Timing of ART initiation with treatment policy changes in South Africa: a cohort study

Background: Early antiretroviral therapy (ART) improves uptake, retention, and viral suppression. However, there is limited real-world data for high HIV burden settings including South Africa. Methods: We conducted a retrospective cohort study using linked clinical CD4 and Viral load (VL) data from South Africa's HIV treatment database (TIER.Net) and National Health Laboratory Service (NHLS). Our analysis included ART non-naïve individuals entering HIV care between January 2010 and March 2017 in four provinces (KwaZulu-Natal, Northern Cape, Limpopo, and Mpumalanga). We estimated days from entry into HIV care (same-day, 2-6 days, 7-89 days, and ≥90 days). Outcome measures included retention, viral suppression (VL<50 copies/ml), and CD4 recovery at 12 months. A Poisson regression model with adjusted Risk Ratios (aRR) was used to identify factors associated with rapid ART initiation (<7days) at 5% significance level. Results: Among 1,211,966 individuals (median age 31 years, 69.6% female), 30% initiated ART on the day of diagnosis, 4.2% within 2-6 days, 26% within 7-89 days, and 39.8% after ≥90 days. Rapid ART initiation increased over time, with same-day initiations rising from 24.6% in 2010 to 60% in 2017. Factors associated with rapid ART initiation included female gender (aRR: 1.04; 95% CI: 1.03-1.04) and lower CD4 count at entry. At 12 months, 77.6% of same-day initiators were retained, with 28.4% having a VL test and 61.2% achieving viral suppression. Conclusions: Rapid ART initiation has increased due to policy changes and healthcare worker efforts in South Africa, but addressing late entry into care and treatment non-adherence remains crucial.