Burden of advanced HIV disease among antiretroviral therapy-experienced persons with HIV in Italy over the past 20 years

Objectives

Data on the burden of advanced HIV disease (AHD) among people with HIV (PWH) already in care remain limited in high-income settings.

Methods

We included all PWH from the Icona Cohort who started ART between 2004 and 2024, with CD4≥200 cells/mm³ and no prior AIDS-defining event (ADE). Probability of AHD (CD4 < 200 cell/mm³ or ADE) occurring ≥3 months after ART initiation was estimated by Kaplan-Meier curves. In a nested case-control study, AHD cases were matched 1:2 to controls by CD4 nadir, age, and ART duration. Predictors of AHD were evaluated by conditional logistic regression. Mortality risk in cases versus controls was also assessed.

Results

Among 9,972 ART-experienced PWH, 429 (4.3%) developed AHD. Incidence was highest during the first year of ART (1.6%) and increased linearly thereafter, with lower rates among more recent ART initiators. In the case-control study, female sex, lower education, unemployment, injecting drugs use, prolonged disengagement from care and suboptimal virologic control were associated with an increased AHD risk. AHD cases exhibited an over 8-fold higher risk of all-cause mortality, particularly within two years post-diagnosis.

Conclusions

Although declining, the risk of AHD following ART, remains a concern in Italy. Efforts to improve sustained care engagement, especially among women and socio-economically vulnerable groups, are critical.