Background
Understanding the prevalence and consequences of opportunistic infections (OIs) at antiretroviral therapy (ART) initiation remains critical for informing HIV testing and care strategies that reduce the likelihood of late presentation for care. We assessed trends in OIs at ART initiation and their association with 1-year survival in the North American AIDS Cohort Collaboration on Research and Design (NA-ACCORD)
Methods
We included adults (≥18 years) with detectable viral loads (>200 copies/mL) initiating ART in the NA-ACCORD from Jan 2017 to Dec 2021. OIs at ART initiation were defined as diagnoses six months prior to two weeks after ART initiation. Annual trends in prevalence of OIs were examined. We estimated the 1-year cumulative incidence of death by OI at ART initiation (with 95% confidence intervals [CI]), and calculated crude (HR) and adjusted hazard ratios (aHR) with 95% CI using Cox proportional hazards models. The adjusted model included age, sex, race and ethnicity, HIV acquisition risk group, HIV viral load, and CD4 count at ART initiation.
Results
Among 6,923 people with HIV (PWH) starting ART, 25% were >50 years, 15% female, 71% non-White or Hispanic, 41% men who have sex with men, 27% with CD4 <200 cells/mm3 and 91% used integrase inhibitors). The prevalence of OIs ranged from 4.7%-6.5% from 2017-2021 (Figure). Among those with an OI at ART initiation (n=374), Pneumocystis pneumonia was most common (44%) followed by esophageal candidiasis (23%). We observed 94 deaths in the first year after ART initiation. The 1-year cumulative incidence of death in those with (vs. without) an OI was 5.5% [CI 3.5%, 8.3%] vs. 1.3% [CI 1.0%, 1.6%]. There was a 4.5-fold increase in the risk of death among those with vs. without an OI at ART initiation in crude models (HR=4.55 [CI 3.09, 7.10]), and in the adjusted model (aHR=1.85 [CI 1.03, 3.34]).
Conclusions
From 2017 to 2021, a low (≈5%) but persistent proportion of PWH in the US and Canada are starting ART with an OI, reflecting delayed ART initiation. There is substantially increased mortality risk in the first year after ART initiation among those with (vs. without) an OI. Test and treat strategies focusing on those at highest risk for delayed ART initiation may assure optimal care for persons presenting with OIs to minimize mortality.