Transitions through the HIV continuum of care in people enrolling in care with advanced HIV disease in Latin America

Objectives

Advanced HIV disease (AHD) at HIV care enrollment is common in Latin America and may bias cross-sectional care continuum estimates. We therefore explored the impact of AHD on HIV care continuum outcomes using a longitudinal approach.

Methods

We analyzed trajectories of 26,174 adult people with HIV enrolled at Caribbean, Central and South America network for HIV epidemiology (CCASAnet) sites (2003-2019) using multi-state Cox regression across five stages: (i) enrolled without antiretroviral therapy (no-ART); (ii) on ART without viral suppression (viral load ≥200 copies/m; ART + non-VS); (iii) on ART with viral suppression (viral load <200 copies/ml; ART + VS); (iv) lost to follow-up; (v) death. We defined AHD as clusters of differentiation 4+ count <200 cells/µl and/or an AIDS-defining illness at enrollment.

Results

People with HIV with AHD had a shorter time with no-ART, a similar time ART + non-VS, but less time ART + VS before 2013 than non-AHD. After 2013, time with no-ART decreased but the 5-year probability of transitioning from no-ART to ART + VS decreased in both groups. The time spent virally suppressed while in care was low, overall. Risk of loss to follow-up and death was persistently worse among adults with AHD.

Conclusions

Using a longitudinal approach to assess the HIV continuum of care provided insight into limitations in HIV care provision in our region previously underexplained by cross-sectional assessments.