Abstract
Prompt initiation of combination antiretroviral therapy (ART) is important to reduce comorbidity and mortality among people living with HIV, especially for those with a low CD4 cell count. However there is evidence that not everyone receives prompt initiation of ART after enrolling into HIV care. The current study investigated factors associated with failure to initiate ART within two years of entering into care among those with a CD4 count at or below 350 cells/mm3. The sample included 4,907 ART-naive patients with a CD4 count at or below 350 cells/mm3 enrolled between January 1, 2003 and December 31, 2012 at any of eight clinical sites in the Center for AIDS Research Network of Integrated Clinical Systems (CNICS). The two-year risk of delayed ART initiation was estimated using a log-binomial regression model with stabilized inverse probability of censoring weights for those lost to follow-up. Adjusting for other factors, an earlier enrollment date was the sole demographic characteristic associated with an increased risk of delayed ART initiation. Higher CD4 count, lower viral load, and a prevalent AIDS diagnosis were clinical characteristics associated with delayed ART initiation. Gender, age, race/ethnicity and HIV risk factors such as reported male-to-male sexual contact and injection drug use were not associated with delayed ART initiation. This study identified characteristics of patients for whom treatment was strongly to moderately recommended but who did not initiate ART within two years of entering care. Despite the known benefits of early antiretroviral therapy initiation, a lower viral load measurement may continue to be an important clinical characteristic in the more recent era with current ART initiation guidelines. These findings provide a target for closer monitoring and intervention to reduce disparities in HIV care.
Highlights
Despite the introduction of effective combination antiretroviral therapy (ART) for HIV in 1996 [1], HIV continues to be a global health crisis
We found that among ART-naïve patients with CD4 count at or below 350 cells/mm3, higher CD4 count, lower viral load, a prevalent acquired immunodeficiency syndrome (AIDS) diagnosis, and an earlier Clinical Systems (CNICS) enrollment date were each independently associated with failure to initiate ART within the first two years after enrollment in CNICS between January 1, 2003 and October 1, 2012
This study identified characteristics of patients who delay ART initiation beyond the first two years of entering in care, which included an earlier CNICS enrollment date, higher CD4 count, lower viral load, and a prevalent AIDS diagnosis
Summary
Despite the introduction of effective combination antiretroviral therapy (ART) for HIV in 1996 [1], HIV continues to be a global health crisis. Infectious Diseases of the National Institutes of Health under award number R01AI100654 (https:// www.niaid.nih.gov/). The funder had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript
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