Uptake of same-day initiation of HIV treatment in Malawi, South Africa, and Zambia: the SPRINT retrospective cohort study

IntroductionSince 2017 global guidelines have recommended "same-day initiation" (SDI) of antiretroviral treatment (ART) for patients considered ready for treatment on the day of HIV diagnosis. Many countries in sub-Saharan Africa have incorporated a SDI option into national guidelines, but uptake of SDI is not well documented. We estimated average time to ART initiation at 12 public healthcare facilities in Malawi, 5 in South Africa, and 12 in Zambia. MethodsWe sequentially enrolled patients who were eligible to start ART between January 2018 and June 2019 and reviewed their medical records from the point of HIV treatment eligibility (HIV diagnosis or first HIV-related interaction with the clinic) to the earlier of treatment initiation or 6 months. We estimated the proportion of patients initiating ART at their original healthcare facilities on the same day or within 7, 14, 30, or 180 days of baseline, stratified by country and gender. ResultsWe enrolled 826 patients in Malawi, 534 in South Africa, and 1,984 in Zambia. 88% of patients in Malawi, 57% in South Africa, and 91% in Zambia were offered and accepted SDI. In Malawi, most patients who did not receive SDI had also not initiated ART [≤] 6 months. In South Africa, an additional 13% of patients initiated [≤] 1 week, but 21% still had no record of initiation [≤] 6 months. Among those who did initiate within 6 months in Zambia, most started [≤] 1 week. There were no major differences by gender. Both WHO Stage III/IV and tuberculosis symptoms were associated with delays in ART initiation. DiscussionAs of 2020, uptake of same-day ART initiation was widespread, if not nearly universal, in Malawi and Zambia but was considerably less common in South Africa. Limitations of the study include pre-COVID-19 data that do not reflect pandemic adaptations and potentially missing data for Zambia. South Africa may be able to increase overall ART coverage by reducing numbers of patients who do not initiate [≤] 6 months. RegistrationClinicaltrials.gov NCT04468399 (Malawi), NCT04170374 (South Africa), and NCT04470011 (Zambia).