Sex Differences in Advanced HIV Disease at Presentation in Care Among People Living With HIV in Latin America and the Caribbean

Introduction: Despite an overall recent decline of 28% in the region, AIDS-related deaths have increased among women in some Latin American countries. Low HIV risk perception among women may contribute to late diagnosis. We compared advanced HIV disease (AHD) at care enrolment between males and females in Latin America and the Caribbean. Methods: Adults (≥18 years old) from clinical sites in the Central and South America network for HIV epidemiology who enrolled between 2003 and 2022 were stratified by sex-at-birth/HIV acquisition group as females, males with male-to-male sexual contact and heterosexual males (HMs). We classified location as within a generalized epidemic (GE: Haiti) or a concentrated epidemic (CE: Argentina, Brazil, Chile, Honduras and Mexico). We estimated the probability of AHD (AIDS diagnosis or CD4<200 cells/µL) at enrolment in care using logistic regression models, stratifying by sex-at-birth/acquisition group and CE/GE setting, adjusting for age, education level and calendar year of enrolment. Results: Of 47,548 people living with HIV, 51% were from GE sites (58% females), and 49% were from CE sites (20% females, 22% HMs and 58% males with male-to-male sexual contact). In GE, 27.7% of persons presented with AHD (23.5% of females; 33.3% of males), while in CE, 44.9% of persons presented with AHD (37.4% of males with male-to-male sexual contact, 47.8% of females and 61.8% of HMs). Males in GE had higher odds of AHD compared with females (aOR: 1.48 [95% CI: 1.40–1.57]). The odds of AHD decreased from 2003 to 2022 (aOR: 0.29 [95% CI: 0.26–0.33] in GE and aOR: 0.32 [95% CI: 0.29–0.36] in CE). In sex-at-birth/acquisition stratified models, in CE sites, odds decreased more in males with male-to-male sexual contact (aOR: 0.22 [95% CI: 0.19–0.25]) than in females (aOR: 0.57 [95% CI: 0.46–0.79]) and HMs (aOR: 0.47 [95% CI: 0.38–0.58]) in 2022 versus 2003. Conclusions: In CE sites, the slight decreasing trend of AHD at enrolment among females and HMs contrasts with the steeper decline among males with male-to-male sexual contact. In the GE site, risk of AHD at enrolment decreased in both males and females over time. Interventions to increase awareness, improve HIV testing, and hasten linkage to care among females and HMs are needed in CE settings in addition to addressing structural and social barriers.