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.