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China has a long way to go before it achieves 90-90-90 targets
Michael Carter, 2016-05-04 07:40:00
A study published
in Clinical Infectious Diseases
suggests that China has a long way to go before it achieves UNAIDS 90-90-90
targets. Research conducted in Shandong
Province showed that only 60% of people with HIV were diagnosed; 42% of
diagnosed patients were on antiretroviral therapy (ART) and 60% of ART-treated patients had viral
“Overall, only 15%
of infected patients transitioned through the care continuum from initial
diagnosis to viral suppression,” comment the investigators. “Attrition occurred
at each step of HIV care especially for HIV diagnosis, HAART eligibility for
treatment, and achieving viral suppression.”
There are a number
of key stages in the HIV care continuum: diagnosis, linkage to care, retention
in care, initiation of ART, and viral suppression. Attrition is known to occur
at each step of the care continuum.
The UNAIDS 90-90-90 target calls on countries to reach the following goals:
- 90% of people living with HIV diagnosed by 2020
- 90% of diagnosed people on antiretroviral treatment by 2020
- 90% of people in treatment with fully suppressed viral load by 2020.
China has invested
heavily in HIV testing, care and treatment. Investigators wanted to assess
progress towards achieving the 90-90-90 goals. They therefore conducted a
cross-sectional study of HIV patient records from the coastal province of
Shandong (population, 97 million) in 2013.
that there would be inequalities in HIV testing and treatment, despite the
existence of a free, inclusive, nationwide, HIV care policy.
patient surveillance system was used to collect information on patients’ age,
gender, HIV risk group, use of ART and viral load.
estimated that at the end of 2013 there were 6500 people living with HIV in
the province. Most infections (85%) were in men and 59% involved MSM (men who have sex with men), with 38%
of infections involving individuals aged between 25 and 35 years.
Sixty per cent of infections were estimated to have been diagnosed, and three-quarters of undiagnosed infections were estimated to be in
Overall, 50% of people with HIV (diagnosed and undiagnosed) were linked to care and 41% were
subsequently retained in care.
Of those diagnosed with HIV, 83% were linked to care and 81% of those linked to care were subsequently retained in care.
Compared to people who acquired HIV through blood donation/transfusion, children who acquired HIV via
vertical transmission (as babies, during pregnancy, birth or breastfeeding) were over 40% less likely to be linked to
care (OR, 0.58; 95% CI, 0.40-0.90) and people who reported injecting drug use were 70% less
likely (OR, 0.33, 95% CI, 0.14-0.80). People aged between 15 and 24 years were
almost half as likely to be retained in care compared to people aged over 55
years (OR, 0.48; 95% CI, 0.27-0.84). Individuals tested when in custody were
less likely to attend follow-up appointments than those tested at medical
facilities (OR, 0.43; 95% CI, 0.25-0.76).
Just over two thirds (67%) of those retained in care were eligible
for HIV treatment under Chinese treatment guidelines recommending
treatment at CD4 counts below 500 from 2014 (below 350 prior to that
date). Of these, 91% were receiving treatment.However, looking at
the data another way, the investigators noted that 58% of people
diagnosed with HIV had no record of a prescription for ART.
Compared to people who acquired HIV via blood
donation/transfusion, those who acquired HIV sexually and by injecting drugs were
less likely to be eligible for ART, and children who acquired HIV via vertical transmission were less
likely to be eligible than people aged 55 and over.
People who reported injecting drugs were considerably less likely to be prescribed antiretrovirals compared
to people who acquired HIV via blood donation/transfusion (OR, 0.12%, 95% CI,
Only one-in-seven people with HIV had an undetectable viral load. Of people on ART,
only 60% were virally suppressed. Compared to people who acquired HIV via blood
donation/transfusion, children who acquired HIV via vertical transmission were 93% less likely to be
virally suppressed (OR, 0.07; 95% CI, 0.02-0.20). MSM (OR, 0.18; 95% 0.09-0.34)
and people who acquired HIV via heterosexual sex (OR, 0.12; 95% CI, 0.06-0.22) were
significantly less likely to achieve an undetectable viral load than people who acquired HIV via blood donation/transfusion.
The investigators say that lower rates of treatment among people who inject drugs may be explained by incarceration and by loss to follow up after release. High levels of stigma are also thought to contribute to the disparities between groups.
suggests, at the current rate, Shandong Province has to accelerate HIV care
efforts to close disparities in HIV care and achieve the 90-90-90 goals