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Page 2 of 6 Original Research

As a counterpoint to SDI of ART enthusiasm, there Study setting and population
are concerns regarding the operational feasibility of The study took place in the Ekurhuleni District (Gauteng
SDI in public health facilities providing routine care. Province) of South Africa. This district has the second-highest
These concerns include failure to rule-out important district-level HIV prevalence (14.3%) in South Africa and is
opportunistic infections, challenges with assuring comprised of urban and peri-urban settings. 21,22 The study
adequate renal function for some primary ART regimens sites consisted of six primary healthcare clinics, three
and patient readiness to cope with a new HIV diagnosis community healthcare centres and one outpatient department
and initiate life-long ART. 1,13,14,15,16 Furthermore, SDI of at a district-level hospital. Facilities were selected to achieve
ART may not allow time (and focussed time) to provide geographic diversity within the district. All facilities had
important HIV education and adherence counselling that HIV counselling and testing personnel (lay counsellors) and
may be valuable for long-term ART success. 16,17,18 Moreover, routinely provide free HIV testing services (HTS) according
a recent South African study demonstrated a reduced rate to the 2015 National HIV Counselling and Testing (HCT) and
of retention among same-day initiators. These reports of the UTT policy guidelines. 23,24
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early findings warrant further investigation to understand
the impact of routine delivery of same-day ART. Lastly, Sampling and data collection
SDI of ART adds a further service burden to an already We aimed to include 100 consecutive adult patients with
overwhelmed system. The shortage of ‘nurse-initiation an HIV-positive diagnosis from each of the 10 health facilities
and management of ART’ (NIMART) trained staff, for a total sample of approximately 1000 patients. This sample
limited resources and long waiting times in facilities size was selected to provide an estimate of LTC within 20% of
pose system-level barriers that may impede the effective the point estimate, assuming 50% LTC, an alpha of 0.05 and
implementation of SDI of ART and contribute to the 80% power. Consecutive patients were identified from the
negative outcomes already reported. HIV testing registers and were included if they were aged
18 or older and had a positive HIV test recorded in the clinic
In spite of the challenges associated with SDI of ART, it HIV testing register between January 1st and July 31st 2017.
still offers important benefits to both the patient and Approximately 1 year after the date of diagnosis, paper and
healthcare system. In addition to early access to a definitive electronic clinical records were abstracted for each selected
management strategy, SDI obviates the need for repeat patient, from the clinic at which HIV testing occurred.
visits and is likely a more attractive option for young The data abstracted included sex, age, CD4 count, viral
working adults. Furthermore, routinisation of SDI may in load (HIV RNA), creatinine, ART initiation, HIV care visits,
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some way normalise ART initiation, by providing a similar tuberculosis (TB) testing, TB test results and TB preventive
approach to HIV management as other chronic health therapy prescribing.
conditions (i.e. high blood pressure management where
antihypertensive medications are often started during the Outcome measures
clinic visit without the need for extensive repeat visits or Linkage to care was defined as documentation of ART
referral to a specialised clinical setting).
prescription. Same-day initiation of ART was defined as
having the same date of HIV diagnosis and ART initiation.
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This study seeks to describe our experience with SDI Rapid ART initiation that did not occur on the day of HIV
across 10 healthcare facilities in the Ekurhuleni District of testing was defined as initiation between 1 and 7 days after
South Africa and characterise both patients- and health HIV diagnosis. Retention in care was defined as evidence of
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facility-associated factors that impact SDI success, namely a care visit (in the same facility where patients had initiated
retention in care and viral load suppression. ART) or HIV-related laboratory testing between 91 and
365 days after ART initiation. Six-month viral suppression
Materials and methods was defined as a viral load of < 400 c/mL (for consistency with
Study design prior reports) between 4 and 8 months after ART initiation.
This is a retrospective clinical review of patients who Statistical analyses
presented for routine care and tested HIV positive at
10 public sector health facilities in the Ekurhuleni District Descriptive statistics were used to explore the relationship
of South Africa between 01 January 2017 and 31 July 2017. between patient characteristics and the timing of ART
We abstracted clinical data from patient charts (including initiation (same-day, 1–7, 8–30, 31–90; > 90 days).
patient files and HIV testing registers) and electronic Comparisons of factors associated with the timing of ART
databases (Tier.Net and the South African National Health initiation were conducted using chi-square tests with
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Laboratory Service [NHLS] database). All data were particular interest in clinic attended, sex, age group,
collected after the pathway of care was completed, there CD4 count and TB testing. Log binomial regression
was no interaction with patients and written informed modelling (used to approximate relative risk) was used to
consent was not obtained. All data were de-identified assess for associations between the timing of ART initiation
prior to data capture and data analysis. and viral suppression and retention in care while adjusting

http://www.sajhivmed.org.za 294 Open Access