# Viral suppression by residency status among men living with HIV in the context of the expanded ART policy in Shanghai, China

## TL;DR

The study found that in Shanghai, China, residency status still affects how well men with HIV control the virus, even with free ART available to all residents.

## Contribution

This study is novel in examining how residency-based policies affect viral suppression among men with HIV in Shanghai under expanded ART access.

## Key findings

- Shanghai Hukou residents had shorter time to ART initiation compared to other residency groups.
- Non-external permanent residents were less likely to achieve viral suppression despite expanded ART access.
- Disparities in viral suppression persisted across residency groups even with policy changes.

## Abstract

Access to China’s national free antiretroviral therapy (ART) program was historically restricted to the home province or province of birth (“Hukou”). During the COVID-19 pandemic, Shanghai facilitated access to free ART and supportive services for all Shanghai residents regardless of residency status. Our aim was to study differences in viral suppression according to residency status in Shanghai, China. We conducted a cross-sectional survey with a nine-month prospective follow-up for viral load testing. Viral suppression was defined as a viral load of <40 copies/mL. Data were analyzed using descriptive statistics and Firth logistic regression. We recruited 151 adult men newly diagnosed with HIV from a downtown satellite clinic of the major HIV reference hospital in Shanghai. Among recruited participants, 23.8% were Shanghai Hukou residents, 23.2% were external permanent residents, 16.6% were temporary migrants, and 36.4% had no Shanghai residency status. Almost all participants (98.7%) initiated ART; 72.8% had an undetectable viral load by nine-months following ART initiation. The median time from HIV diagnosis to ART initiation was shorter for Shanghai Hukou residents (9.0 days) compared to other groups (15.0-19.0 days, p = 0.023). Shanghai Hukou residents (aOR: 0.24; 95% CI: 0.05, 1.00; p = 0.05), temporary migrants (aOR:0.20; 95% CI: 0.04, 0.92; p = 0.038), and men with no Shanghai residence identification (aOR:0.16; 95% CI: 0.03, 0.61; p = 0.006) were less likely to attain viral suppression when compared with external permanent residents, after adjusting for sociodemographic, sexual behaviour, and clinical covariates. Overall, differences in viral suppression between residency groups persisted despite the new policy of free ART regardless of residency status. These disparities highlight the need to better understand the underlying dynamics of viral suppression with attention to residency status. Future work should focus on developing complementary interventions and expanding supportive services to facilitate rapid viral suppression among all residency groups to achieve optimal population health outcomes.