HIV Care Continuum Among Newly Diagnosed Student and Non-Student Youths in Hangzhou, China: A Retrospective Analysis (2012–2016)
Introduction
Youths aged 15–24 years represent a critical demographic in the global HIV epidemic, accounting for over 30% of new infections worldwide. In China, this age group has experienced a sharp rise in HIV cases, particularly among students, with infections increasing from 527 cases in 2008 to 2,695 in 2014. Despite advancements in antiretroviral therapy (ART) and national policies promoting free treatment, gaps persist in linking youths to care and achieving viral suppression. This study evaluates the HIV care continuum—specifically ART initiation and viral suppression rates—among student and non-student youths in Hangzhou, China, between 2012 and 2016, to identify disparities and inform targeted interventions.
Methods
Data Source and Study Population
Data were extracted from the Chinese HIV/AIDS Comprehensive Response Information Management System (CRIMS), a national surveillance platform. The analysis included youths aged 15–24 years newly diagnosed with HIV in Hangzhou from 2012 to 2016. Students were defined as individuals enrolled in educational institutions, while non-students included unemployed or employed youths not in school.
Variables and Definitions
Key variables included:
- ART initiation: Proportions starting ART within 30 days, 90 days, and 12 months of diagnosis.
- Viral suppression: Defined as a viral load <400 copies/mm³, measured at 12 months post-diagnosis and 12 months post-ART initiation.
- Demographics: Age, gender, education level, HIV transmission route (homosexual/heterosexual), diagnosis setting (hospital, voluntary counseling and testing [VCT] sites, or other), and CD4+ T-cell counts at diagnosis.
Statistical Analysis
Pearson’s chi-square and Fisher’s exact tests compared differences between student and non-student groups. Analyses were conducted using SPSS 17.0, with statistical significance set at P < 0.05.
Results
Study Population Characteristics
A total of 707 youths were included: 29.6% students (n = 209) and 70.4% non-students (n = 498). Key differences included:
- Age: 83.3% of students were aged 17–22, while 82.7% of non-students were 21–24.
- Gender: All students were male, compared to 92.6% of non-students.
- Education: 89.0% of students had college-level education vs. 49.8% of non-students.
- Transmission route: Homosexual contact predominated (students: 88.0%; non-students: 75.9%).
- Diagnosis setting: Students were more frequently diagnosed at VCT sites (40.2% vs. 30.7%), while non-students were often diagnosed in hospitals (47.8% vs. 39.2%).
ART Initiation Trends
Significant improvements in ART initiation were observed from 2012 to 2016:
- Within 30 days: Increased from 10.6% (2012) to 68.0% (2016) overall. Students consistently outperformed non-students (45.5% vs. 37.0%, P = 0.044).
- Within 90 days: Rates rose from 26.6% to 92.0% overall, with no significant difference between groups (students: 67.0% vs. non-students: 62.7%, P = 0.273).
- Within 12 months: Over 90% initiated ART by 2016, with students showing marginally higher rates (83.7% vs. 78.5%, P = 0.113).
Factors associated with faster ART initiation included:
- Low CD4+ T-cell counts: 90.0% of students with <200 cells/mm³ started ART within 30 days vs. 62.5% of non-students (P = 0.02).
- Younger age: Students aged 17–18 had higher 30-day initiation rates (48.0% vs. 14.3%, P < 0.001).
- Diagnosis at VCT sites: 50.0% of students diagnosed at VCTs initiated ART within 30 days vs. 36.6% of non-students (P < 0.05).
Viral Suppression Rates
Despite improvements in ART access, viral suppression rates remained suboptimal:
- At 12 months post-diagnosis: Only 9.6% of students and 17.1% of non-students achieved suppression (P = 0.011).
- At 12 months post-ART initiation: Suppression rates improved but showed no group difference (students: 69.9% vs. non-students: 71.1%, P = 0.743).
Notably, students with higher CD4+ counts (≥350 cells/mm³) and college education had lower suppression rates post-diagnosis (8.6% vs. 24.7%, P < 0.01; 9.7% vs. 18.5%, P = 0.01).
Discussion
ART Initiation Improvements
The study highlights remarkable progress in ART initiation, attributable to China’s 2012 policy expanding free treatment eligibility to individuals with CD4+ counts <500 cells/mm³. However, disparities persisted:
- Structural barriers: Non-students faced challenges such as unstable housing, employment, and healthcare navigation.
- Late diagnosis: Many youths initiated ART only after significant immune decline (CD4+ <200 cells/mm³), underscoring the need for earlier testing.
Viral Suppression Challenges
Low suppression rates at 12 months post-diagnosis suggest systemic issues in retention and adherence:
- Student-specific barriers: Fear of stigma in academic settings, lack of privacy in dormitories, and financial constraints likely hindered adherence.
- Non-student challenges: Mobile lifestyles, inconsistent routines, and limited social support affected continuity of care.
Implications for Policy
- Tailored interventions: Students may benefit from campus-based counseling and discreet ART delivery, while non-students require community-led support and flexible clinic hours.
- Strengthening VCT services: Expanding VCT access and integrating HIV care into general health services could reduce diagnostic delays.
Conclusion
From 2012 to 2016, Hangzhou achieved significant progress in linking youths to ART, yet viral suppression rates lagged behind global targets. Students demonstrated faster ART initiation but poorer early suppression, while non-students faced systemic barriers to timely care. Addressing these gaps requires youth-specific strategies, including enhanced mental health support, stigma reduction campaigns, and robust follow-up systems. Future research should explore longitudinal adherence patterns and the impact of mobile health technologies on retention.
doi.org/10.1097/CM9.0000000000000264
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