Addressing late HIV presentation: the current knowledge and unmet needs

Introduction: HIV late presentation, defined as a CD4+ cell count below 350 cells/μL or the presence of an AIDS-defining condition at diagnosis, represents a significant global challenge, accounting for approximately 50% new HIV diagnoses worldwide. This phenomenon is associated with suboptimal clinical outcomes, increased morbidity and mortality, and elevated transmission risks due to prolonged undiagnosed infection. Areas covered: This review examines the definitions, risk factors, epidemiology, and clinical implications of late presentation in HIV. It highlights evidence supporting the timely initiation of antiretroviral therapy (ART), discusses the choice of optimal therapeutic regimens, and addresses the management of opportunistic infections in late presenters. Special attention is given to challenges posed by advanced disease, including immune reconstitution inflammatory syndrome, and drug–drug interactions in the context of opportunistic infections. Expert opinion: Late HIV presenters face unique clinical and therapeutic challenges. High-risk groups, including older individuals, women, people who inject drugs, and migrants, require tailored prevention efforts to improve early diagnosis and care access. While INSTI-based ART regimens are preferred due to their efficacy and tolerability, evidence gaps persist regarding optimal ART strategies and timing in severe opportunistic conditions, such as cryptococcal and tuberculous meningitis. Further studies are needed to address these gaps.