Risk of Mortality Associated with Rapid versus Delayed ART Initiation and Associated Factors Among Late-Presenting People with HIV: An 8-Year Retrospective Analysis in China

Objective: To explore the association between the timing of antiretroviral therapy (ART) initiation and all-causes mortality, as well as related risk factors, for late presenters living with HIV (PWH). Methods: Treatment-naive PWH with CD4+T cell count< 350 cells/μL, also called late presenters, who initiated ART at the Nanjing Second Hospital from January 2017 to June 2022 were enrolled in this study and followed for at least 3 year and a maximum of 8 years. Based on the time from diagnosis to ART initiation, subjects were divided into a rapid ART group (ART initiation≤ 14 days after HIV diagnosis, median 12 days) and a delayed ART group (ART initiation> 14 days after HIV diagnosis, median 35 days), with a significant difference in initiation time (p< 0.001). The difference in mortality, cause of death and immunological profiles between the two groups were compared, and a Cox proportional hazards model was constructed to analyze death-related risk factors. Results: A total of 1538 PWH were included in the study, and 68 patients died, with the total case mortality rate of 4.42%. There were 459 (29.8%) patients in the rapid ART initiation group, and the mortality rate was 3.92% (18/459), there was no significant difference in case mortality compared to the delayed initiation group (4.63%, 50/1079). The most common cause of death among these patients was non-AIDS-related cancer. Besides, risk factors for death were being single, divorced or widowed, and having a baseline CD4+T cell count < 200 cells/μL. Conclusion: The all-cause mortality rate of PWH with CD4+T cell counts < 350 cells/μL was 4.42%, and the cause of death in China have shifted over time. Rapid initiation of ART was not significantly associated with reduced mortality in this cohort; however, low CD4+T cell counts at baseline and social factors showed a more significant association with mortality.