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Late cART Initiation Consistently Driven by Late HIV Presentation: A Multicenter Retrospective Cohort Study in Taiwan
Chun-Yuan Lee1,2,3, Yi-Pei Lin1, Sheng-Fan Wang4,5,6
1Division of Infectious Diseases, Department of Internal Medicine, Kaohsiung Medical University Hospital, No. 100, Ziyou 1st Rd., Sanmin Dist., Kaohsiung City, Taiwan ROC.
Insights
Late initiation of combination antiretroviral therapy (cART) remains a concern, with late presentation of HIV significantly contributing to this trend and increasing mortality risk. Intensified interventions are needed to promote earlier cART initiation, especially for those with delayed HIV testing.
Area of Science:
- Public Health
- Infectious Diseases
- Epidemiology
Background:
- Late initiation of combination antiretroviral therapy (cART), defined by low CD4+ counts or AIDS-defining illnesses, is linked to poor outcomes and persists globally.
- Trends and causes of late cART initiation following HIV policy implementation require further investigation.
- Understanding determinants of patient status at cART initiation and their impact on mortality is crucial.
Purpose of the Study:
- To assess concerns related to late initiation of cART.
- To characterize the determinants of patient status at cART initiation.
- To evaluate the impact of initiation status on all-cause mortality post-cART.
Main Methods:
- A multicenter retrospective cohort study included 1198 patients diagnosed with HIV between 2009-2019.
- Patients were categorized into non-late initiation (non-LI), late initiation without late presentation (LILP(-)), and late initiation with late presentation (LILP(+)) groups.
- Joinpoint regression analyzed changes in the proportion of late initiation over time.
Main Results:
- The median CD4+ count at cART initiation significantly improved from 2009 to 2015 but stabilized thereafter.
- A notable decrease in late initiation occurred from 2009 to 2015, followed by a slight, non-significant increase.
- Late presentation of HIV (LILP(+)) accounted for the majority of late cART initiation cases; older age and acute HIV infection were identified as risk factors for LILP(+) and LILP(-), respectively. Both LI groups showed higher mortality risk.
Conclusions:
- The observed increase in late cART initiation since 2015 necessitates intensified strategies to promote earlier treatment.
- Targeted interventions are crucial, particularly for populations experiencing delays in accessing HIV testing services.
- Addressing late presentation of HIV is key to reducing late cART initiation and improving patient outcomes.
Introduction:
Late initiation (LI) of combination antiretroviral therapy (cART)-defined as having a CD4+ count of < 200 cells/μL or an AIDS-defining disease at cART initiation-has detrimental outcomes but remains prevalent worldwide, with LI trends and etiologies following the implementation of various HIV policies remaining underinvestigated. We assessed key concerns, characterized the determinants of various statuses at cART initiation, and evaluated the effects of those statuses on all-cause mortality after cART initiation.
Methods:
This multicenter retrospective cohort study enrolled 1198 patients with newly diagnosed HIV infection during 2009-2019 who were grouped by status at cART initiation: those without LI (non-LI group, 56.01%); those with LI but without late presentation (LP) of HIV (LP: a CD4 + count of < 200 cells/μL at HIV presentation or AIDS events ≤ 3 months of HIV diagnosis) [LILP(-) group, 4.51%]; and those with LI and with LP of HIV [LILP(+) group, 39.48%]. Joinpoint regression was used to identify changes in LI proportion.
Results:
The median CD4+ count at cART initiation increased significantly between 2009 (98 cells/μL) and 2015 (325 cells/μL) and stabilized thereafter (P for trend < 0.001). For LI, we identified one joinpoint in 2015: a substantial decrease from 77.14% in 2009 to 34.45% in 2015, followed by a nonsignificant increase to 39.1% in 2019. Overall, LILP(+) explained 89.8% of LI, without significant changes (92.59% in 2009 to 94.23% in 2019). In addition to HIV diagnosis during 2009-2012, multinomial logistic regression identified an age over 30 years and acute HIV infection as risk factors for LILP(+) and LILP(-), respectively. LILP(-) and LILP(+) were associated with a higher all-cause mortality risk.
Conclusion:
Given the rise in LI from 2015 in the era of treat-all and rapid cART initiation, strategic interventions to increase earlier cART initiation must be intensified in Taiwan, especially among populations with delayed access to HIV testing services.
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