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

Dvora Joseph Davey, Kathleen Kehoe, Claire Serrao, Marlien Prins, Ntokozo Mkhize, Khanyo Hlophe, Senate Sejake, and Todd Malone


South 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.


We 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.


Overall, 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.


Same‐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.

June 30, 2020
Year of publication
Resource types
Journal and research articles
Retention, antiretroviral therapy (ART), loss to follow-up

Similar Resources

This issue of the Southern African HIV Clinicians Society's "HIV Nursing Matters" online magazine focuses on vulnerable populations, including TB in prisons and intimate partner violence in the context of HIV.

This issue of the Southern African HIV Clinicians Society's "HIV Nursing Matters" online magazine focuses on key populations.


The goal of virtual elimination of horizontal and mother-to-child HIV transmission in South Africa (SA) has been proposed, but there have been few systematic investigations of which interventions are likely to be most critical to reducing HIV incidence.

Many countries are working to reduce or eliminate mother-to-child transmission (MTCT) of HIV. Prevention efforts have been conceptualized as steps in a cascade but cascade completion rates during and after pregnancy are low.

Achieving the promise of antiretroviral therapy (ART) to reduce HIV-associated mortality and transmission in sub-Saharan Africa relies on increasing behavioral change toward earlier engagement and sustained retention in HIV care after HIV diagnosis. Health communication may be an…

South Africa has the largest number of individuals living with HIV and the largest antiretroviral therapy (ART) programme worldwide. In September 2016, ART eligibility was extended to all 7.1 million HIV-positive South Africans.

Antiretroviral therapy (ART) that enables suppression of HIV replication has been successfully rolled out at large scale to HIV-positive patients in low-income and middle-income countries.

Treatment with efavirenz has been associated with rare but severe liver complications among patients receiving antiretroviral therapy (ART) in South Africa.


Attrition along the HIV care continuum slows gains in mitigating the South African HIV epidemic. Understanding population-level gaps in HIV identification, linkage, retention in care and viral suppression is critical to target programming.

Objective: To estimate time from HIV infection to linkage-to-care and its determinants. Linkage-to-care is usually assessed using the date of HIV diagnosis as the starting point for exposure time.