Temporal trends from HIV diagnosis to ART initiation among adults living with HIV in the Asia–Pacific (2013–2023)

Abstract

Introduction

Data on the impact of World Health Organization (WHO)’s guideline changes and COVID-19 on ART initiation in the Asia–Pacific remain scarce. This study described temporal trends from HIV diagnosis to ART initiation from 2013 to 2023 and its associated factors.

Methods

Adults (≥ 18 years) diagnosed with HIV after 2013 in a regional observational cohort were included. Fine and Gray competing risk regression examined predictors of ART initiation (≥ 3 antiretroviral medications), accounting for those lost to follow-up or deceased before treatment considered as competing risks.

Results

Among 14,968 participants, most were male (70.1%), with a median age of 36 years (interquartile range [IQR]: 28–44). At HIV diagnosis, median CD4 count was 208 cells/µL (IQR: 69–395), and median viral load was 86,296 copies/mL (IQR: 13,186–392,000). Over 85% of participants had initiated ART during the study period. Median time from HIV diagnosis to ART initiation differed across years of HIV diagnosis: 51 days (2013–2015), 28 days (2016–2019), and 26 days (≥ 2020). Factors associated with shorter time to ART initiation were higher country income-level (upper-middle: sub-distribution hazard ratio [SHR] = 1.34, 95% CI: 1.28, 1.40; high: SHR = 1.35, 95% CI: 1.28, 1.43; vs. lower-middle); HIV transmission via male-to-male contact (SHR = 1.06, 95% CI: 1.02, 1.11) or injection drug use (SHR = 1.23, 95% CI: 1.09, 1.38; vs. heterosexual contact); and later years of HIV diagnosis (2016–2019: SHR = 1.33, 95% CI: 1.28, 1.38; ≥ 2020: SHR = 1.40, 95% CI: 1.33, 1.48; vs. 2013–2015). Those with higher CD4 counts had longer time to ART start (350–499 cells/µL: SHR = 0.76, 95% CI: 0.67, 0.86; > 500 cells/µL: SHR = 0.55, 95% CI: 0.49, 0.61; vs. CD4 < 200 cells/µL).

Conclusion

Time to ART initiation from HIV diagnosis decreased after 2016, aligning with evolving WHO guidelines, and did not appear to be impacted by COVID-19. Optimizing treatment initiation during the treat-all era is crucial, especially among those with higher CD4 counts.