Sex‐based differences in antiretroviral therapy initiation, switching and treatment interruptions: global overview from the International Epidemiologic Databases to Evaluate AIDS (IeDEA)

Abstract

IntroductionIn 2015, the World Health Organization recommended that all HIV‐infected individuals consider ART initiation as soon as possible after diagnosis. Sex differences in choice of initial ART regimen, indications for switching, time to switching and choice of second‐line regimens have not been well described. The aims of this study were to describe first‐line ART and CD4 count at ART initiation by sex, calendar year and region, and to analyse time to change or interruption in first‐line ART, according to sex in each region.MethodsParticipating cohorts included: Southern, East and West Africa (IeDEA‐Africa), North America (NA‐ACCORD), Caribbean, Central/South America (CCASAnet) and Asia‐Pacific including Australia (IeDEA Asia‐Pacific). The primary outcomes analysed for each region and according to sex were choice of initial ART, time to switching and time to discontinuation of the first‐line regimen.Results and DiscussionThe combined cohort data set comprised of 715,252 participants across seven regions from low‐ to high‐income settings. The median CD4 count at treatment initiation was lower in men compared with women in nearly all regions and time periods. Women from North America and Southern Africa were more likely to switch ART compared to men (p < 0.001) with approximately 90% of women reporting a major change after 10 years in North America. Overall, after 8 years on ART, >50% of HIV‐ positive men and women from Southern Africa, East Africa, South and Central America remained on their original regimen. Men were more likely to have a treatment interruption compared with women in low‐ and middle‐income countries from the Asia/Pacific region (p < 0.001) as were men from Southern Africa (p < 0.001). Greater than 75% of men and women did not report a treatment interruption after 10 years on ART from all regions except North America and Southern Africa.ConclusionsThere are regional variations in the ART regimen commenced at baseline and rates of major change and treatment interruption according to sex. Some of this is likely to reflect changes in local and international antiretroviral guideline recommendations but other sex‐specific factors such as pregnancy may contribute to these differences.

Outcomes of patients lost to follow‐up after antiretroviral therapy initiation in rural north‐eastern South Africa

“…Our finding that men and pregnant or breastfeeding women were at an increased risk of LTFU corroborates the results from other studies in sub‐Saharan Africa . For pregnant women in particular, it has been hypothesised that they are more likely to disengage from care because they are often asymptomatic and discontinue treatment once the risk of onwards transmission to her child has dissipated .…”

Research priorities to inform “Treat All” policy implementation for people living with HIV in sub‐Saharan Africa: a consensus statement from the International epidemiology Databases to Evaluate AIDS (IeDEA)

“… Context: Global data suggest that the timeliness of ART initiation, as measured by the level of immunodeficiency at the start of ART, is highly suboptimal in relation to WHO guidelines, particularly in SSA, where a recent analysis of data from 767,000 patients in 21 countries showed that median CD4 counts at ART initiation remained below 300 cells/mm 3 in 2015 . Infants, adolescents, and men, in particular, are more likely to initiate treatment late and to not be retained in care . Research approaches : Important factors for further study include quality of care; policy and administrative requirements; costs of services, including user fees; HIV‐related stigma; integrated screening and treatment of other health conditions (i.e. non‐communicable diseases); and community‐ and home‐based services (e.g.…”

“…), stigma remains a barrier to HIV care, contributing to delays in ART initiation . Men, particularly, are not adequately served by traditional approaches, as they remain less likely than women to start ART and they have more advanced disease than women when they start ART . Wide‐scale implementation of Option B+ may further increase gender disparities in access to ART, as has been reported in Malawi and Mozambique .…”

“…Recent data demonstrate that PLWH in the SSA region continue to initiate ART late , indicating that many PLWH live for years before achieving first viral suppression. Late ART initiation has persisted and is preventing more rapid declines in HIV mortality and incidence in the region. Importantly, men, those experiencing multiple dimensions of stigma, and other underserved populations are being left behind as HIV treatment expands in SSA .…”

Decreasing time to antiretroviral therapy initiation after HIV diagnosis in a clinic‐based observational cohort study in four African countries

“…Country-specific guidelines do not necessarily keep apace with evolving WHO guidelines and individual countries may also vary in their approach to HIV testing [14]. One prior multi-country cohort study described gender-based regional variations in ART regimen selection, changes and discontinuations and found that median CD4 count was consistently lower in West Africa as compared to East Africa [15].…”