Transitions through the HIV continuum of care in people enrolling in care with advanced HIV disease in Latin America

Objectives: Advanced HIV disease (AHD) at HIV care enrollment is common in Latin America and may bias cross-sectional care continuum estimates. We therefore explored the impact of AHD on HIV care continuum outcomes using a longitudinal approach. Methods: We analyzed trajectories of 26,174 adult people with HIV enrolled at Caribbean, Central and South America network for HIV epidemiology (CCASAnet) sites (2003-2019) using multi-state Cox regression across five stages: (i) enrolled without antiretroviral therapy (no-ART); (ii) on ART without viral suppression (viral load ≥200 copies/m; ART + non-VS); (iii) on ART with viral suppression (viral load <200 copies/ml; ART + VS); (iv) lost to follow-up; (v) death. We defined AHD as clusters of differentiation 4+ count <200 cells/µl and/or an AIDS-defining illness at enrollment. Results: People with HIV with AHD had a shorter time with no-ART, a similar time ART + non-VS, but less time ART + VS before 2013 than non-AHD. After 2013, time with no-ART decreased but the 5-year probability of transitioning from no-ART to ART + VS decreased in both groups. The time spent virally suppressed while in care was low, overall. Risk of loss to follow-up and death was persistently worse among adults with AHD. Conclusions: Using a longitudinal approach to assess the HIV continuum of care provided insight into limitations in HIV care provision in our region previously underexplained by cross-sectional assessments.