Same‐day antiretroviral therapy is associated with increased loss to follow‐up in South African public health facilities: a prospective cohort study of patients diagnosed with HIV

Abstract

IntroductionSouth Africa introduced Universal Test and Treat in 2016 including antiretroviral therapy (ART) initiation on the same‐day as HIV diagnosis. Our study sought to evaluate the impact of same‐day ART initiation on loss to follow‐up (LTFU) and mortality comparing with patients who initiated ART after their HIV diagnosis.MethodsWe conducted a file review of patients with a HIV diagnosis and ART start date on file between September 2016 and May 2018 in six high HIV burden districts. Our primary outcome was LTFU (>90 days from the last clinical visit or drug pick‐up until database closure 31 July 2018). The secondary outcome was mortality after ART initiation. Time to outcome was assessed comparing same‐day vs. one to seven, eight to twenty‐one and ≥ twenty‐two days to ART initiation using Kaplan‐Meier estimators stratified by sex. We investigated predictors using univariate and multivariable Cox proportional hazards models, adjusting for a priori characteristics.ResultsOverall, 92,609 ART patients contributed 43,922 person‐years from ART initiation, with a median follow‐up time of 246 days (IQR = 112 to 455). Of these patients, 33,399 (36%) initiated ART on the same‐day as their HIV diagnosis date and had a median follow‐up time of 174 days (IQR = 85 to 349). Same‐day patients were predominantly non‐pregnant females (56%) and aged 25 to 34 years (40%). Same‐day ART initiation increased from 2.8% in September 2016 to 7.1% in April 2018. In same‐day patients, 33% (n = 11,114) were classified as LTFU with a median time of 55 days (IQR = 1 to 185), compared to 371 mean days (IQR = 161 to 560) in patients who initiated ≥22 days after diagnosis. A similar proportion of LTFU was observed for patients who initiated later: 31% 1 to 21 day and 33% ≥22 day. Same‐day ART patients had an increased risk of LTFU vs. ≥1 day (adjusted hazard ratio (aHR) = 1.28, 95% CI = 1.24 to 1.33) adjusting for covariates. Although all‐cause mortality was slightly lower in same‐day patients (0.9%) vs. >1 day (1.4%; aHR = 0.87, 95% CI = 0.72 to 1.05) adjusting for covariates. Men had highest risk of mortality and LTFU.ConclusionsSame‐day ART increased the risk of LTFU, but same‐day patients experienced slightly lower mortality. Same‐day patients may require additional counselling and interventions to improve retention. Additional research is needed on targeted interventions, including differentiated care, to reduce LTFU in patients initiating ART same‐day.

Impact of SMS and peer navigation on retention in HIV care among adults in South Africa: results of a three‐arm cluster randomized controlled trial

“…At one end, ART clubs have high retention (90% retained up to 24 months post‐diagnosis) [ 13 , 14 ], however, with eligibility restricted to patients who first reliably engage in care at clinics [ 40 ], findings are indicative of a population that may have fewer retention challenges. At the other end, studies have identified higher rates of loss‐to‐follow‐up among patients linked to ART on the day of diagnosis, with such patients being lost on average within 55 days [ 41 ]. This finding is likely due to same‐day initiation policies improving linkage outcomes most strongly among those with substantial engagement challenges, who are then quickly lost.…”

Incidence and predictors of attrition among patients receiving ART in eastern Zimbabwe before, and after the introduction of universal ‘treat-all’ policies: A competing risk analysis

“…In addition, questions remain on how determinants of attrition may be altered by the introduction of treat-all guidelines, particularly patient characteristics such as CD4 cell count and WHO clinical staging. Previously, correlates of attrition have been sameday ART initiation, young age, sex, and being unmarried [13,18,[21][22][23]. Facility-level factors have also been noted.…”

Rapid antiretroviral therapy initiation and its effect on treatment response in MSM in West Africa

“…However, the authors concluded that pragmatic research is needed to validate the effects observed in trials when rapid ART initiation is implemented in health systems. In contrast to trials, recent observational studies in Southern Africa found that same-day ART initiation was associated with lower retention in care [ 19 – 21 ].…”