Late initiation of combination antiretroviral therapy in Canada: a call for a national public health strategy to improve engagement in HIV care

Abstract

IntroductionCombination antiretroviral therapy (ART) significantly decreases morbidity, mortality and HIV transmission. We aimed to characterize the timing of ART initiation based on CD4 cell count from 2000 to 2012 and identify factors associated with late initiation of treatment.MethodsParticipants from the Canadian Observational Cohort (CANOC), a multi-site cohort of HIV-positive adults initiating ART naively after 1 January 2000, in three Canadian provinces (British Columbia, Ontario and Québec) were included. Late initiation was defined as a CD4 count <200 cells/mm3 or an AIDS-defining illness before ART initiation (baseline). Temporal trends were assessed using the Cochran–Armitage test, and independent correlates of late initiation were identified using logistic regression.ResultsIn total, 8942 participants (18% female) of median age 40 years (Q1–Q3 33–47) were included. The median baseline CD4 count increased from 190 cells/mm3 (Q1–Q3 80–320) in 2000 to 360 cells/mm3 (Q1–Q3 220–490) in 2012 (p<0.001). Overall, 4274 participants (48%) initiated ART with a CD4 count <200 cells/mm3 or AIDS-defining illness. Late initiation was more common among women, non-MSM, older individuals, participants from Ontario and BC (vs. Québec), persons with injection drug use (IDU) history and individuals starting ART in earlier calendar years. In sub-analysis exploring recent (2008 to 2012) predictors using an updated CD4 criterion (<350 cells/mm3), IDU and residence in BC (vs. Québec) were no longer significant correlates of late initiation.ConclusionsThis analysis documents increasing baseline CD4 counts over time among Canadians initiating ART. However, CD4 counts at ART initiation remain below contemporary treatment guidelines, highlighting the need for strategies to improve earlier engagement in HIV care.

Socio‐economic status and time trends associated with early ART initiation following primary HIV infection in Montreal, Canada: 1996 to 2015

“…In contrast, Cescon et al . reported late ART initiation in older adult participants from the CANOC . This difference may be due to our analysis focusing on patients diagnosed during primary HIV infection and the differing study period, 1996 to 2015 versus 2000 to 2012 for the CANOC study.…”

“…ART initiation has also been linked to a variety of socio‐demographic and behavioural characteristics , even in the context of publicly funded health care and medication access . For instance, studies conducted in several African countries have shown that older age, female sex, pregnancy, lower psychological distress, no perceived communication barriers with providers and a gap in care of less than six months were associated with early ART initiation .…”

“…Moreover, Cescon et al . observed that late ART initiation was more likely among females, non‐MSM and older age in 8942 participants in the Canadian Observational Cohort Study (CANOC) .…”

Revealing geographical and population heterogeneity in HIV incidence, undiagnosed HIV prevalence and time to diagnosis to improve prevention and care: estimates for France

“…In most settings affected by HIV, including high‐income countries, late cART initiation remains common . Current major obstacles to early access to cART are undiagnosed and late‐diagnosed HIV infections .…”

Immune recovery of middle-aged HIV patients following antiretroviral therapy

“…As older patients were more likely to be late for treatment, [8] early initiation of HAART for the middle-aged would advance their treatment start-date to match with that of young adults, whose immunological recovery should be superior to the other 2 groups. To prove this hypothesis, we examined the immune recovery of middle-aged HIV patients in a clinical cohort in Hong Kong, where standard HAART regimens have been offered in accordance with established protocols.…”