The impact of same-day antiretroviral therapy initiation under the WHO Treat-All policy

Abstract

Background: The World Health Organization recommends rapid initiation of antiretroviral therapy (ART) for people living with HIV, with the option to start treatment on the day of diagnosis (same day ART). However, the effect of same day ART remains unknown in realistic public sector settings. Methods: We established a cohort of ≥16 year old patients who initiated first-line ART under Treat-All in Eswatini between 2014-2016, either on the day of HIV care enrolment (same day ART) or 1-14 days thereafter (early ART). Directed acyclic graphs, flexible parametric survival analysis and targeted maximum likelihood estimation (TMLE) were used to estimate the effect of same day ART initiation on the composite unfavourable treatment outcome (loss to follow-up;death;viral failure). Results: Of 1328 patients, 839 (63.2%) initiated same day ART. The adjusted hazard ratio of the unfavourable outcome was increased by 48% (95% CI:1.16-1.89) for same day ART compared with early ART. TMLE suggested that after 1 year, 28.9% of patients would experience the unfavourable outcome under same day ART compared with 21.2% under early ART (difference: 7.7%; 1.3-14.1%). This effect varied over time in regression analysis and TMLE, with a higher hazard during the first year after HIV care enrolment and a similar hazard thereafter. Conclusions: Caution is needed in implementing same day ART in routine settings.

Retention in care and viral suppression after same‐day ART initiation: One‐year outcomes of the SLATE I and II individually randomized clinical trials in South Africa

“…Recent observational studies of routine ART initiation have reported higher loss to follow‐up among patients who start ART on the same day than among those who do not [16–18]. We speculate that there are two main explanations for the discrepancy between our results and these studies’ findings.…”

Same‐dayand rapid initiation of antiretroviral therapy in people living withHIVin Asia. How far have we come?

“…An Eswatini cohort study observed that treatment outcomes (loss to follow-up, death, or virological failure) in people living with HIV initiating same-day ART were inferior to those starting early ART (1-14 days). It was suggested that people newly diagnosed with HIV did not have enough time to accept an HIV-positive status and to consider life-long therapy, which may have contributed to immediate disengagement from care [34]. Two studies in South Africa also observed increased disengagement from care, with a greater loss to follow-up in people with HIV who had same-day initiation than in those who initiated at later timepoints.…”

“…Hence, additional counselling, adherence support, and interventions to improve adherence and retention are required [36]. Clinical and counselling tools need to be appropriate to identify people living with HIV ready for rapid/same-day ART initiation [34]. Streamlined education about the benefits of rapid ART initiation needs to be delivered to people living with HIV in a limited timeframe to increase acceptance and adherence [38].…”