“Ending AIDS”? An analysis of HIV late diagnoses and AIDS-defining conditions in Germany in the era of antiretroviral therapy

The introduction of effective antiretroviral therapy (ART) in the late 1990s has been a breakthrough in HIV medicine. Despite major improvements in treatment outcomes, AIDS-defining conditions are still observed in Germany. The objective of this doctoral dissertation was to analyse the characteristics of HIV late diagnoses and AIDS-defining conditions in Germany in the era of ART to inform the public health response in regard to UNAIDS’ goal of “Ending the AIDS epidemic as a public health threat by 2030”. This was done on the basis of three research studies. In Study 1, we examined the impact of regional socioeconomic deprivation on the timing of HIV diagnoses. A causal inference approach was used in the analyses. The adjusted prevalence ratios indicated that men who have sex with men who live in socioeconomically deprived countryside regions were more likely to be diagnosed in advanced stages. This effect was not observed among heterosexual persons who overall presented late more often, however irrespective of socioeconomic status. In Study 2, we investigated the incidence of the first AIDS-defining event among people living with HIV (PLHIV) under clinical care. Moreover, we examined the predictive utility of established prognostic factors using different performance measures. It was found that the rate had continuously declined over the course of follow-up as well as through-out the calendar years. We observed predictive associations of a low CD4 cell count, high viral load, and advanced age at baseline with the outcome. In Study 3, we put the focus on the first AIDS-defining event that occurred after more than one year of uninterrupted ART. Here, meaningful predictors were examined using a bootstrap stepwise selection procedure. We found that two thirds of the PLHIV were virally suppressed at the time of their AIDS event and that the types of AIDS-defining illnesses differed across the investigated strata. A low CD4 cell count at ART initiation, a previous AIDS event, and transmission through intravenous drug use were identified as relevant prognostic factors. Overall, the findings corroborated the significance of sustained ART and underlined that late diagnoses have been a central driver of HIV-related morbidity in Germany in the era of effective ART. In this doctoral dissertation, identified remaining barriers are discussed together with resulting public health opportunities. Addressing these presents a chance to reduce AIDS in Germany to a level by 2030 that no longer poses a public health threat.