Effect of rapid antiretroviral therapy initiation on loss to follow-up, virologic failure, and immunologic failure among people living with HIV under the treat-all policy in China: a retrospective cohort study (2016-2023).

INTRODUCTION: Since 2016, China has fully implemented the Treat-All policy, which eliminated the CD4 cell count threshold and ensures timely antiretroviral therapy (ART) for all people living with HIV (PLWH). This study aimed to evaluate the impact of rapid ART initiation ( ≤ 7 days post-HIV diagnosis) versus delayed initiation on loss to follow-up (LTFU), virologic failure, and immunologic failure among PLWH. METHODS: This study enrolled newly diagnosed, ART-naive adult PLWH in Guizhou Province, China, between 2016 and 2023. Kaplan-Meier analysis was used to examine LTFU across groups. Multivariable Cox regression was employed to evaluate the association between rapid ART initiation and LTFU, and logistic regression with multiple imputation was used to assess 12-month virologic and immunologic outcomes. RESULTS: Among 8163 participants, 2604 (31.9%) initiated ART within 7 days of diagnosis. The rapid ART initiation rate increased from 26.5% in 2016 to 47.0% in 2023. The LTFU rate was comparable between rapid and delayed (≥30 days) initiators (31.2% vs. 32.5%, P = 0.120). Compared with deferred ART, immediate rapid initiation was associated with significantly higher odds of virologic failure (aOR: 1.406; 95% CI: 1.020-1.940; P = 0.038) and immunologic failure (aOR: 1.540; 95% CI: 1.221-1.941; P < 0.001). DISCUSSION: Real-world data indicate that rapid ART initiation does not reduce LTFU risk, but significantly elevates the dual risks of virologic and suboptimal immunologic failure. To achieve clinical benefits when scaling up rapid ART in resource-limited settings, initiation pathways must be paired with individualized, intensified pre-ART counselling and comprehensive adherence support.