Late initiation of antiretroviral therapy: inequalities by educational level despite universal access to care and treatment

Rodrigues, Amanda; Struchiner, Cláudio J.; Coelho, Lara E.; Veloso, Valdiléa G.; Grinsztejn, Beatriz; Luz, Paula M.

doi:10.1186/s12889-021-10421-8

Cited by 21 publications

(23 citation statements)

References 41 publications

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“…In addition, Black participants tended to have low PrEP adherence, which is consistent with other HIV research [5]. Among people living with HIV, lower schooling was associated with worse HIV care outcomes, such as late presentation to care [29], not being on antiretroviral treatment and not being virologically suppressed [30]. The combination of transphobic experiences, racism and discrimination poses Black TGW at a higher vulnerability to HIV and negatively impact their HIV care and prevention outcomes, including adherence [31,32].…”

Section: Discussionsupporting

confidence: 77%

Low PrEP adherence despite high retention among transgender women in Brazil: the PrEParadas study

et al. 2022

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Introduction:We aimed to evaluate daily oral pre-exposure prophylaxis (PrEP) uptake, retention, and adherence and predictors of study non-attendance and low PrEP adherence in a Brazilian trans-specific 48-week study (PrEParadas). Methods: We enrolled transgender women (TGW) engaging in high-risk sexual behaviours between August 2017 and December 2018. PrEP adherence was based on tenofovir diphosphate concentrations in dried blood spots (DBS). We used random effects logistic regression models and ordinal models to estimate the odds of having a missed visit and of low PrEP adherence, respectively. Multivariable models were adjusted for variables with p-value<0.10 in the univariate analysis. Results: From the 271 eligible, 130 participants were enrolled in the study (PrEP uptake: 48%), out of which 111 (85.4%) were retained at 48 weeks. Multivariable model for study non-attendance included study visit, age, main sexual partner and stimulant use. The odds of missing a visit increased after the week 24. Participants aged 18-24 (adjusted odds ratio [aOR] = 8.76, 95% CI: 2.09-36.7) and 25-34 years (aOR = 6.79, 95% CI: 1.72-26.8) compared to TGW aged 35+ years had significantly higher odds of having a missed visit. The odds of a missed visit were higher among participants reporting stimulant use (aOR = 4.99, 95% CI: 1.37-18.1) compared to no stimulant use. DBS levels at week 48 showed that 42 (38.5%), 14 (12.8%) and 53 (48.6%) of 109 participants had low, moderate and high PrEP adherence. Multivariable model for low PrEP adherence included study visit, age, schooling, race/colour, housing, binge drinking, stimulant use, feminizing hormone therapy (FHT) use and received text message. Low PrEP adherence was significantly higher among participants with less years of schooling (aOR = 6.71, 95% CI: 1.30-34.5) and had a borderline association with Black colour/race (aOR = 6.72, 95% CI: 0.94-47.8). Participants using the FHT available at the site had decreased odds of low PrEP adherence (aOR = 0.38, 95% CI: 0.16-0.88). No participant seroconverted over the course of the study. Conclusions: Although high PrEP retention can be achieved in a gender-affirming setting, PrEP adherence may be an important challenge faced among TGW due to social disparities. The scale-up of prevention tools like PrEP will have to address systemic social determinants as these stand as important barriers for TGW's access to health services.

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Section: Discussionsupporting

confidence: 77%

Low PrEP adherence despite high retention among transgender women in Brazil: the PrEParadas study

et al. 2022

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“…Although the proportion of patients with a CD4 + count of ≤ 350 or ≤ 500 cells/μL at cART initiation decreased from 2009 to 2019, a rising trend was observed in the proportion of patients with a count of ≤ 200 cells/μL since 2016, reflecting a rising trend in the proportion of late initiators since 2015. Notably, a Brazilian study reported a similar trend: the proportion of patients with LI decreased from > 50% in 2004 to nearly 25% in 2014 and then increased until 2018 [ 22 ]. In the present study, although the reason for the increase in LI was unclear, it might be due to the nonsignificant increase in the proportion of late presenters from 33.03% in 2015 to 37.80% in 2019 ( P for trend = 0.267; data not shown).…”

Section: Discussionmentioning

confidence: 87%

“…To generalize our findings, we enrolled three HIV-designated hospitals from different medical care provision levels (one medical center and two regional hospitals) to represent the entire HIV-positive population in Taiwan. However, geographic differences in accessibility to medical resources, educational status, country income, and cultural grounds may prevent the direct generalization of the HIV care continuum in the present study to other countries [ 9 , 22 , 27 , 66 ]. Second, we analyzed neither the effect of fear of negative consequences (discrimination or stigmatization) [ 43 ] from a positive HIV diagnosis nor the effect of a history of aVCT [ 43 ] on LI because of the unavailability of relevant data.…”

Section: Discussionmentioning

confidence: 97%

“…LI has been associated with inflammation and metabolic abnormalities [ 12 ], increased 48-week mortality [ 11 , 13 – 15 ], HIV transmission to sexual partners [ 16 , 17 ], virological failure-induced regimen modification [ 11 ], and decreased life expectancy [ 18 ]. Although LI is prevalent in the Asia–Pacific region [ 9 , 19 , 20 ], Canada [ 21 ], South America [ 22 , 23 ], and sub-Saharan Africa [ 10 , 14 , 24 ], how the causes of LI have changed in response to the implementation of various HIV policies has not been comprehensively explored [ 25 – 27 ]. LI may be due to late HIV diagnosis or late cART initiation [ 25 – 27 ], and an assessment of LI causes and barriers to early initiation is necessary.…”

Section: Introductionmentioning

confidence: 99%

“…LI may be due to late HIV diagnosis or late cART initiation [ 25 – 27 ], and an assessment of LI causes and barriers to early initiation is necessary. Moreover, the currently reported risk factors for LI, including socioeconomic inequalities [ 22 ], male sex [ 9 , 28 ], older age [ 28 ], cART initiation early in the calendar year [ 9 , 21 ], and HIV exposure risk [ 9 ], have primarily been reported by studies that have analyzed the risks for all participants with LI rather than by those that have analyzed the risks for participants classified by various LI etiologies [ 25 , 27 , 29 ]. This may explain the limited applicability of the study findings and the interventions thereof.…”

Section: Introductionmentioning

confidence: 99%

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Late cART Initiation Consistently Driven by Late HIV Presentation: A Multicenter Retrospective Cohort Study in Taiwan from 2009 to 2019

et al. 2022

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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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Factors associated with long‐term HIV pre‐exposure prophylaxis engagement and adherence among transgender women in Brazil, Mexico and Peru: results from the ImPrEP study

et al. 2022

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Introduction The HIV epidemic continues to disproportionately impact Latin‐American transgender women (TGW). We assessed factors associated with long‐term pre‐exposure prophylaxis (PrEP) engagement and adherence among TGW enrolled in the Implementation of PrEP (ImPrEP) study, the largest PrEP demonstration study in Latin America. Methods HIV‐negative TGW aged ≥18 years reporting 1+eligibility criteria in the 6 months prior to enrolment (e.g. sex partner known to be living with HIV, condomless anal sex [CAS], transactional sex or having a sexually transmitted infection [STI]) who could safely take PrEP were enrolled. Follow‐up visits were conducted at 4 weeks and then quarterly. We conducted logistic regression to identify factors associated with long‐term PrEP engagement (3+ follow‐up visits in 52 weeks) and complete self‐reported adherence (no missed pills in the past 30 days) during follow‐up. For both outcomes, we constructed multivariable models controlling for country, socio‐demographics, sexual behaviour, substance use, STIs and self‐reported adherence at 4 weeks (long‐term engagement outcome only). Results From March 2018 to June 2021, ImPrEP screened 519 TGW, enrolled 494 (Brazil: 190, Mexico: 66 and Peru: 238) and followed them for 52 weeks. At baseline, 27.5% of TGW were aged 18–24 years, 67.8% were mixed‐race and 31.6% had >secondary education. Most, 89.9% reported CAS, 61.9% had >10 sex partners and 71.9% reported transactional sex. HIV incidence was 1.82 cases per 100 person‐years (95% confidence interval [CI]: 0.76–4.38). Almost half of TGW (48.6%) had long‐term PrEP engagement, which was positively associated with reporting complete adherence at week 4 (aOR:2.94 [95%CI:1.88–4.63]) and was inversely associated with reporting CAS with unknown‐HIV partner (aOR:0.52 [95%CI:0.34–0.81]), migration (aOR:0.54 [95%CI:0.34–0.84]), and being from Mexico (aOR:0.28 [95%CI:0.14–0.53]). Self‐reported adherence was associated with TGW aged >34 (aOR:1.61 [95%CI:1.10–2.34]) compared to those aged 25–34 and those with >secondary education (aOR:1.55 [95%CI:1.10–2.19]) and was lower among TGW from Peru (aOR:0.29 [95%CI:0.21–0.41]) or reporting PrEP‐related adverse effects (aOR:0.63 [95%CI:0.42–0.92]). Conclusions Although TGW were willing to enrol in ImPrEP, long‐term PrEP engagement and complete self‐reported adherence were limited, and HIV incidence remained relatively high. A successful HIV prevention agenda should include trans‐specific interventions supporting oral PrEP and exploring long‐acting PrEP strategies for TGW.

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Late initiation of antiretroviral therapy: inequalities by educational level despite universal access to care and treatment

Cited by 21 publications

References 41 publications

Low PrEP adherence despite high retention among transgender women in Brazil: the PrEParadas study

Low PrEP adherence despite high retention among transgender women in Brazil: the PrEParadas study

Late cART Initiation Consistently Driven by Late HIV Presentation: A Multicenter Retrospective Cohort Study in Taiwan from 2009 to 2019

Factors associated with long‐term HIV pre‐exposure prophylaxis engagement and adherence among transgender women in Brazil, Mexico and Peru: results from the ImPrEP study

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