population were still the focus of intervention. A wide range of economic and socio-cultural factors are responsible for increasing the vulnerability of African women to HIV infection [ 22 ]. Some spatial analyses of the HIV also found that HIV clusters tend to be in economically developed areas [ 11 , 13 ]. People living in economically developed areas have more open sexual concepts, more convenient ways finding temporary sexual partners. This study detected that the clustered areas of HIV/AIDS during 2016 to 2022 were mainly in the urban areas centered of Jinan, Qingdao and Yantai cities, three cities with GDP ranked the top three in Shandong Province. There are more clubs, bars and gay meeting places in these cities. MSM are more active in economically developed areas, and had higher incidence of unprotected anal sex and group sex [ 6 ], and the higher utilization rate of new type drugs [ 7 ], all these would increase risk of HIV transmission. In addition, studies of Congo have shown a gradual spread of AIDS from more developed cities to rural areas [ 23 ]. This study found that the HIV clusters in Shandong Province fully covered the spatial clusters found in 2016 [ 24 ], and the scope was expanded, which may be due to the spread of HIV from urban to rural areas. The cluster areas of male cases were also in urban areas, similar to the cluster areas of the whole cases perhaps due to the HIV/AIDS were dominated by MSM cases in Shandong. Female cases clusters, distributed in western areas, were quitely different with male cases. In Henan Province of China, HIV/AIDS were mainly transmitted by heterosexual behavior [ 25 ]. Heze city bordered Henan province, so maybe affected. In addition, the female HIV clusters were located in the inland area where the industry and commerce are relatively poor. So a large number of people here went to Coastal areas looking for jobs. Linyi, Jining and Zaozhuang cities, three of the female HIV clusters are adjacent to Jiangsu Province, economically developed provinces and gathering places for migrant workers. Due to the influence of Confucianism, men have ethical pressure to marry and give birth to children. So some migrant workers would go back home, get married, and maybe transmit HIV to their wives or female sexual partners. From 2016 to 2019, the number of HIV/AIDS reported in Shandong Province had been increasing over the years, but since 2020, there had been a decline and the HIV clusters shrank obviously. Sichuan and Guangxi provinces in China had also reported the decline of newly diagnosed HIV/AIDS in 2020 [ 26 ]. This decline may be related to the epidemic of COVID−19, because medical resources, including most of CDC staffs and doctors in hospitals were engaged in the treatment and prevention of COVID−19, fewer medical resources available for HIV diagnosis [ 27 ]. In addition, in order to control the spread of COVID−19, China has taken measures such as sealing off areas with more COVID−19 cases and strengthening management of floating population, restricting the movement of people, which may had reduced the occurrence of temporary sex. This could be confirmed partially by that the HIV clusters in Shandong Province were more concentrated and the proportion of cases registered in shandong province increased during 2020–2022. Thirdly, the decrease of infectious resources leads to a decrease of the new diagnosed HIV/AIDS. Research showed that PLWH had not received ART were at elevated risk for COVID−19[ 28 ]. For well-controlled HIV/AIDS, the risk of severe COVID−19 outcomes is similar with HIV-negative individuals [ 29 ]. HIV/AIDS who had not been diagnosed would not know their infectious status so as receive ART, so they would have poor COVID−19 related outcomes. Some studies believed that COVID−19 caused difficulties for PLWH accessing medical resources [ 29 ]. The study also found a lower CD4 test rate in HIV/AIDS during 2020–2022. No variation for crude mortality rate of HIV/AIDS was found before and during the epidemic of COVID−19, may be due to China had taken measures such as mailing drugs, borrowing drugs from the other provinces, and dispensing drugs for longer time to ensure most HIV/AIDS maintain ART [ 30 ]. In addition, the reported incidence rate of HIV/AIDS in Shandong Province was lowest in China, and the medical resources on HIV care continuum was relative abundance. Furthermore, PlWH prefered to receive ART as soon as possible due to the fear of the weakened immunity after HIV infection and uncertained access for medical services. The proportion of HIV/AIDS received ART increased, which may had a compensatory effect on the medical resources for ART during the COVID−19 pandemic. Our study has several limitations. Fristly, the objects of our study were HIV/AIDS cases diagnosed and reported in the CRS, so the epidemiological characters and variation trends of undiagnosed cases would not be analyzed. But the bias could be reduced by intensifying testing and strengthening continuous, ongoing HIV/AIDS surveillance and monitoring systems around the country. Secondly, those undiagnosed cases were at greater risk of death during COVID-19 epidemic, which could lead to an underestimation of the mortality rate of HIV/AIDS, more in-depth research on the undiagnosed HIV/AIDS will be required in future. Conclusions This study presented that most HIV/AIDS in Shandong province were transmitted through sexual behaviors, among which homosexual transmission appeared an increasing trend. The HIV clusters were in economically developed areas centered on major cities such as Jinan, Qingdao and Yantai cities, and the cluster areas of male cases and female cases were different significantly. To control the spread of HIV, more classified prevention and education should be done for MSM in urbans areas and female in western rural areas, such as cracking down on sex workers, expanding the coverage of HIV testing, and implementing condom use planning. The proportion of HIV/AIDS aged 50 years and older increased rapidly, measures should be taken to deal with the increasing. Interpretation HIV care continuum in Shandong, China was affected by the COVID-19 epidemic at various levels. Efforts to maintain the HIV care continuum during public health emergencies should leverage collaborations between stakeholders. Declarations Conflicts of interest The authors declare no conflicts of interest. Ethical approval All data used in this study were anonymized to protect the privacy of participants. The research protocol was approved by the Ethical Committee of Prevention Medicine of Shandong Center for Disease Control and Prevention (ethical code: SL2023-040-01). Declaration of Competing Interest The authors report no declarations of interest. Funding source This work was supported by Natural Science Foundation of Shandong Province (ZR2022MH160, ZR2014HQ038), and Medical and Health Science and Technology Development Plan of Shandong Province (202312050984). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. Author Contribution Ling Li, Na Zhang and Xingguang Yang supervised and designed the study, revised the manuscript. Ling Li and Haiying Yu analyzed the data, Ling Li, Xiaoyan Zhu, Lianzheng Hao and Guoyong Wang conducted the investigation, Ling Li and Meizhen Liao wrote the main manuscript text, All authors read and approved the final manuscript. Acknowledgement The authors are thankful to all the staff members of the HIV/AIDS Case Reporting System in Shandong Province. References Van Schalkwyk C, Mahy M, Johnson LF, Imai-Eaton JW. 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COVID–19: immunopathogenesis and Immunotherapeutics. Signal Transduct Target Ther. 2020;5:128. 10.1038/s41392-020-00243–2 . Lesko CR, Bengtson AM. HIV and COVID–19: Intersecting Epidemics With Many Unknowns. Am J Epidemiol. 2021;190(1):10–6. 10.1093/aje/kwaa158 . Shi L, Tang W, Hu H, Qiu T, Marley G, Liu X, et al. The impact of COVID–19 pandemic on HIV care continuum in Jiangsu, China. BMC Infect Dis. 2021;21(1):768. 10.1186/s12879-021-06490–0 . Puyat JH, Fowokan A, Wilton J, Janjua NZ, Wong J, Grennan T, COVAXHIV Study Team, et al. Risk of COVID–19 hospitalization in people living with HIV and HIV-negative individuals and the role of COVID–19 vaccination: A retrospective cohort study. Int J Infect Dis. 2023;135:49–56. 10.1016/j.ijid.2023.06.026 . Mao Y, Wu Z, Poundstone K, Wang C, Qin Q, Ma Y, et al. Development of a unified web-based national HIV/AIDS information system in China. Int J Epidemiol. 2010;39(Suppl 2):ii79–89. 10.1093/ije/dyq213 . Kulldorff M. A spatial scan statistic. Commun Stat Theory Methods. 1997;26:1481–96. Yuan FS, Liu L, Liu LH, Zeng YL, Zhang LL, He F, et al. Epidemiological and spatiotemporal analyses of HIV/AIDS prevalence among older adults in Sichuan, China between 2008 and 2019: A population-based study. Int J Infect Dis. 2021;105:769–75. 10.1016/j.ijid.2021.02.077 . Zhang RH, Li YJ, Xiao M, Zhang N, Liao MZ, Huang PX et al. Virological effect and influencing factors for HIV/AIDS patients after one-year antiretroviral treatment in Heze City from 2011 to 2020. Chin J AIDS STD 2023 Nov 29; 29(11):1231–4. 10.13419/j.cnki.aids.2023.11.13 . Solomon M, Furuya-Kanamori L, Wangdi K. Spatial Analysis of HIV Infection and Associated Risk Factors in Botswana. Int J Environ Res Public Health. 2021;18(7):3424. 10.3390/ijerph18073424 . Carrel M, Janko M, Mwandagalirwa MK, Morgan C, Fwamba F, Muwonga J, et al. Changing spatial patterns and increasing rurality of HIV prevalence in the Democratic Republic of the Congo between 2007 and 2013. Health Place. 2016;39:79–85. 10.1016/j.healthplace.2016.02.009 . Epub 2016 Mar 11. Zhang N, Yang XG, Wang GY, Tao XR, Kang DM, Wang N. Spatiotemporal characteristics of HIV/AIDS in Shandong province, 2009–2015. Zhonghua Liu Xing Bing Xue Za Zhi. 2017;38(2):226–230. Chinese. 10.3760/cma.j.issn.0254–6450.2017.02.018 . Liang Y, Xu YK, Fan PY, Zhao DY, Shi JC, Yan JZ. Epidemiological characteristics of newly reported HIV-infected cases aged 50 years and above in Henan province, 1995–2020. Zhonghua Liu Xing Bing Xue Za Zhi. 2022;43(12):1912–9. 10.3760/cma.j.cn112338-20220419-00320 . Chinese. Deng XF, Liu JH, Tang HY, Zhong YQ, Nong MN, Cen P, et al. To Explore the Impact of COVID–19 on HIV /AIDS Case Report in Nanning. Chin J Dermatovenereol. 2021;35(11):1257–61. 10.13735/j.cjdv.1001–7089.202105096 . Kimberly S, Jessica S, Taylor MM. ,LB–6. Increased Diagnoses of Acute HIV Infection through Routine ED Screening and Rapid Linkage to Care and initiation of HAART During the COVID–19 Pandemic[J].Open Forum Infectious Diseases(Supplement_1): Supplement_1 [2024-04-10]. 10.1093/ofid/ofaa515.1903 . Chang JJ, Bruxvoort K, Chen LH, Akhavan B, Rodriguez J, Hechter RC, Brief Report. COVID–19 Testing, Characteristics, and Outcomes Among People Living With HIV in an Integrated Health System. J Acquir Immune Defic Syndr. 2021;88(1):1–5. 10.1097/QAI.0000000000002715 . Tesoriero JM, Swain CE, Pierce JL, Zamboni L, Wu M, Holtgrave DR, et al. COVID–19 Outcomes Among Persons Living With or Without Diagnosed HIV Infection in New York State. JAMA Netw Open. 2021;4(2):e2037069. 10.1001/jamanetworkopen.2020.37069 . Han J, Su Y, Zhou ZJ, Wang KR, Yu YP, Huang HJ, et al. Analysis of antiretroviral medicine availability to people living with HIV from different designated medical institutions during the COVID–19 pandemic. Chin J AIDS STD. 2020;26(7):698–700. 10.13419/j.cnki.aids.2020.07.06 . Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4645289","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":319846984,"identity":"44783549-39b0-498a-961c-d2151df39e90","order_by":0,"name":"Ling Li","email":"","orcid":"","institution":"Shandong Center for Disease Control and Prevention","correspondingAuthor":false,"prefix":"","firstName":"Ling","middleName":"","lastName":"Li","suffix":""},{"id":319846985,"identity":"b269f16e-606e-46a0-b6c2-93f3d929237a","order_by":1,"name":"Na Zhang","email":"","orcid":"","institution":"Shandong Center for Disease Control and Prevention","correspondingAuthor":false,"prefix":"","firstName":"Na","middleName":"","lastName":"Zhang","suffix":""},{"id":319846986,"identity":"1e335499-2a7c-432c-8284-f22136149d4f","order_by":2,"name":"Xingguang Yang","email":"","orcid":"","institution":"Shandong Center for Disease Control and Prevention","correspondingAuthor":false,"prefix":"","firstName":"Xingguang","middleName":"","lastName":"Yang","suffix":""},{"id":319846989,"identity":"345bc928-0bd5-45c1-bec7-618606fd85e8","order_by":3,"name":"Xiaoyan Zhu","email":"","orcid":"","institution":"Shandong Center for Disease Control and Prevention","correspondingAuthor":false,"prefix":"","firstName":"Xiaoyan","middleName":"","lastName":"Zhu","suffix":""},{"id":319846990,"identity":"261a60f4-2021-4469-b319-45ffde47c56a","order_by":4,"name":"Lianzheng Hao","email":"","orcid":"","institution":"Shandong Center for Disease Control and Prevention","correspondingAuthor":false,"prefix":"","firstName":"Lianzheng","middleName":"","lastName":"Hao","suffix":""},{"id":319846992,"identity":"c7b5f132-6497-43ad-b756-31255b451b09","order_by":5,"name":"Haiying Yu","email":"","orcid":"","institution":"Shandong Center for Disease Control and Prevention","correspondingAuthor":false,"prefix":"","firstName":"Haiying","middleName":"","lastName":"Yu","suffix":""},{"id":319846994,"identity":"e0532f95-daf3-4954-89df-1e003a4cea34","order_by":6,"name":"Meizhen Liao","email":"","orcid":"","institution":"Shandong Center for Disease Control and Prevention","correspondingAuthor":false,"prefix":"","firstName":"Meizhen","middleName":"","lastName":"Liao","suffix":""},{"id":319846995,"identity":"b497b4ef-3984-4523-8cd2-f98af4d84e46","order_by":7,"name":"Guoyong Wang","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAoElEQVRIiWNgGAWjYFACHjaGBxUScvKkaUk4Y2Fs2ECSlsS2ikSGA8RqMDh/9tiDxHkSCYwNzA8f3SBKy428dIPEbRJ57AxsxsY5xGnhMZMAailmbOBhkyZOy/kzQC1zJBIbDhCt5UAOUEsDKVokbwC1JByTMDZsJtYvfCCHfaipk5Nnb374mCgtCgdgLGZilIOAfAOxKkfBKBgFo2DkAgA2Ti6iAG2c9QAAAABJRU5ErkJggg==","orcid":"","institution":"Shandong Center for Disease Control and Prevention","correspondingAuthor":true,"prefix":"","firstName":"Guoyong","middleName":"","lastName":"Wang","suffix":""}],"badges":[],"createdAt":"2024-06-27 01:21:16","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4645289/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4645289/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":60710355,"identity":"72a3f3aa-d556-4c3c-bc4d-37c2cd1df69b","added_by":"auto","created_at":"2024-07-19 20:02:36","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":301982,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eDistribution of transmission routes of HIV/AIDS ( Two pictures on the left ) and\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eexposure history of heterosexual HIV/AIDS ( Two pictures on the right ) during 2016 to 2022 in Shandong, China. a \u003c/strong\u003eDistribution of male HIV/AIDS transmission routes; \u003cstrong\u003eb\u003c/strong\u003eDistribution of female HIV/AIDS transmission routes; \u003cstrong\u003ec \u003c/strong\u003eDistribution of exposure history of male heterosexual\u003c/p\u003e\n\u003cp\u003eHIV/AIDS; \u003cstrong\u003ed\u003c/strong\u003eDistribution of exposure history of female heterosexual HIV/AIDS.\u003c/p\u003e","description":"","filename":"Figure1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4645289/v1/157e1862df2cf8fd5c556da8.jpg"},{"id":60709363,"identity":"80b20289-ad17-421c-b7e4-c720861b907d","added_by":"auto","created_at":"2024-07-19 19:54:37","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":818216,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eThe spatial distribution of HIV clusters reported during 2016 to 2022. a \u003c/strong\u003eDistribution of HIV clusters of all cases; \u003cstrong\u003eb \u003c/strong\u003eDistribution of HIV clusters of male cases; \u003cstrong\u003ec \u003c/strong\u003eDistribution of HIV clusters of female cases.\u003c/p\u003e","description":"","filename":"Figure2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4645289/v1/51c1eef7f1b6d01319fc3b91.jpg"},{"id":81539606,"identity":"d677125b-cb2d-414a-b1e1-05bb618d8fd6","added_by":"auto","created_at":"2025-04-28 11:01:56","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2250573,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4645289/v1/c353e5e0-ebdb-416a-abe9-2a7b088a4f54.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Epidemiological and spatial analyses of HIV/AIDS prevalence in Shandong, China from 2016 and 2022: A population-based study","fulltext":[{"header":"Introduction","content":"\u003cp\u003eThere are currently 39\u0026nbsp;million people living with HIV (PLWH) worldwide as of the end of 2022. Although the number of new infections is declining, the pace is insufficient to meet the targets set by the United Nations Political Declaration on HIV/AIDS, which aims for fewer than 350,000 new infections by 2030 [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. In China, there have been two important outbreaks of HIV infection since the first case was reported in 1985. The first stage was dominated by HIV/AIDS infected through injecting drug, and the second was by commercial blood/plasma donors [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Heterosexual transmission is the main transmission route of HIV/AIDS in China nowadays [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Unlike injecting drug users and commercial blood/plasma donors, the population at high risk of HIV infection through sexually behavior are difficult to be found and intervened.\u003c/p\u003e \u003cp\u003eShandong had the second largest permanent population and third highest GDP in China in 2023 [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e], but the number of reported HIV/AIDS here was less than most provinces in China [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. The main transmission route of HIV/AIDS here was sexual behaviors, of which homosexual transmission accounted for about 70% [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Although Shandong Province has adopted a series of public health programs and interventions to curb transmission of HIV, the results were not satisfactory. Huang et al. [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e] observed the incidence of new drug abuse of a MSM cohort in Qingdao city, one city in Shandong Province, was 6.80/100 person-years, and the proportion of unprotected anal sex and group sex after using new type drugs was 93.55% and 48.39%. The study conducted by Huang et al. [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e] found that 87.5% of MSM had anal sex in the last 6 months, 30.4% of them had never used condoms, and 41.4% could not insist on using condoms every time in Qingdao city and Jinan city, Shandong Province. Wang et al. [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e] found that although the HIV related knowledge awareness rate of MSM was 96.94%, 16.29% had group anal sex and 63.00% had not been tested for HIV in the last 6 months in Shandong Province. In addition, an increasing rate of female cases were transmitted through non-marital non-commercial heterosexual behaviors, for whom the general publicity interventions would not acquire satisfactory achievement [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Although pre-exposure prophylaxis (PrEP) and post-exposure prophylaxis (PEP) is now proposed to play a very important role in blocking sexual transmission, the utilization was limited by high cost and limited resources [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Many studies suggest that there is a significant difference in HIV prevalence across regions [\u003cspan additionalcitationids=\"CR12\" citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Geographical spacial analysis plays an important role in the identification of the cluster area of HIV epidemic. So identifying high-risk population and HIV clustered areas to implement targeted interventions was required, such as PrEP campaigns, HIV testing, distributing free condoms, educations to decrease the incidence of HIV.\u003c/p\u003e \u003cp\u003eThe COVID-19 outbreak was declared a pandemic by the World Health Organization on March 11, 2020 [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Some studies have suggested that the COVID-19 pandemic had an impact on the HIV epidemic [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Shi et al.[\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e] believed that the COVID-19 pandemic had a negative impact on the HIV healthcare system including patients' access to HIV care in Jiangsu Province, China. A study in Canada [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e] found that PLWH had about two times the risk of COVID-19 hospitalization than HIV-negative individuals in crude analyses by propensity score-weighted models.\u003c/p\u003e \u003cp\u003eConsequently, we utilized case report data to analyze the epidemiological characters and spatiotemporal trends of HIV/AIDS reported during 2016\u0026ndash;2022 in Shandong, China and searched for HIV clustered areas, so as to take targeted efforts to close disparities in resources for prevention and control. Furthermore, by comparing difference of the reported cases number, crude death rate, and HIV care status of HIV/AIDS before and during the COVID-19 pandemic, we explored the impact of COVID-19 pandemic on the HIV epidemic.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy area\u003c/h2\u003e \u003cp\u003eThe study area is Shandong Province, located on the east coast of China, the Yellow River mouth area,located in eastern China (114\u0026deg;47.5\u0026prime;-122\u0026deg;42.3\u0026prime;, 34\u0026deg;22.9\u0026prime;~38\u0026deg;24.01\u0026prime;), has a resident population of approximately 1.01\u0026nbsp;billion [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Shandong Province borders Hebei, Henan, Anhui and Jiangsu provinces from north to south, and has 16 prefecture-level cities, which comprise 139 counties or urban districts. Data on HIV/AIDS cases in all of these areas were covered in this study.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eData sources\u003c/h2\u003e \u003cp\u003eData were obtained from the National HIV/AIDS comprehensive response information management system (CRS), excluding Hong Kong, Macao, Taiwan and foreign cases. The system was established by Chinese Center for Disease Control and Prevention in 1985 and available online since 2005 [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. All health care facilities in China (such as hospitals, centers for Disease Control and Prevention, et al.) must report the case information to this system within 24 hours after HIV/AIDS diagnosis by the principles of HIV/AIDS diagnostics and the Chinese national HIV/AIDS test technology regulation and criteria, respectively. The information reported includes socio-demographic characteristics (age, gender, occupation, education), disease status, route of transmission, and risk behaviors, etc. All data used in this study were anonymized to protect the privacy of participants. The research protocol was approved by the Ethical Committee of Prevention Medicine of Shandong Center for Disease Control and Prevention (ethical code: SL2023-040-01).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eStatistical Analysis\u003c/h2\u003e \u003cp\u003eData were processed and analyzed with SPSS 21.0 (SPSS IBM Inc., Armonk, New York). Linear-by-Linear Association (LLA) test was used to analyze the temporal trend over these years and if a variable had more than 2 categories, it was transformed into a binary variable, that is, the category to be analyzed for a trend was taken as one category, and the total of remaining categories as another category. \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05 was considered statistically significant.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eSpatial analysis\u003c/h2\u003e \u003cp\u003espatial cluster analysis was done with Kulldorff\u0026rsquo;s scan statistic, using the SaTScan\u0026trade; software [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. The spatial scan statistic identifies statistically significant clusters using scanning windows (circular or elliptical) of varying sizes. These windows move around the study area to identify HIV-positive individuals within a window that is more than what is expected by chance. The relative risk (RR) of positive cases for each window is calculated using the observed number of positive and negative individuals within the windows. The highest log-likelihood ratio (LLR) was calculated for each cluster to determine the most likely cluster. A Bernoulli Probability Model was used for this study because of the binomial outcome of interest (HIV-positive and -negative). We ran multiple analyses by setting the maximum spatial cluster size of 50%, 25%, 20% and 15% of the population at risk of HIV infection. The best cluster size was obtained at the maximum spatial cluster size of 25%. The statistically significant clusters with the radius of the scanning window, the number of observed and expected positives within the circle, \u003cem\u003eRR, LLR\u003c/em\u003e and \u003cem\u003eP\u003c/em\u003e value were saved for analysis and mapping. All analyses were run using Monte Carlo replications of 999 for defining clusters and \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05 was considered significant. The significant clusters obtained by SaTScan\u0026trade; were mapped using ArcMap 10.5.1 (ESRI, Redlands, CA, USA).\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eStudy population\u003c/h2\u003e \u003cp\u003eApproximately 19730 HIV/AIDS were reported in Shandong, China, during 2016–2022, with 2,536, 2,718, 2,853, 3,108, 2,825, 3,174 and 2,516 cases in the respective years. The subjects were predominantly male (91.4%), Han nationality (97.7%), 25–49 years old (63.0%), HIV (75.9%). A relatively higher proportion of people registered in Shandong Province (85.8%) and most of the subjects had a junior high school education (31.5%). Larger proportion of cases were single (62.1%), transmitted through homosexual behavior (69.7%). In every counties of China, CDC and hospital had setted up HIV voluntary counseling and testing (VCT) clinic providing free test. In our research, VCT (36.9%) and hospitals (49.6%) were the main resources for HIV diagnosis. 11.6% HIV/AIDS had history of STD, 27.4% were lately diagnosed, 94.8% received CD4 test, 78.7% received ART, and 4.6% died in their reporting year (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Among 5719 cases transmitted by heterosexual behavior, female cases were mainly transmitted through non-marital non-commercial sexual behaviors (60.7%) and sexual behaviors with their spouse (34.7%), but male cases were mainly commercial heterosexual sexual behaviors (41.9%) and non-marital non-commercial heterosexual sexual behaviors (51.6%) (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003eTrend analysis\u003c/h2\u003e \u003cp\u003eAmong all HIV/AIDS, the proportion of cases aged 50 years and older increased from 13.1% (2016) to 26.7% (2022) (\u003cem\u003eLLA statistic\u003c/em\u003e = 222.872, \u003cem\u003eP\u003c/em\u003e \u0026lt; 0.05); the proportion of cases of Han nationality increased from 96.6% (2016) to 97.7% (2022) (\u003cem\u003eLLA statistic\u003c/em\u003e = 33.018, \u003cem\u003eP\u003c/em\u003e \u0026lt; 0.05); the proportion of cases registered in Shandong province increased from 84.1% (2016) to 85.8% (2022)(\u003cem\u003eLLA statistic\u003c/em\u003e = 7.202, \u003cem\u003eP\u003c/em\u003e \u0026lt; 0.05); the proportion of AIDS increased from 21.1% (2016) to 24.1% (2022)(\u003cem\u003eLLA statistic\u003c/em\u003e = 7.202, \u003cem\u003eP\u003c/em\u003e \u0026lt; 0.05); the proportion of cases transmitted through homosexual behavior increased from 67.3% (2016) to 69.7% (2022) (\u003cem\u003eLLA statistic\u003c/em\u003e = 58.509, \u003cem\u003eP\u003c/em\u003e \u0026lt; 0.05); the proportion of cases diagnosed by hospital increased from 40.5% (2016) to 49.6% (2022) (\u003cem\u003eLLA statistic\u003c/em\u003e = 227.721, \u003cem\u003eP\u003c/em\u003e \u0026lt; 0.05); the proportion of cases with college degree or above increased from 31.6% (2016) to 32.3% (2022) (\u003cem\u003eLLA statistic\u003c/em\u003e = 5.493, \u003cem\u003eP\u003c/em\u003e \u0026lt; 0.05); the proportion of cases received CD4 test decreased from 95.0% (2016) to 94.8% (2022) (\u003cem\u003eLLA statistic\u003c/em\u003e = 9.024, \u003cem\u003eP\u003c/em\u003e \u0026lt; 0.05); the proportion of cases received ART increased from 62.5% (2016) to 78.7% (2022) (\u003cem\u003eLLA statistic\u003c/em\u003e = 966.343, \u003cem\u003eP\u003c/em\u003e \u0026lt; 0.05); the proportion of cases diagnosed later increased from 21.4% (2016) to 25.5% (2022) (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e\u003cdiv class=\"gridtable\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eTrends of epidemic characteristics for HIV/AIDS in Shandong Province from 2016 to 2022\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e\u003ccolgroup cols=\"9\"\u003e\u003c/colgroup\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariables\u003c/p\u003e \u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2016\u003c/p\u003e \u003cp\u003e\u003cem\u003eN (%)\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2017\u003c/p\u003e \u003cp\u003e\u003cem\u003eN (%)\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2018\u003c/p\u003e \u003cp\u003e\u003cem\u003eN (%)\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2019\u003c/p\u003e \u003cp\u003e\u003cem\u003eN (%)\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2020\u003c/p\u003e \u003cp\u003e\u003cem\u003eN (%)\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e\u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003e2021\u003c/p\u003e \u003cp\u003e\u003cem\u003eN (%)\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e\u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003e2022\u003c/p\u003e \u003cp\u003e\u003cem\u003eN (%)\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e\u003cth align=\"left\" colname=\"c9\"\u003e \u003cp\u003eSummation\u003c/p\u003e \u003cp\u003e\u003cem\u003eN (%)\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGender\u003c/p\u003e \u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003emale\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2327(91.8)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2486(91.5)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2609(91.4)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2850(91.7)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2571(91.0)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e2920(92.0)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e2270(90.2)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e18033(91.4)\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003efemale\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e209(8.2)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e232(8.5)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e244(8.6)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e258(8.3)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e254(9.0)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e254(8.0)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e246(9.8)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e1697(8.6)\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAge of diagnosis\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colspan=\"6\" nameend=\"c7\" namest=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026lt; 15\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12(0.5)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12(0.4)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e11(0.4)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e12(0.4)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e6(0.2)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e8(0.3)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e11(0.4)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e72(0.4)\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e15–24\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e468(18.5)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e500(18.4)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e519(18.2)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e542(17.4)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e505(17.9)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e556(17.5)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e368(14.6)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e3458(17.5)\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e25–49\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1724(68.0)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1829(67.3)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1850(64.8)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1932(62.2)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1706(60.4)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e1932(60.9)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e1464(58.2)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e12437(63.0)\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e≥ 50*\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e332(13.1)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e377(13.9)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e473(16.6)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e622(20.0)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e608(21.5)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e678(21.4)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e673(26.7)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e3763(19.1)\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eNationality\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHan nationality*\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2451(96.6)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2634(96.9)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2773(97.2)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3054(98.3)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2781(98.4)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e3118(98.2)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e2472(98.3)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e19283(97.7)\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMinority nationality\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e85(3.4)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e84(3.1)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e80(2.8)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e54(1.7)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e44(1.6)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e56(1.8)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e44(1.7)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e447(2.3)\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eRegistered area\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eShandong province*\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2133(84.1)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2335(85.9)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2428(85.1)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2670(85.9)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2457(87.0)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e2730(86.0)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e2181(86.7)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e16934(85.8)\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eThe other province\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e403(15.9)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e383(14.1)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e425(14.9)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e438(14.1)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e368(13.0)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e444(14.0)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e335(13.3)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e2796(14.2)\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eDisease phases\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHIV\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2000(78.9)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2083(76.6)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2168(76.0)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2358(75.9)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2082(73.7)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e2400(75.6)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e1877(74.6)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e14968(75.9)\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAIDS*\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e536(21.1)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e635(23.4)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e685(24.0)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e750(24.1)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e743(26.3)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e774(24.4)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e639(25.4)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e4762(24.1)\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eRoute of transmission\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHomosexual*\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1707(67.3)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1811(66.6)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1926(67.5)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2125(68.4)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1958(69.3)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e2399(75.6)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e1816(72.2)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e13742(69.7)\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHeterosexual\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e766(30.2)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e847(31.2)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e872(30.6)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e940(30.2)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e852(30.2)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e760(23.9)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e682(27.1)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e5719(29.0)\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eThe other\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e63(2.5)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e60(2.2)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e55(1.9)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e43(1.4)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e15(0.5)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e15(0.5)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e18(0.7)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e269(1.4)\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eResource of diagnosis\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHospital*\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1026(40.5)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1184(43.6)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1360(47.7)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1541(49.6)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1548(54.8)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e1679(52.9)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e1457(57.9)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e9795(49.6)\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVCT\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1073(42.3)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1088(40.0)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1097(38.5)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1133(36.5)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e945(33.5)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e1125(35.4)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e813(32.3)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e7274(36.9)\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eThe other\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e437(17.2)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e446(16.4)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e396(13.9)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e434(14.0)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e332(11.8)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e370(11.7)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e246(9.8)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e2661(13.5)\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eDegree of education\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePrimary and below\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e254(10.0)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e257(9.5)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e289(10.1)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e339(10.9)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e356(12.6)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e350(11.0)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e306(12.2)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e2151(10.9)\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eJunior high school\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e827(32.6)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e876(32.2)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e896(31.4)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1024(32.9)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e877(31.0)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e938(29.6)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e783(31.1)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e6221(31.5)\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHigh school or technical secondary school\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e654(25.8)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e747(27.5)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e730(25.6)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e787(25.3)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e668(23.6)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e785(24.7)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e608(24.2)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e4979(25.2)\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCollege degree or above*\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e801(31.6)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e838(30.8)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e938(32.9)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e958(30.8)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e924(32.7)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e1101(34.7)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e819(32.6)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e6379(32.3)\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHistory of STD\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e296(11.7)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e356(13.1)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e317(11.1)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e346(11.1)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e353(12.5)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e343(10.8)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e285(11.3)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e2296(11.6)\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNone/unknown\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2240(88.3)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2362(86.9)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2536(88.9)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2762(88.9)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2472(87.5)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e2831(89.2)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e2231(88.7)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e17434(88.4)\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMarital status\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSingle\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1573(62.0)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1686(62.0)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1779(62.4)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1888(60.7)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1701(60.2)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e2039(64.2)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e1596(63.4)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e12262(62.1)\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMarried/ had permanent sexual partner\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e958(37.8)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1028(37.8)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1070(37.5)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1209(38.9)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1118(39.6)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e1127(35.5)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e915(36.4)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e7425(37.6)\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUnknown\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5(0.2)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4(0.1)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4(0.1)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e11(0.4)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e6(0.2)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e8(0.3)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e5(0.2)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e43(0.2)\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eLate diagnosis\u003c/b\u003e\u003csup\u003e\u003cb\u003e\u0026amp;\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes*\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e516(21.4)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e637(24.5)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e720(26.5)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e756(25.6)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e739(27.5)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e763(25.8)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e645(27.1)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e4776(25.5)\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1892(78.6)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1967(75.5)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1993(73.5)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2197(74.4)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1951(72.5)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e2194(74.2)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e1735(72.9)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e13929(74.5)\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eCD4 test\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes*\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2408(95.0)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2604(95.8)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2713(95.1)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2953(95.0)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2690(95.2)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e2957(93.2)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e2380(94.6)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e18705(94.8)\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e128(5.0)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e114(4.2)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e140(4.9)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e155(5.0)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e135(4.8)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e217(6.8)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e136(5.4)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e1025(5.2)\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eART\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes*\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1584(62.5)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1810(66.6)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2198(77.0)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2480(79.8)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2427(85.9)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e2837(89.4)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e2198(87.4)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e15534(78.7)\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e952(37.5)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e908(33.4)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e655(23.0)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e628(20.2)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e398(14.1)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e337(10.6)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e318(12.6)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e4196(21.3)\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eDeath\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2426(95.7)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2605(95.8)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2729(95.7)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2952(95.0)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2683(95.0)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e3045(95.9)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e2375(94.4)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e18815(95.4)\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e110(4.3)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e113(4.2)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e124(4.3)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e156(5.0)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e142(5.0)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e129(4.1)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e141(5.6)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e915(4.6)\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"9\"\u003e\u003cb\u003eNotes\u003c/b\u003e: \u003csup\u003e\u0026amp;\u003c/sup\u003e Late diagnosis was defined as a patient with CD4 less than 200/\u003cem\u003eµL\u003c/em\u003e at diagnosis, and 5.2% (1025/19730) HIV/AIDS were eliminated due to they had not test CD4; * the trend of these variables were analyzed and significant change ware observed (\u003cem\u003eP\u003c/em\u003e \u0026lt; 0.05).\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e \u003cp\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003eSpatial analysis\u003c/h2\u003e \u003cp\u003eThe cumulative cases reported from 2016 to 2022 were mainly concentrated in eastern and Central areas of Shandong, including the three clusters covering Jinan, Qingdao and Yantai and one cluster appeared in the border area of Weifang, Zibo, Binzhou and Dongying cities (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003ea). The male clusters were distributed significantly different with female cases (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003eb). The cluster areas of male cases were similar to the cluster areas of the whole HIV/AIDS, while the clusters of female cases were in the western areas, including the whole Heze City, the border area of Linyi, Jining and Zaozhuang cities, Guangrao County of Dongying and Gangcheng District of Jinan City (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003ec).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eIn Shandong Province, the proportion of HIV/AIDS transmitted through homosexual behaviors was higher than most regions of China [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. The lower proportion of heterosexual transmitted cases maybe due to Shandong Province was the hometown of Confucius and was deeply influenced by Confucianism, people here had the conservative sexual concepts and lower acceptance of extramarital sex. On the other hand, the well-developed industry and commerce attracted immigrant population, including some MSM, from western and northern areas of China. The results showed that the proportion of HIV/AIDS over 50 years old increased year by year, which is as same as studies in other provinces of China [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. The sexual demands of older people were often neglected in China and unprotected sexual exposures remained common, which in turn increased the risk of HIV transmission in old people [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Some studies [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e] have suggested that older HIV/AIDS were more susceptible to comorbidity, so we must focus on the vulnerabilities of these people and provide public health programs. The occupations reported in Shandong Province were mainly farmers, housekeeping, housework and unemployed, workers and business service staffs, all these above had not regular jobs. In order to earn more money, farmers in China would like to look for a temporary job in the city. They knew less about AIDS prevention and treatment, had a high risk of infection. Their job was not fixed, and when they lost jobs or their labor force declined, they would return to countryside and became the infectious resource. Zhang et al [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e] found that the ART effect of farmer cases was worse than that of non-farmer cases in Heze City, Shandong Province, all these above suggested immigrant population were still the focus of intervention.\u003c/p\u003e\u003cp\u003eA wide range of economic and socio-cultural factors are responsible for increasing the vulnerability of African women to HIV infection [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. Some spatial analyses of the HIV also found that HIV clusters tend to be in economically developed areas [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. People living in economically developed areas have more open sexual concepts, more convenient ways finding temporary sexual partners. This study detected that the clustered areas of HIV/AIDS during 2016 to 2022 were mainly in the urban areas centered of Jinan, Qingdao and Yantai cities, three cities with GDP ranked the top three in Shandong Province. There are more clubs, bars and gay meeting places in these cities. MSM are more active in economically developed areas, and had higher incidence of unprotected anal sex and group sex [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e], and the higher utilization rate of new type drugs [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e], all these would increase risk of HIV transmission. In addition, studies of Congo have shown a gradual spread of AIDS from more developed cities to rural areas [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. This study found that the HIV clusters in Shandong Province fully covered the spatial clusters found in 2016 [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e], and the scope was expanded, which may be due to the spread of HIV from urban to rural areas.\u003c/p\u003e\u003cp\u003eThe cluster areas of male cases were also in urban areas, similar to the cluster areas of the whole cases perhaps due to the HIV/AIDS were dominated by MSM cases in Shandong. Female cases clusters, distributed in western areas, were quitely different with male cases. In Henan Province of China, HIV/AIDS were mainly transmitted by heterosexual behavior [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. Heze city bordered Henan province, so maybe affected. In addition, the female HIV clusters were located in the inland area where the industry and commerce are relatively poor. So a large number of people here went to Coastal areas looking for jobs. Linyi, Jining and Zaozhuang cities, three of the female HIV clusters are adjacent to Jiangsu Province, economically developed provinces and gathering places for migrant workers. Due to the influence of Confucianism, men have ethical pressure to marry and give birth to children. So some migrant workers would go back home, get married, and maybe transmit HIV to their wives or female sexual partners.\u003c/p\u003e\u003cp\u003eFrom 2016 to 2019, the number of HIV/AIDS reported in Shandong Province had been increasing over the years, but since 2020, there had been a decline and the HIV clusters shrank obviously. Sichuan and Guangxi provinces in China had also reported the decline of newly diagnosed HIV/AIDS in 2020 [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. This decline may be related to the epidemic of COVID−19, because medical resources, including most of CDC staffs and doctors in hospitals were engaged in the treatment and prevention of COVID−19, fewer medical resources available for HIV diagnosis [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. In addition, in order to control the spread of COVID−19, China has taken measures such as sealing off areas with more COVID−19 cases and strengthening management of floating population, restricting the movement of people, which may had reduced the occurrence of temporary sex. This could be confirmed partially by that the HIV clusters in Shandong Province were more concentrated and the proportion of cases registered in shandong province increased during 2020–2022. Thirdly, the decrease of infectious resources leads to a decrease of the new diagnosed HIV/AIDS. Research showed that PLWH had not received ART were at elevated risk for COVID−19[\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. For well-controlled HIV/AIDS, the risk of severe COVID−19 outcomes is similar with HIV-negative individuals [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. HIV/AIDS who had not been diagnosed would not know their infectious status so as receive ART, so they would have poor COVID−19 related outcomes. Some studies believed that COVID−19 caused difficulties for PLWH accessing medical resources [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. The study also found a lower CD4 test rate in HIV/AIDS during 2020–2022. No variation for crude mortality rate of HIV/AIDS was found before and during the epidemic of COVID−19, may be due to China had taken measures such as mailing drugs, borrowing drugs from the other provinces, and dispensing drugs for longer time to ensure most HIV/AIDS maintain ART [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. In addition, the reported incidence rate of HIV/AIDS in Shandong Province was lowest in China, and the medical resources on HIV care continuum was relative abundance. Furthermore, PlWH prefered to receive ART as soon as possible due to the fear of the weakened immunity after HIV infection and uncertained access for medical services. The proportion of HIV/AIDS received ART increased, which may had a compensatory effect on the medical resources for ART during the COVID−19 pandemic.\u003c/p\u003e\u003cp\u003eOur study has several limitations. Fristly, the objects of our study were HIV/AIDS cases diagnosed and reported in the CRS, so the epidemiological characters and variation trends of undiagnosed cases would not be analyzed. But the bias could be reduced by intensifying testing and strengthening continuous, ongoing HIV/AIDS surveillance and monitoring systems around the country. Secondly, those undiagnosed cases were at greater risk of death during COVID-19 epidemic, which could lead to an underestimation of the mortality rate of HIV/AIDS, more in-depth research on the undiagnosed HIV/AIDS will be required in future.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eThis study presented that most HIV/AIDS in Shandong province were transmitted through sexual behaviors, among which homosexual transmission appeared an increasing trend. The HIV clusters were in economically developed areas centered on major cities such as Jinan, Qingdao and Yantai cities, and the cluster areas of male cases and female cases were different significantly. To control the spread of HIV, more classified prevention and education should be done for MSM in urbans areas and female in western rural areas, such as cracking down on sex workers, expanding the coverage of HIV testing, and implementing condom use planning. The proportion of HIV/AIDS aged 50 years and older increased rapidly, measures should be taken to deal with the increasing. Interpretation HIV care continuum in Shandong, China was affected by the COVID-19 epidemic at various levels. Efforts to maintain the HIV care continuum during public health emergencies should leverage collaborations between stakeholders.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e \u003ch2\u003eConflicts of interest\u003c/h2\u003e \u003cp\u003eThe authors declare no conflicts of interest.\u003c/p\u003e \u003ch2\u003eEthical approval\u003c/strong\u003e \u003cp\u003eAll data used in this study were anonymized to protect the privacy of participants. The research protocol was approved by the Ethical Committee of Prevention Medicine of Shandong Center for Disease Control and Prevention (ethical code: SL2023-040-01).\u003c/p\u003e\u003ch2\u003eDeclaration of Competing Interest\u003c/h2\u003e \u003cp\u003eThe authors report no declarations of interest.\u003c/p\u003e \u003ch2\u003eFunding source\u003c/h2\u003e \u003cp\u003eThis work was supported by Natural Science Foundation of Shandong Province (ZR2022MH160, ZR2014HQ038), and Medical and Health Science and Technology Development Plan of Shandong Province (202312050984). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eLing Li, Na Zhang and Xingguang Yang supervised and designed the study, revised the manuscript. Ling Li and Haiying Yu analyzed the data, Ling Li, Xiaoyan Zhu, Lianzheng Hao and Guoyong Wang conducted the investigation, Ling Li and Meizhen Liao wrote the main manuscript text, All authors read and approved the final manuscript.\u003c/p\u003e\u003ch2\u003eAcknowledgement\u003c/h2\u003e\u003cp\u003eThe authors are thankful to all the staff members of the HIV/AIDS Case Reporting System in Shandong Province.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eVan Schalkwyk C, Mahy M, Johnson LF, Imai-Eaton JW. J Acquir Immune Defic Syndr. 2024;95(1S):e1\u0026ndash;4. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1097/QAI.0000000000003344\u003c/span\u003e\u003cspan address=\"10.1097/QAI.0000000000003344\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. 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Chin J AIDS STD. 2020;26(7):698\u0026ndash;700. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.13419/j.cnki.aids.2020.07.06\u003c/span\u003e\u003cspan address=\"10.13419/j.cnki.aids.2020.07.06\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"HIV, AIDS, spatial analysis, epidemiological character","lastPublishedDoi":"10.21203/rs.3.rs-4645289/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4645289/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eObjectives\u003c/h2\u003e \u003cp\u003eTo describe epidemiological and spatial characters of HIV/AIDS in Shandong, China during 2016\u0026ndash;2022, and provide scientific reference for HIV prevention.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eData on HIV/AIDS cases was extracted from the National HIV/AIDS comprehensive response information management system. Spatial analysis were conducted with Kulldorff\u0026rsquo;s scan statistic.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eA total of 19730 HIV/AIDS were reported in Shandong, China during 2016\u0026ndash;2022, 69.7% of them were transmitted through homosexual behavior. The proportion of HIV/AIDS aged 50 years and older increased from 13.1\u0026ndash;26.7%. Spatial analysis indicated that the HIV clusters were located in urbans areas with higher economic level. The cluster areas of male cases were distributed in urban areas, but the cluster areas of female cases were in the western areas with backward economy. During the COVID-19 pandemic, the number of newly reported HIV/AIDS decreased, the proportion of patients receiving CD4\u0026thinsp;+\u0026thinsp;T cell test (CD4) decreased, the proportion of patients receiving antiretroviral therapy (ART) had increased in Shandong, China.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eMore prevention and education should be done for MSM in urban areas, and women in the western areas to curl the transmission of HIV. The rapidly increasing proportion of elderly HIV/AIDS should be focused on and responded.\u003c/p\u003e","manuscriptTitle":"Epidemiological and spatial analyses of HIV/AIDS prevalence in Shandong, China from 2016 and 2022: A population-based study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-07-19 19:54:32","doi":"10.21203/rs.3.rs-4645289/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"2fee6095-5825-49a8-b3ab-51762e055a11","owner":[],"postedDate":"July 19th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-04-28T10:53:46+00:00","versionOfRecord":[],"versionCreatedAt":"2024-07-19 19:54:32","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4645289","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4645289","identity":"rs-4645289","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}