Sarita Shah, MD, MPH, reveals a decline in timely ART initiation from 86.5% in 2019 to 83.9% in 2020, with viral suppression rates dropping from 91.1% to 84.7%, before showing signs of recovery by 2021.
Sarita Shah, MD MPH
Image credits: Emory University
A study presented at CROI 2025 by Sarita Shah, MD, MPH, professor of epidemiology and global health at the Rollins School of Public Health, Emory University, examined the impact of the COVID-19 pandemic on early antiretroviral therapy (eART) initiation and viral suppression (eVS) among people with HIV (PWH). The study analyzed data from 13 NA-ACCORD clinical cohorts and revealed that while disruptions in HIV care were significant during the pandemic, there was a recovery in ART initiation by 2021, though viral suppression remained challenged.
"A major goal in ensuring high-quality HIV care is to start ART as soon as possible after HIV diagnosis and to achieve viral suppression," Shah said. "This improves not only long-term health outcomes for people with HIV but also for reducing HIV at a population level because people who are undetectable cannot transmit HIV."
Pandemic Disruptions in HIV Care:
The study found that, while early ART initiation in 2021 returned to pre-pandemic levels, viral suppression had not yet fully recovered. In 2019, 86.5% of individuals initiated ART within 30 days of entering care. However, in 2020, only 83.9% initiated ART within 30 days, showing a decline in timely care. Shah observed, "We saw this progress reverse in 2020, but the good news is that by 2021, we saw that timely ART initiation was recovering."
The COVID-19 pandemic caused a decline in timely ART initiation, from 86.5% in 2019 to 83.9% in 2020, and a drop in viral suppression rates from 91.1% to 84.7%.
By 2021, ART initiation had returned to pre-pandemic levels, although viral suppression had not fully recovered.
People with substance use issues and lower CD4 cell counts experienced slower viral suppression, underscoring the need for enhanced support for these populations.
Similarly, viral suppression rates, which had improved from 2018 to 2019, reversed in 2020. In 2019, 91.1% achieved viral suppression within six months of starting ART, but in 2020, that number dropped to 84.7%. Although viral suppression showed signs of improvement in 2021, it had not yet fully rebounded to pre-pandemic levels. Shah explained, "We observed a similar effect on viral suppression rates where progress made from 2018 to 2019 was reversed in 2020. In 2021, viral suppression had not yet recovered but was improving."
Factors Contributing to Slower Progress:
The study identified factors that contributed to slower viral suppression progress during the pandemic, including substance use and lower CD4 cell counts, which are associated with more severe immunosuppression. Shah noted, "We identified people who inject drugs and people with lower CD4 cell counts (i.e., those who were more immunosuppressed) as having slower time to viral suppression. These groups are important to ensure we are providing strong support for adherence and retention in care."
Resilience of HIV Care Systems:
Despite the setbacks, Shah highlighted the resilience of HIV care systems and providers. "It was encouraging to see the recovery of timely ART initiation but not surprising. HIV care providers are extraordinary people who are deeply committed to the community they serve," she said. The transition to telehealth and other strategies during the pandemic helped ensure continuity of care for PWH. "Looking around at the amazing work being presented at CROI 2025 is another reminder of how dedicated and passionate this entire community is to continually improving HIV care."
Although timely ART initiation recovered by 2021, viral suppression continued to lag behind, particularly for certain vulnerable populations. Shah concluded, "Though COVID was a setback in 2020, the resilience of the people who make up HIV care systems was shown in the recovery of timely ART initiation by 2021. I think we’ll see the same with viral suppression, hopefully, with the 2022 data."
