Persistence of late HIV diagnosis and poorer response to antiretrovirals: a comparison between migrants and native-born people with HIV in Spain.

OBJECTIVES

Migrants living with HIV face barriers to accessing and staying in care, potentially worsening outcomes. We compared key HIV care continuum indicators by region of origin (ROI) overall/by sex and assessed whether disparities changed over time.

METHODS

We included adults with HIV enrolled in the Spanish CoRIS cohort (2004-2023). Outcomes were late diagnosis (LD; CD4 <350 cells/μL or AIDS at enrolment), antiretroviral treatment (ART) initiation within 3 months of cohort entry, virological suppression (viral load <50 copies/mL), and CD4 change at 48 weeks after ART initiation. We assessed associations between ROI and outcomes using multivariable models and tested temporal trends by including region-by-calendar-period interactions.

RESULTS

Among 20 215 participants, 54.1% were from Spain and 45.9% were born abroad. The proportion of people born abroad increased from 37.1% (2004) to 59.3% (2023), mainly driven by Latin Americans (LA). LD was more frequent among LA (adjusted OR [aOR] 1.58; 95% CI 1.44-1.73), Sub-Saharan Africans (SSA) (1.43; 1.24-1.64), and other regions (1.22; 1.05-1.41) compared with people born in Spain. Among men, LD was higher in LA and SSA; among women it was higher only in LA. Overall, ART initiation within 3 months did not differ, although LA men had lower odds in 2019-2023 (aOR 0.60; 0.37-0.95). Virological suppression at 48 weeks was lower only in SSA men (aOR 0.55; 0.41-0.75). CD4 recovery was reduced in SSA (adjusted mean difference -77.0; 95% CI -94.9 to -59.1) and LA (-21.3; -30.6 to -11.9). Disparities in LD and treatment-response persisted over time.

CONCLUSIONS

Migrants account for a growing share of new HIV diagnoses in Spain. LD remains more common among SSA and LA, and healthcare access policy changes have not ameliorated these gaps. Although ART initiation appears comparable, inequalities in treatment-response persist by ROI. Better strategies for prevention, early diagnosis, and care engagement are needed.