ART initiation among women newly diagnosed with HIV in a contraceptive trial in sub-Saharan Africa

Abstract

Current guidelines recommend starting antiretroviral therapy (ART) as soon as possible after HIV diagnosis to reduce morbidity, mortality and onward HIV transmission. We examined factors influencing ART initiation by women who seroconverted during the Evidence for Contraceptive Options and HIV Outcomes (ECHO) Trial. ECHO, conducted between 2015 and 2018, enrolled HIV-negative, sexually active women, aged 16-35 years, from four African countries. Follow-up was 12-18 months, with quarterly HIV testing. Women with incident HIV infection received extensive counselling by trial staff and referral to local facilities for HIV care. Of 304 women with ≥90 days follow-up time since HIV diagnosis, 186(61.2%) initiated ART within 90 days, 69(22.7%) initiated after 90 days, and 49(16.1%) had not initiated by the end of the study. There were no statistically significant differences in characteristics among women who initiated ART ≤90 days versus those who did not. Frequent reasons for delayed or non-initiation of ART included not feeling ready to start ART and being newly diagnosed. In a large clinical trial, ART initiation was modest within 90 days of HIV diagnosis and grew to 84% with longer observation. Despite extensive counselling on the importance of early ART initiation, personal barriers delayed some women from starting ART.

Predictors of Time-to-ART-Initiation Survival Times in a Random Sample of Adults Living with HIV from Malawi – A Historical, Nationally Representative Cohort Sample of 2004-2015 HIV Data

“…On patient’s education levels, compared to tertiary education incomplete basic education, and secondary education explained a 9% and 6% positive association with rapid ART-initiation [aHR 1.09, 95%CI: (1.02-1.20) versus aHR=1.06, 95%CI: (1.01-1.12)] respectively. This association was however not reported from a recent study from Africa which observed no correlation [93]. Comparably, the likelihood of rapid ART-initiation was increased by 7% in Northern region and by 6% in Southern region compared to the Central region of Malawi ( p= 0.001).…”

“…On health facility types as a factor influencing ART-initiation, secondary and tertiary healthcare facilities were associated with 21% [aHR 0.79, 95%CI: (0.73-0.86) and 14% [aHR 0.86, 95%CI: (0.79-0.93), negative association with early ART-initiation compared to primary health facilities. The findings also demonstrated that contraceptive use likewise acted as a barrier to rapid ART-initiation and was associated with delayed initiation by 7% - a different finding from South Africa that demonstrated no association with TTAT [93]. On HIV duration variable, the findings demonstrated that increase of every 5 and 10 years of HIV survivorship explained a 24% and 42% negative association to rapid ART-initiation.…”

“…According to socioeconomic-education level relationship, these people possess expectedly incomplete basis or basic education levels. However, conversely, participants with wealth index within Quantiles 2-5 were found to be statistically significantly associated with 38% higher probability of early ART-initiation in a logistic regression [93].…”

“…In addition, two more studies from Canada both demonstrated significant positive associations between patient's residential status and rapid ART-initiation [71, 101].In another setting, Ivana & colleagues (2022) in the ECHO Trial involving women from four African nations observed that one's geographical location had an influence on TTAT. Thus, the ECHO Trial observed that compared to RSA, participants from Zambia were 2.73-fold (95%CI:1.21-6.11) highly likely to rapid ART initiate[93]. Similarly, geographical location was likewise observed to be highly associated with rapid ARTinitiation; thus, compared to Lome (Togo), the hazard (aHR) for rapid ART-initiation was 5.15-fold for Abidjan (Côte d'Ivoire), 4.36-fold for Bamako (Mali), and 7.77-fold for Ouagadougou (Burkina Faso)[94].…”