Abstract
BackgroundIn 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.MethodsA 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.ResultsIn 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).ConclusionsReduced 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.
Highlights
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
According to the latest national antiretroviral therapy (ART) guideline, PLHIV are immediately linked to an ART clinic for a confirmatory test, counseling, adherence preparation and rapid ART initiation - including same-day ART for persons who are ready to start ART at the first clinical visit and have no sign of opportunistic infections (OI) (e.g. Tuberculosis (TB) and cryptococcal meningitis) that would result in delayed ART initiation [17]
Our findings demonstrated that individuals who started ART on the same-day of HIV diagnosis had lower retention at 6-months (82.0% vs 89.4%) and 12-months (75.8% vs 82.0%) of ART follow-up compared to those who started ART > 7 days after their HIV diagnosis
Summary
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. Patients started on ART with advanced World Health Organization (WHO) clinical stage (III/IV) or bed ridden/seriously ill functional status [5,6,7,8] or lower CD4 cell count [8,9,10] had increased risk of attrition This was mainly linked with delayed treatment initiation [5,6,7] that resulted from restricted initiation criteria following the earlier WHO guidance [11]. In 2016, the WHO released a recommendation to provide universal “test and treat” services for PLHIV, regardless of their CD4 cell count or WHO clinical stage, in order to improve clinical outcomes This universal eligibility strategy aimed to increase access to antiretroviral (ARV) drugs for treating and preventing HIV, and thereby achieve the “goal of ending the HIV epidemic as a major public health threat by 2030” [15]
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