Analysis on epidemiological characters and HIV care continuum of HIV-infected students: a retrospective cohort study in Shandong province, China

This study analyzed the epidemiological characters and HIV care status of HIV-infected students in Shandong province during 2017 to 2019. From 2017 to 2019, 403 HIV-infected students were reported in Shandong Province, most of them were male and homosexual transmitted. They mainly distributed in Jinan city and Qingdao city. 276 cases (68.5%.) accepted CD4 test in 30 days, and 196 cases (48.6%) started ART in 30 days.The heterosexual route, area they accepted HIV care were associated with the timeliness of CD4 test. The age, accepted CD4 test within 30 days or not, diagnosis source and area they accepted HIV care were associated with the timeliness of ART.

This study shows that most student cases were detected through VCT, which may be related with that young students knew more AIDS related knowledge, they could actively look for professional help after unsafe sexual behavior. In Shandong Province, MSM occupied 92.1% of all the students cases, so publicity and education for MSM is the key for eliminating the spread of AIDS among young students. High-risk behaviors during them such as unprotected sex, multiple sex partners and temporary partner [35‐37] still occurred due to the separation of knowledge, belief and practice. And this group is harder to reach for CDC staffs, some people reached the populations through collaboration with gay-friendly CBO [38].Non-occupational postexposure prophylaxis (nPEP) was an effective means of prevention [39], but the cost was high for students. Treatment and care interventions are still effective interventions for these populations.

In this study, 276 cases (68.5%) tested CD4 within 30 days after diagnosis; 196 cases (48.6%) received ARTwithin 30 days after diagnosis. Although these proportion were higher than the survey results of 15–24 years HIV infected students in Hangzhou city conducted by Yan et al [40], they were still not high. More efforts should be done to encourage young students to receive CD4 test and ART as soon as possible. Some studies found that delaying in CD4 test was associated with older age, low education level, injection or routes of transmission, HIV diagnosis in a hospital or in a detention center, and being a migrant worker [41]. However, in our study, young students had relatively similiar education level and age, so only the transmission route was found be associated with delaying in CD4 test.

A cross-sectional survey including HIV infected patient in 19 hospitals across Spain showed that people living with HIV (PLWH) didn’t start ART was associated with limited doctors and medical resource [42]. There was also research showed that medical staffs had influence on the ART effect of patient [43]. In Shandong Province, east coastal areas, including Qingdao, Weihai and Yantai city, et al., have more developed economy, abundant medical resources, and more higher level medical staff equipped to do HIV care. So this study showed that patients accepted HIV care in central area (AOR = 0.407; 95%CI: 0.251–0.657) and western area (AOR = 0.508; 95%CI: 0.261–0.989) were less willing to receive ART within 30 days than that in eastern area. We also found that cases aged 23 years and above prefered to receive ART within 30 days than those aged 15–22 (AOR = 2.316, 95%CI: 1.009–5.316), maybe attributing to students aged 15–22 were inconvenient to get and take medicine. 15–22 years old students mainly lived in school with their classes and did not want other people know their infectious status due to shame and stigma [44], all these will add difficulty for young students take medicine. Jiao et al [45] showed that digital intervention could improve ART adherence. Designing more privacy-friendly pill boxes for residential students may be beneficial for students to take medicine. Notably, this study found that patients diagnosed through voluntary blood donation were less willing to receive ART in 30 days than those detected through VCT (AOR = 0.352; 95%CI: 0.144–0.864). This may be related to a lapse of patients in referral to a treatment hospital from detection sites. Staffs in blood donation agency usually did not understand the treatment knowledge and the initiation time of treatment, so they could not adequately inform and refer patients. Study in Vietnam [46] also showed that clinical characteristics (time and facility at first time received HIV-positive result) were associated with HAART non-adherence. Liu et al [37] thoght people tried to know their infection status through voluntary blood donation maybe due to the stigma, so reduction of homosexuality- related stigma [37, 47] could be part of effective intervention efforts. We found that patients tested CD4 within 30 days were more likely to start ART in 30 days (OR = 4.377; 95%CI: 2.572–7.447). Patients detected CD4 early tend to have good compliance and high cooperation with medical personnel. Through subsequent follow-up and detection process, the interaction between medical personnel and patients was enhanced, so as student cases would more likely to cooperate to ART. Some studies [46, 48] showed that demographic (education levels) was associated with HAART non-adherence. However, this study does not found similar results, may be due to we chosed 15–24 years students as study object, whose demographic characteristics, such as education levels were similar.

The geographical distribution figure showed, about 20% of counties/districts in Shandong Province had not reported any young student cases during 2017 to 2019, and the reported cases were concentrated in economically developed cities such as Jinan, Qingdao, Yantai, Weihai. These places also have more colleges and universities. Chen et al [49] studied on the spatial distribution of student cases in Zhejiang Province also found similar characters. Some spatial analysis of HIV/AIDS also found that cases tend to be cluster in urban areas and areas with railways and roads [50]. The proportion of the young student cases receiving CD4 test and ART within 30 days in southeast coastal area showed higher than northwest inland area. But areas reported more student cases, such as Jinan, Tai ‘an, Qingdao and Weihai in the blue box, the rates of student cases received CD4 test and ART within 30 days were not higher. About geographical distribution, the proportion of student cases received CD4 test during 30 days was not consistent with student cases received ART. Maybe the distribution of medical resources is not completely reasonable for student cases. More targeted research is needed to understand the reasons of mismatches.

There are some shortcomings in this study. For example, although the data of the basic information system of AIDS prevention and control in this study can fully reflect the situation of young student PLWH, its epidemic characteristics may be affected by the intensity of detection. In addition, we only found the distribution of medical resources is not completely matching for student cases, but we haven’t found the reason in depth, more researches were needed in future.