Effectiveness of same-day antiretroviral therapy initiation in retention outcomes among people living with human immunodeficiency virus in Ethiopia: empirical evidence

Abstract

Background In August 2016, Ethiopia endorsed a universal “test and treat” strategy for people living with human immunodeficiency virus (PLHIV) based on World Health Organization recommendation. However, there is limited evidence on the routine application of the same-day “test and treat” recommendation in low-income settings. This study assessed the effect of same-day treatment initiation on individual-level retention at 6- and 12-months follow-up. Methods A multicenter facility-based retrospective cohort study was conducted to compare retention-in-care between PLHIV who started antiretroviral therapy (ART) on the same-day and those started ART > 7 days following HIV diagnoses. Participants were at least 15 years-old and were newly diagnosed and started on ART between October 2016 and July 2018 in 11 health facilities in the Amhara region of Ethiopia. Multivariable logistic regression controlling for potential confounders and Kaplan-Meier survival analysis were used to assess differences in outcomes between the groups. Results In total, 433 PLHIV started ART on the same-day of diagnosis and 555 PLHIV who started ART > 7 days after HIV diagnosis were included in the study. At 6-months, 82.0% (355) in the same-day group vs 89.4% (496) in the > 7 days group were retained-in-care (absolute risk difference (RD) = 7.4%; 95% confidence interval (CI): 2.9–11.8%). At 12-months, 75.8% (328) in the same-day group vs 82.0% (455) in the > 7 days group were retained-in-care (absolute RD = 6.2%; 95% CI: 1.1, 11.4%). The major drop in retention was in the first 30 days following ART initiation among same-day group. After adjusting for baseline and non-baseline covariates, the same-day group was less likely to be retained-in-care at 6- and 12-months (adjusted risk ratio (RR) = 0.89; 95% CI: 0.87, 0.90 and adjusted RR = 0.86; 95% CI: 0.83, 0.89, respectively). Conclusions Reduced retention-in-care can threaten the benefit of the same-day “test and treat” policy. The policy needs to be implemented cautiously with greater emphasis on assessment and preparation of PLHIV for ART to ensure treatment readiness before starting them on same-day ART and close monitoring of patients during early follow-up periods.

Virologic outcomes of people living with human immunodeficiency virus who started antiretroviral treatment on the same-day of diagnosis in Ethiopia: A multicenter observational study

“…From patient side, some people may need more time to comprehend the result and cope with the news of being HIV positive before deciding to start a lifelong treatment immediately after diagnosis. Additionally, the suboptimal viral load status among same-day group could be related to a higher attrition in this group that has been published elsewhere [18]. In this study, LTFU individuals with no documented viral load result were considered as having high viral load.…”

“…This study was part of the study that evaluates the effectiveness of same-day ART initiation in Ethiopia. The detail of the study setting has been published elsewhere [18]. Briefly, this study was conducted at 11 public health facilities in Bahir Dar and Gondar, towns in Amhara region of northwest Ethiopia.…”

“…The description of data sources, methods of data collection and variable measurement in this study has been previously published [18].…”

“…As rapid ART initiation immediately after HIV diagnosis is a relatively new approach in low-income settings (LIS), there is a scarcity of evidence to evaluate its effectiveness in viral load suppression in routine clinical care settings. Even though two earlier randomized control trials (RCTs) demonstrated the efficacy of same-day ART initiation in improving retention and viral suppression at 12-months [11,15], recent empirical observational studies raise concerns about whether the benefits measured in RCTs fully translate into real-world settings [16][17][18]. A recent South African observational study that compared the virologic outcomes of same-day initiators with later initiators identified no difference in viral suppression (<400 copies/mL) at 6-months post-ART initiation [19].…”

Adherence to Antiretroviral Treatment Among People Who Started Treatment on the Same-Day of HIV Diagnosis in Ethiopia: A Multicenter Observational Study

“…The sample size of this study was 988 (433 same-day and 555 after 7 days), which includes all eligible PLHIV who were newly diagnosed and started on ART between 20 October 2016 and 18 July 2018 at study sites. 20 We calculated a required sample size of 427 study participants for both groups to be able to detect a 10% absolute difference in the proportion of individuals with optimal adherence between the two groups, based on results from studies conducted in the Amhara region of Ethiopia on self-reported optimal adherence among PLHIV who started ART before universal "test and treat" approach. 23,24 We used P 1 of 98% (proportion of PLHIV having optimal adherence among individuals in the sameday group) and P 2 of 88% (proportion of PLHIV having optimal adherence among individuals in the control group).…”