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Late, Delayed ART Initiation in China Significantly Decreased After Guideline Update


Researchers found that Beijing residents with HIV sought out treatment earlier after China updated its HIV treatment guidelines in 2016.

The proportion of late or delayed antiretroviral therapy (ART) initiation in patients with HIV living in Beijing, China, decreased significantly after the country updated its HIV treatment guidelines in 2016, according to a study published in the International Journal of Public Health.

This study helped researchers identify factors associated with late, delayed, and either late or delayed ART initiation between 2010 and 2020; in particular, it assessed how ART initiation patterns changed after the implementation of China’s updated guidelines in 2016. The researchers defined late ART initiation as having a CD4 cell count of less than 200 cells/µL or having a clinical AIDS diagnosis at ART initiation. Delayed ART initiation was defined as more than 1 month between the HIV diagnosis date and ART initiation, and either late or delayed ART initiation was defined as having at least 1 of the 2 outcomes.

The study population consisted of 20,692 patients. The researchers examined multiple variables related to ART across the population, including infection type, CD4 cell count, and lag time. Of the population, the researchers defined 6733 (32.5%) as having late ART initiation, 9641 (46.6%) as having delayed ART initiation, and 13,534 (65.4%) as having either late or delayed ART initiation.

In 2010, the patients’ median (IQR) count at ART initiation was 145.5 (39.0-221.0) cells/μL. Ten years later, patients who initiated ART had significantly increased CD4 cell counts (P for trend = .001). Additionally, the median (IQR) lag time between HIV diagnosis and ART initiation significantly decreased over 10 years from 35 (19-75) days to 14 (7-33) days (P for trend = .001). Similarly, the researchers found the proportions of late ART initiation, delayed ART initiation, and either late or delayed ART initiation in 2010 to be 52.5%, 85.0%, and 97.7%, respectively, decreasing steadily to 30.1%, 17.7%, and 41.7% in 2020 (P for trend = .002, <.001, and <.001).

The researchers also investigated factors associated with late ART initiation. They found that patients with a body mass index (BMI) below 18.5 (vs BMI of 18.5-24.9: odds ratio [OR], 2.18; 95% CI, 1.95-2.44), hepatitis B virus or hepatitis C virus (HBV/HCV; vs without: OR, 1.24; 95% CI, 1.09-1.41), and tuberculosis (vs without: OR, 11.73; 95% CI, 7.25-18.96) were more likely to initiate ART late. Additionally, researchers found that patients aged 25 to 34, 35 to 45, and older than 45 years were 1.6-, 2.2-, and 3.0-fold more likely, respectively, to have late ART initiation compared with those younger than 24 years. Lastly, patients with a lag time of less than 1 month, 1 to 6 months, and more than 12 months were 2.2-, 1.5-, and 1.1-fold more likely to receive late ART initiation compared with those who had a lag time of 6 to 12 months.

In terms of those with delayed ART initiation, researchers found that people who inject drugs (PWID), patients with tuberculosis, and patients who were HBV/HCV seropositive were more likely to delay ART initiation.

As for either late or delayed ART initiation, the researchers found that patients who were male, were heterosexual, had early HIV diagnosis, were HBV/HCV seropositive, and had tuberculosis were more likely to have either outcome. PWID (OR, 4.73; 95% CI, 2.43-9.22) were also considered more likely to have either outcome.

The researchers identified various limitations to their study, one being that cross-sectional studies may show inverted causality. Other limitations include potential bias due to a greater proportion of men and homosexual individuals within the study population. Also, the database the researchers utilized did not include patients’ socioeconomic characteristics at diagnosis, so they could not fully describe the status of late-diagnosed patients and analyze the impact of related factors.These limitations indicated to the researchers other topics future studies should explore.

“Future studies should focus on identifying the barriers to healthcare access that contribute to delayed ART initiation such as transportation, financial barriers, and stigma,” the authors wrote. “The role of health system factors such as healthcare provider attitudes, treatment guidelines, and resource allocation also cannot be neglected in related analyses.”


Mi Y, Zhou M, Zeng Y, Wang P, Gao L, Cheng F. Factors associated with delayed and late initiation of antiretroviral therapy among patients with HIV in Beijing, China, 2010-2020. Int J Public Health. 2023;68:1605824. doi:10.3389/ijph.2023.1605824

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