Late HIV diagnosis and subsequent time to antiretroviral initiation and viral suppression in a large London HIV centre.

INTRODUCTION

Based on clear clinical trial evidence for the benefit of early antiretroviral therapy (ART) for people with HIV, British guidelines recommended in 2016 that ART should start as soon as possible after diagnosis. Timely diagnosis has also been shown to lead to improved outcomes. We investigate factors associated with late diagnosis, time from diagnosis to ART initiation and time from diagnosis to virological suppression in one London centre.

METHODS

Data from 294 people diagnosed with HIV at the Royal Free Hospital, London, UK, between 2014 and 2023 were included. Factors associated with late HIV diagnosis (<350 cells/mm3) were assessed using logistic regression. Standard survival methods were used to assess factors associated with time from HIV diagnosis to ART initiation and viral suppression (<40 copies/ml).

RESULTS

At the time of diagnosis, the mean age was 42 years; 29.9% (n = 88) were female; 41.8% (n = 123) were gay, bisexual and other men who have sex with men (GBMSM) and 29.9% (n = 88) of a black ethnicity. In total, 58.2% (n = 171) were diagnosed late-this was more common in heterosexual men of black African ethnicity (adjusted odds ratio [aORs] = 15.2 vs. GBMSM of any ethnicity, 95% confidence interval [CI] 1.93-120) and less common in people using recreational drugs (aORs = 0.44; 0.23-0.83). Before 2017, 29.4% (n = 37/126) of people started ART within 7 days and median time from diagnosis to viral suppression was 134 days (95% CI 103-163). For people diagnosed from 2017 onwards, these numbers were 52.3% (n = 88/168) and 81 days (95% CI 69-96), respectively. Factors independently associated with faster ART initiation were: diagnosis after 2017 (hazard ratio [HR] = 2.07; 95% CI 1.60-2.69), homeownership (1.55 vs. non-homeowners; 1.11-2.18), university education (1.77 vs. less than secondary education; 1.23-2.53) and late HIV diagnosis (for CD4 < 350 cells/mm3, HR 2.06, 95% CI 1.57-2.71). Factors associated with faster time to virological suppression were similar, with the additional factor of having a partner at the time of HIV diagnosis (HR = 1.40; 1.07-1.83).

CONCLUSION

Time to ART initiation has decreased markedly since the introduction of BHIVA guidance in 2016. Despite this, only just over half are commenced on ART within 1 week of diagnosis, which highlights the need to further reduce time between HIV testing/diagnosis and linkage to HIV services. Socio-economic privilege (home ownership, education) is associated with faster treatment start, suggesting that support should target less privileged patients. A continued focus on earlier diagnosis is important as we move towards eliminating HIV transmission.