The Impact of Same-Day Antiretroviral Therapy Initiation Under the World Health Organization Treat-All Policy

Abstract Rapid initiation of antiretroviral therapy (ART) is recommended for people living with human immunodeficiency virus (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. We e...

Full description

Saved in:
Bibliographic Details
Published in:American journal of epidemiology 2021-08, Vol.190 (8), p.1519-1532
Main Authors: Kerschberger, Bernhard, Boulle, Andrew, Kuwengwa, Rudo, Ciglenecki, Iza, Schomaker, Michael
Format: Article
Language:English
Subjects:
Antiretroviral agents
Antiretroviral drugs
Antiretroviral therapy
Drug therapy
Graph theory
HIV
Human immunodeficiency virus
Maximum likelihood estimation
Original Contribution
Public sector
Survival analysis
Citations: Items that this one cites
Items that cite this one
Online Access:Get full text
Tags: Add Tag
No Tags, Be the first to tag this record!
Description
Summary:Abstract Rapid initiation of antiretroviral therapy (ART) is recommended for people living with human immunodeficiency virus (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. We established a cohort of ≥16-year-old patients who initiated first-line ART under a treat-all policy in Nhlangano (Eswatini) during 2014–2016, either on the day of HIV care enrollment (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 a composite unfavorable treatment outcome (loss to follow-up, death, viral failure, treatment switch). Of 1,328 patients, 839 (63.2%) initiated same-day ART. The adjusted hazard ratio of the unfavorable outcome was higher, 1.48 (95% confidence interval: 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 unfavorable outcome under same-day ART compared with 21.2% under early ART (difference: 7.7%; 1.3%–14.1%). This estimate was driven by loss to follow-up and varied over time, with a higher hazard during the first year after HIV care enrollment and a similar hazard thereafter. We found an increased risk with same-day ART. A limitation was that possible silent transfers that were not captured.
ISSN:0002-9262
1476-6256
DOI:10.1093/aje/kwab032