Evaluating the care cascade after antiretroviral therapy initiation in Latin America

Abstract

Accelerating antiretroviral therapy (ART) administration, improving retention, and achieving viral suppression in low- and middle-income countries must be prioritized. We evaluated trends and disparities in these milestones in a large Latin American cohort. Adults starting ART (ARTstart) from 2003 to 2014 at Caribbean, Central, and South America network for HIV epidemiology sites were assessed for care cascade outcomes: CD4 cell count >200 cells/mm3 at ARTstart; retention (≥1 visit at one year after ARTstart); viral suppression (≥1 HIV-1 RNA <200 copies/ml at one year after ARTstart). Modified Poisson regression provided adjusted prevalence ratios by age, gender, and HIV transmission risk, accounting for site and year of ARTstart. Proportions achieving ARTstart and suppression improved over time (p < 0.05). Older age was associated with better retention and viral suppression, but not ARTstart at CD4 cell count >200 cells/mm3. Females and men who have sex with men (MSM) were more likely to have CD4 cell count >200 cells/mm3 at ARTstart. Injection drug users (IDUs) were less likely to be retained while MSM were more likely to achieve viral suppression (all p < 0.05). Despite improvements in these outcomes over the course of a decade in this cohort, significant disparities existed, disadvantaging younger patients, men, and IDUs. These gaps indicate continued progress in providing early diagnosis and ARTstart remain critical.

Keywords: AIDS; ART; Epidemiology; HIV; South America; homosexual.

Conflict of interest statement

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Figures

Figure 1

Flow diagram for inclusion in ARTstart with CD4 cell count >200 cells/mm3, retention at one year after ARTstart, and viral suppression at one year after ARTstart analyses, CCASAnet, 2003–2014. ART: antiretroviral therapy; CCASAnet: Caribbean, Central and South America network for HIV epidemiology.

Figure 2

Adjusted probability of ART initiation with a CD4 cell count >200 cells/mm3, among those initiating ART in CCASAnet, 2003–2014. Probabilities derived from multivariable modified Poisson regression adjusting for age, sex, HIV transmission risk factor, and year of ART initiation; age and year of ART initiation were modeled using restricted cubic splines with four knots. ART: antiretroviral therapy; CCASAnet: Caribbean, Central and South America network for HIV epidemiology.

Figure 3

Adjusted probabilities and marginal effects for having a missing CD4+ cell count at ARTstart by year of ART initiation, CCASAnet, 2003–2014. Probabilities are from linear predictors from multivariable modified Poisson regression of missing CD4+ cell count adjusting for age, sex, HIV transmission risk factor, and year of ART initiation; age and year of ART initiation were modeled using restricted cubic splines with four knots. ART: antiretroviral therapy; CCASAnet: Caribbean, Central and South America network for HIV epidemiology.