Abstract
To the Editor:
T
Newly diagnosed PLHIV in China have been encouraged to initiate immediate ART promptly, following the implementation of the test-and-immediate-treat policy since 2016. Several studies have been conducted in China to evaluate the benefits of immediate ART. 3 However, few studies have investigated the uptake of, and barriers to, immediate ART initiation among newly diagnosed PLHIV in China. 4
Therefore, we conducted this prospective cohort study to examine factors associated with immediate ART initiation among newly diagnosed PLHIV aged ≥18 years between May 2018 and June 2019 at six study sites in Guangdong Province. Six cities (Shantou, Yunfu, Yangjiang, Zhuhai, Jiangmen, and Huizhou) were selected based on geographical location and economic status. 5 This study was approved by the Ethics Committee of Guangdong Pharmaceutical University.
Participants were asked to sign a written informed consent before completing a self-administered questionnaire when they were diagnosed with HIV infection (at baseline). They were then routinely followed up for 12 months from the date of enrolment to confirm ART initiation. All data were collected from a self-administered questionnaire and the national HIV surveillance system, which was matched by the unique infectious disease reporting card identification (ID). 5
Stigma was measured using the 10-item Berger HIV Stigma Scale (Cronbach's α = 0.89). Depression was assessed using the 20-item Center for Epidemiologic Studies—Depression scale, with scores ≥28 indicating depression (Cronbach's α = 0.92). The 10-item Social Support Rating Scale was used to measure social support (Cronbach's α = 0.70). Advanced HIV disease was defined as a first reported CD4 count <200 cells/μL or an AIDS-defining event within 1 month of HIV diagnosis. 5 Immediate ART initiation was defined as PLHIV starting ART within 1 month of HIV diagnosis. 3 Delayed ART initiation was defined as PLHIV starting ART after 1 month of HIV diagnosis but within 1 year, and individuals who did not start ART within 1 year of HIV diagnosis were referred to as no ART.
Pearson's chi-squared test and multivariable multinomial logistic regression were performed to explore factors associated with immediate ART initiation among PLHIV. All statistical analyses were performed using R (version 4.2.1).
Between May 2018 and June 2019, 1071 newly diagnosed PLHIV with a median age of 44 years (interquartile range, 31–56) were included in this analysis. The proportions of immediate, delayed, and no ART initiation were 72.83%, 14.94%, and 12.23%, respectively. These three groups differed significantly (p < 0.05) in their characteristics, except for employment, marital status, sample source, ever having had AIDS-related clinical symptoms, stigma, depression, and social support (Table 1).
Characteristics of Newly Diagnosed People Living With HIV By Antiretroviral Therapy Initiation Status in Guangdong Province, China
Medical facilities: testing before surgery, blood transfusion and donation, invasive examination, premarital and prenatal examination, sexually transmitted disease clinics, and so on. VCT clinics: testing in VCT clinics.
The median score was used as the cut-off value.
ART, antiretroviral therapy; VCT, voluntary counseling and testing.
Multivariable multinomial logistic regression showed that with immediate ART as the reference outcome, women [adjusted odds ratio (aOR) = 0.50, 95% confidence interval (CI): 0.28–0.89], those with a college education or higher (aOR = 0.34, 95% CI: 0.13–0.90), and those with active HIV testing (aOR = 0.45, 95% CI: 0.30–0.68) were less likely to refuse ART. Individuals with no partner (aOR = 2.39, 95% CI: 1.21–4.74) or with an HIV-unknown partner (aOR = 2.35, 95% CI: 1.18–4.67) were more likely not to receive ART than those with an HIV-positive partner. Individuals with syphilis coinfection (aOR = 0.31, 95% CI: 0.13–0.75) were less likely to delay ART. Individuals with an intention to start ART early were less likely to delay ART initiation (aOR = 0.33, 95% CI: 0.11–0.93) or not receive ART (aOR = 0.21, 95% CI: 0.08–0.54). Individuals with an unknown CD4 count were more likely to delay ART initiation (aOR = 3.26, 95% CI: 1.91–5.57) or not receive ART (aOR = 2.54, 95% CI: 1.39–4.64) than those with a CD4 count <200 cells/μL. In addition, individuals with a CD4 count >500 cells/μL were more likely not to receive ART (aOR = 2.44, 95% CI: 1.25–4.77) than those with a CD4 count <200 cells/μL (Table 2).
Factors Associated With Immediate Antiretroviral Therapy Initiation Among Newly Diagnosed People Living With HIV in Guangdong Province, China
ART, antiretroviral therapy; CI, confidence interval; OR, odds ratio.
To the best of our knowledge, this was one of the few studies to comprehensively investigate the factors associated with immediate ART initiation among newly diagnosed PLHIV in China. In our study, the proportion of ART initiation was 87.77%, suggesting a gap with the 95–95–95 targets. In addition, the proportion of immediate ART was higher than in Shandong Province (56.34%), 4 but lower than in West Africa (89.0%). 6 Therefore, more efforts are needed to improve the immediate ART initiation among newly diagnosed PLHIV in Guangdong Province.
Women had a higher perception of HIV risk than men and were more likely to start ART early. 7 Participants with higher levels of education were more likely to initiate ART immediately, which may be attributed to their greater concern for their health. 4 Further efforts, including raising awareness among PLHIV of the importance of immediate ART initiation, are needed to improve uptake of immediate ART.
Compared with single PLHIV, those with partners may receive more support from their partners, leading to immediate ART initiation. 8 Individuals would quickly seek HIV testing if they found out that their partners were HIV positive, which may encourage them to seek early diagnosis and start treatment. Therefore, partner notification was necessary and beneficial to facilitate immediate ART initiation.
Individuals with active HIV testing may perceive themselves to be at high risk of HIV infection, which may motivate them to seek clinical care services. 9 A study conducted in South Africa found that patients who perceived themselves to be at high risk of HIV infection were more likely to initiate ART immediately. 7 Intention to start ART early was also associated with immediate ART initiation. Although over 95% of participants in our study were willing to start treatment early, only about 70% of respondents actually started ART immediately, highlighting the need for better efforts to translate intentions into action, particularly to achieve the 95–95–95 targets.
ART initiation depended on the severity of HIV infection, with those with high CD4 cell counts believing that they were “too healthy” to need ART. 10 However, PLHIV who were diagnosed late were more likely to present with advanced disease, or to have been more strongly encouraged by health care providers to start ART. 11 As a result, individuals with lower CD4 cell counts were more likely to start ART when they presented to health care services. Individuals coinfected with HIV/syphilis were more likely to have a poor prognosis and may be encouraged by health care providers to start ART. 12
This study has several limitations. First, Guangdong is one of the most developed provinces in China, so the study may not be representative of all PLHIV in China. Second, data on sociodemographic characteristics and some of HIV-related information were self-reported, which may be subjective and subject to recall bias.
In conclusion, the proportion of immediate ART initiation among newly diagnosed PLHIV in Guangdong Province was relatively low, and there is a gap between treatment rates and the 95–95–95 targets. Our results highlight the importance of providing intensive counseling and education about the immediate invitation to ART, as well as encouraging partner notification, to promote ART initiation in Guangdong Province.
Footnotes
Authors' Contributions
H.J., Y. Yang, and Y.L. designed the research study.
Data Access Statement
The full qualitative data set supporting this study cannot be publicly shared for ethical and privacy reasons. These questions may be directed to the corresponding author.
Author Disclosure Statement
The authors declare that they have no competing interests.
Funding Information
This work was supported by Department of Education of Guangdong Province (2022KTSCX060, 2022SFKC074), Guangdong Office of Philosophy and Social Science (GD21YSH08), and the National Natural Science Foundation of China (81703282).