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. 2017 Jun 30;12(6):e0179870.
doi: 10.1371/journal.pone.0179870. eCollection 2017.

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

Kuan-Yin Lin  1 , Chien-Yu Cheng  2   3 , Chia-Wen Li  4   5 , Chia-Jui Yang  6   7 , Mao-Song Tsai  6 , Chun-Eng Liu  8 , Yuan-Ti Lee  9   10 , Hung-Jen Tang  11   12 , Ning-Chi Wang  13 , Te-Yu Lin  13 , Yi-Chien Lee  14 , Shih-Ping Lin  15 , Yu-Shan Huang  16 , Jun-Yu Zhang  17 , Wen-Chien Ko  4   5 , Shu-Hsing Cheng  2   18 , Chien-Ching Hung  19   20   21   22 ; Taiwan HIV Study Group
Affiliations

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

Kuan-Yin Lin et al. PLoS One. .

Abstract

Objectives: The 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.

Methods: Between 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.

Results: We 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).

Conclusions: While 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.

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Conflict of interest statement

Competing Interests: One of the authors, Hung CC, has the following competing interests: research support from Janssen, Merck, Bristol-Myers Squibb, and ViiV, speaker honoraria from Abbvie, Bristol-Myers Squibb, Gilead Sciences, and ViiV, and serving on advisory boards for Gilead Sciences, Janssen, ViiV, and Abbvie. The other authors have no competing interest to disclose. This does not alter our adherence to PLOS ONE policies on sharing data and materials.

Figures

Fig 1
Fig 1. Trends in median and distribution of CD4 cell counts at initiation of combination antiretroviral therapy (cART) from 1 June 2012 to 31 May 2016.
Fig 2
Fig 2. Changes over time in proportion of patients with late initiation of combination antiretroviral therapy (cART) and AIDS-defining illnesses from 1 June 2012 to 31 May 2016.
Fig 3
Fig 3. Kaplan-Meier estimates of the cumulative proportion of patients with treatment outcomes.
All-cause mortality stratified by late initiation and non-late initiation (A), All-cause mortality stratified by baseline CD4 cell counts <500 and ≧500 cells/mm3 (B), Regimen modification stratified by late initiation and non-late initiation (C), and Regimen modification stratified by baseline CD4 cell counts <500 and ≧500 cells/mm3 (D).
See this image and copyright information in PMC

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