Sex‐ and migration‐related differences in viral suppression and life expectancy among people with HIV : The PISCIS cohort, 1998–2023

Background Despite advances in antiretroviral therapy (ART), inequalities in HIV outcomes persist by sex and migration status. Few studies have examined how these factors jointly relate to treatment outcomes across successive ART eras. Aim To examine differences in time to first viral suppression and life expectancy according to sex and migration status, and how these differences changed across successive ART eras. Methods We conducted a population‐based retrospective cohort study using the PISCIS cohort in Catalonia and the Balearic Islands, Spain. Participants aged ≥16 years diagnosed with HIV between 1998 and 2023, with a recorded ART initiation date and at least one viral load measurement within 12 months after ART initiation, were included. Time to first viral suppression (<50 copies/mL) was analysed using Kaplan–Meier methods and period‐specific (P1: 1998–2001; P2: 2002–2009; P3: 2010–2015; P4: 2016–2023) Cox proportional hazards models including an interaction between sex and migration status and adjusting for age at diagnosis, transmission group, baseline CD4 count, HIV‐RNA and socioeconomic deprivation. Life expectancy at age 20 was estimated using abridged life tables. A complementary analysis among participants with sexually acquired HIV examined differences in viral suppression according to migration status after further disaggregation into women, men who have sex with men (MSM) and heterosexual men. Results The analysis included 18 323 participants (16·0% women; 46.2% migrants). Time to viral suppression shortened substantially across all sex‐migration groups over successive ART periods. By the most recent period (P4), compared with migrant males, migrant females had a lower hazard of viral suppression (adjusted hazard ratios [aHR] 0.84, 95% CI 0.73–0.96), as did non‐migrant males (aHR 0.88, 95% CI 0.81–0.95), whereas non‐migrant females had comparable hazards (aHR 1.09, 95% CI 0.92–1.30). Complementary analyses of sexually acquired HIV revealed further heterogeneity in the most recent period (interaction p < 0.001): Migrant women had a lower adjusted hazard of viral suppression than migrant MSM (aHR 0.77, 95% CI 0.67–0.89), while a particularly low hazard was observed among migrant heterosexual men (aHR 0.60, 95% CI 0.51–0.69). Life expectancy at age 20 increased by approximately 12 years across all groups over the study period, with differences between groups narrowing over time. Conclusion Viral suppression and life expectancy improved substantially across all sex‐migration groups over 26 years. However, differences in time to viral suppression persisted in the most recent ART era, including slower suppression among migrant women compared with migrant men. Further disaggregation of sexually acquired HIV revealed additional heterogeneity, particularly between migrant MSM and heterosexual men. These findings highlight the importance of considering the intersection of sex, migration status and HIV acquisition group to better identify population‐specific inequalities in HIV care.