Trends and outcomes of late initiation of combination antiretroviral therapy driven by late presentation among HIV-positive Taiwanese patients in the era of treatment scale-up

Abstract

ObjectivesThe international and national HIV treatment guidelines in 2016 have focused on scaling up access to combination antiretroviral therapy (cART). We aimed to assess the trends and treatment outcomes of late cART initiation in Taiwan.MethodsBetween June 2012 and May 2016, we retrospectively included antiretroviral-naive HIV-positive adults who initiated cART. Late initiation was defined as when cART was initiated in patients with a CD4 count <200 cells/mm3 or having experienced AIDS-defining illnesses. The treatment outcomes were assessed up to 6 months after starting cART.ResultsWe included 3655 HIV-positive patients, and the majority of the patients were male (95.4%) with a median age of 31 years and initiated non-nucleoside reverse-transcriptase inhibitor-containing regimens (87.0%). The median CD4 count at cART initiation increased from 207 cells/mm3 in 2012 to 298 cells/mm3 in 2016, and the overall proportion of late cART initiation decreased from 49.1% in 2012 to 29.0% in 2016 (P for trend <0.001). Late cART initiation mainly resulted from late presentation for HIV care and was associated with older age (per 1-year increase, adjusted odds ratio [AOR], 1.05; 95% CI, 1.04–1.06), HBsAg seropositivity (AOR, 1.31; 95% CI, 1.04–1.64), HIV care in central and southern Taiwan, initiating cART in earlier year, non-intravenous drug users (AOR, 1.96; 95% CI, 1.33–2.86), and negative hepatitis C serostatus (AOR, 1.47; 95% CI, 1.04–2.08). Compared with non-late initiators, late initiators had a higher rate of all-cause mortality (1.7% vs. 0.3%) and regimen modification due to virological failure (7.1% vs. 2.6%). The predicting factors of all-cause mortality were late cART initiation (adjusted hazard ratio [AHR], 5.40; 95% CI, 2.14–13.65) and older age (AHR, 1.06; 95% CI, 1.03–1.10).ConclusionsWhile the proportion of late cART initiation decreased over time in Taiwan, late initiation remained in a substantial proportion of HIV-positive patients. The late initiators had higher risk for poor outcomes. The need for strategies to earlier detection of HIV infection and expediting cART initiation should be highlighted, especially among the older population.

Hepatitis E Virus Infections Among Human Immunodeficiency Virus–Positive Individuals During an Outbreak of Acute Hepatitis A in Taiwan

“…HIV‐related medical care has been provided free of charge in Taiwan, including combination antiretroviral therapy (cART), monitoring of CD4 cell count and plasma HIV RNA load (PVL), and serologies of HAV, hepatitis B virus (HBV), hepatitis C virus (HCV), and syphilis. According to the HIV treatment guidelines in Taiwan, HIV‐positive patients are regularly followed every 3‐6 months for their virological, immunological, and clinical status …”

“…According to the HIV treatment guidelines in Taiwan, HIV-positive patients are regularly followed every 3-6 months for their virological, immunological, and clinical status. (20) The study was reviewed and approved by the National Taiwan University Hospital Research Ethics Committee (registration number, 201605103RINC). Written informed consent to HEV testing performed on archived blood samples was obtained from patients before inclusion.…”

Impact of antiretroviral therapy containing tenofovir disoproxil fumarate on the survival of patients with HBV and HIV coinfection

“…The CD4 count threshold for cART initiation increased from 350 to 500 cells per µL in September 2013, which was further revised to treat all patients irrespective of CD4 counts in June 2016. CART mainly consisted of two nucleos(t)ide reverse‐transcriptase inhibitors plus non‐nucleoside reverse‐transcriptase inhibitor or boosted or unboosted protease inhibitor . TAF‐containing regimens or single‐tablet regimens were not available during the study period (Supplementary Figure ).…”

Early Seroreversion After 2 Doses of Hepatitis A Vaccination in Human Immunodeficiency Virus–Positive Patients: Incidence and Associated Factors

“…HIV‐related medical services, including combination antiretroviral therapy (cART) and monitoring of plasma HIV‐RNA load and CD4 count, have been provided free of charge in the designated hospitals around Taiwan. Routine care for HIV‐positive patients in the study hospitals included clinical assessment and determinations of immunological and virological status every 3‐6 months and regular serological evaluations for hepatitis B, hepatitis C, and syphilis according to Taiwanese HIV treatment guidelines …”

“…Routine care for HIV-positive patients in the study hospitals included clinical assessment and determinations of immunological and virological status every 3-6 months and regular serological evaluations for hepatitis B, hepatitis C, and syphilis according to Taiwanese HIV treatment guidelines. (25)…”