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Accelerating Progress on Late Presentation: Preventing Advanced HIV Disease in Thailand

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Released: October 13, 2026

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Despite major advances, late presentation and advanced HIV disease remain significant clinical and public health challenges across Asia. The prevalence of advanced HIV disease in Asia reflects interconnected, systemic barriers across the HIV care continuum. Here, I discuss factors contributing to late diagnosis, what healthcare professionals can do to overcome barriers to timely diagnosis, and what can be done to optimize care for people who present with advanced HIV disease. 

Sasisopin Kiertiburanakul
Sasisopin Kiertiburanakul, MD, MHS
Preventing Advanced HIV Disease in Thailand

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Despite major advances in HIV testing, antiretroviral therapy (ART), and prevention, late presentation remains a significant clinical and public health challenge across Asia. Many people living with HIV continue to enter care with advanced HIV disease, often after prolonged periods of undiagnosed infection. This is associated with higher morbidity and mortality, greater healthcare utilization, and increased demands on health system resources.

Delayed diagnosis also prolongs the period during which HIV may be unknowingly transmitted, highlighting the importance of earlier diagnosis and timely treatment.

Contributing Factors
Advanced HIV disease should not be viewed simply as a clinical consequence of missed or delayed diagnosis. Rather, the prevalence of advanced HIV disease in Asia reflects interconnected, systemic barriers across the HIV care continuum. Limited access to testing, concerns about confidentiality, stigma and discrimination, low perception of personal risk, missed opportunities for routine screening, and delayed recognition of HIV-related clinical presentations can all contribute to late diagnosis. 

For healthcare professionals (HCPs), recognizing clinical indicators of HIV and incorporating HIV testing into appropriate routine clinical encounters are essential steps toward reducing missed diagnoses. However, steps must also be taken at the public health level to normalize discussions of sexual health, HIV prevention, and HIV screening to reduce stigma and fear of discrimination. 

Initial Treatment
For individuals who present with advanced HIV disease, the immediate priority is to rapidly identify and manage potentially life-threatening complications while establishing effective HIV treatment.

A systematic approach should include assessment of CD4+ cell count, screening for opportunistic infections (OIs), evaluation for tuberculosis and other regionally relevant infections, and assessment of nutritional, psychosocial, and comorbidity-related needs.

WHO-aligned approaches emphasize timely ART initiation, while recognizing that treatment initiation may need to be individualized according to the presence of specific OIs, such as cryptococcal and tuberculous meningitis. If same-day ART initiation is not feasible, rapid ART initiation should be pursued when clinically appropriate. Furthermore, appropriate OI prophylaxis and treatment are critical components of advanced HIV disease management and can substantially influence clinical outcomes.

The primary goal of ART initiation in the setting of advanced HIV disease is swift, effective virologic suppression, but ART selection for people presenting with advanced HIV disease requires more than choosing a potent regimen. HCPs must consider concomitant medications, potential drug–drug interactions, organ dysfunction, comorbidities, pill burden, tolerability, adherence, and the potential for HIV drug resistance.

In Thailand, dolutegravir-based regimens are often preferred because of their high potency and favorable tolerability profile, but treatment should be individualized according to each person’s clinical context. Decision support tools, such as HIV-ASSIST, and up-to-date treatment guidance can help HCPs make informed choices and reduce risks of drug interactions, treatment failure, resistance, and treatment discontinuation.

Treating the Whole Individual
Successful management of HIV and advanced HIV disease extends beyond the first ART prescription. People presenting with advanced HIV disease may face stigma, depression, unstable employment or housing, limited health literacy, and difficulty accessing healthcare. All these factors may contribute to adherence challenges, which can significantly affect the risk for negative outcomes with advanced HIV disease. Adherence support, therefore, needs to be individualized and integrated into routine HIV care. Differentiated service delivery, multidisciplinary care, peer support, simplified treatment strategies, and proactive follow-up can help patients remain engaged in care and achieve sustained viral suppression.

In Thailand, we have learned that managing advanced HIV disease requires more than prescribing ART. Multidisciplinary care is essential to manage OIs and address psychological and social challenges. Peer support and community-based services help reduce stigma and improve engagement in care, while differentiated service delivery, such as telemedicine and flexible appointments, reduces the burden of treatment. Another important lesson is proactive, nonjudgmental follow-up. Rather than blaming patients for missed appointments, we need to understand and address the underlying barriers.

Ultimately, reducing late presentation requires action at both the individual and health system levels. Earlier diagnosis through expanded and routine HIV testing, HCP-initiated and community-based approaches, improved recognition of clinical indicators, and stronger linkage to care should occur alongside efforts to reduce stigma and normalize HIV testing.

By combining earlier diagnosis, rapid linkage to care, evidence-based management of advanced HIV disease, appropriate OI prevention and treatment, individualized ART selection, and sustained adherence support, HCPs across Asia can help reduce morbidity and mortality, prevent onward HIV transmission, decrease avoidable healthcare utilization, and make late presentation an increasingly preventable event.

Your Thoughts
How prevalent is advanced HIV disease in your region, and what do you think are the primary factors behind that? Leave a comment to join the discussion!

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