China has a long way to go before it achieves 90-90-90 targets

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 suppression.

“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.


virological suppression

Halting of the function or replication of a virus. In HIV, optimal viral suppression is measured as the reduction of viral load (HIV RNA) to undetectable levels and is the goal of antiretroviral therapy.

90-90-90 target

A target set by the Joint United Nations Programme on HIV/AIDS (UNAIDS) for 90% of people with HIV to be diagnosed, 90% of diagnosed people to be taking treatment, and 90% of people on treatment to have an undetectable viral load. 

vertical transmission

Transmission of an infection from mother-to-baby, during pregnancy, childbirth, or breastfeeding.


continuum of care

A model that outlines the steps of medical care that people living with HIV go through from initial diagnosis to achieving viral suppression, and shows the proportion of individuals living with HIV who are engaged at each stage. 

retention in care

A patient’s regular and ongoing engagement with medical care at a health care facility. 

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.

They hypothesised that there would be inequalities in HIV testing and treatment, despite the existence of a free, inclusive, nationwide, HIV care policy.

An electronic patient surveillance system was used to collect information on patients’ age, gender, HIV risk group, use of ART and viral load.

The investigators 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 MSM.

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, 0.03-0.50).

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.

“Our report 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 equitably.”


Zhang N et al. Disparities in HIV care along the path from infection to viral suppression: a cross-sectional study of HIV/AIDS patient records in 2013, Shandong Province, China. Clin Infect Diseases, online edition, 2016.