Abstract Body

Ensuring early universal access to combination antiretroviral treatment (cART), and especially within the first year of HIV infection, is critical to reach the end of AIDS and control the HIV epidemic. However, how far or how close we are from early universal cART initiation remains unknown.

We estimated the timing of HIV care in France in 2010 using statistical modeling and two large data sources: the national HIV surveillance system and the French Hospital Database on HIV (FHDH). To estimate the distribution of times from infection to diagnosis, we fitted a back-calculation model to the annual numbers of new HIV diagnoses. To estimate the distribution of times from HIV diagnosis to care entry, from care entry to cART initiation and from cART initiation to reaching undetectable viral load, we used survival methods and data on the dates of HIV diagnosis, care entry, cART initiation and viral suppression of the 6268 HIV-infected individuals who newly engaged in care between 2008 and 2010 and were enrolled onto the FHDH cohort. We summed up the distributions to obtain the distributions of time intervals from HIV infection to cART access. Figures were computed overall and by HIV exposure group.

We found that only 8.3% of HIV-infected individuals accessed cART within the first year of infection (see Table). This proportion reached 10.1% among men who have sex with men (MSM). The estimated median time interval from HIV infection to cART initiation was 5.0 years (IQR: 2.7-7.9). MSM had the shortest median time to cART initiation (4.4 years) and injecting drug users (IDUs) the longest (8.1 years). Time lost in accessing cART was mainly due to delays in HIV testing (overall median: 3.2 years), except for IDUs where it was also due to delayed care entry once diagnosed (median of ~1 year versus <1 month for other groups). Times to access cART once in care and times to reaching viral suppression once on cART were short (<6 months in median).

Our study shows that even in a country like France, where the health care system offers one of the best environments for HIV care, we are far from early ART for all. Similar gap is likely to exist in other settings and should be investigated. To close this gap, evaluating patient flow-time through the continuum of care will be key to identify what kind of actions is needed to accelerate cART access.