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We found several patient-level characteristics that impacted This study has the strength of assessing multiple clinics
the likelihood of SDI, namely sex, age and CD4 count. that provided routine care in a real-world setting without
Healthier, young women were more likely to be initiated on augmentation from research or academic staff. We also
ART and initiated on the same day. It is unclear if this used multiple sources for data collection, paper and
was because of provider biases in terms of who was offered electronic and both local and national, to the covert
SDI of ART, or a potential pitfall when engaging older male possibility of missing or incorrect data in one source. Some
patients into SDI of ART. It is possible that higher rates of ART notable limitations arise from the use of chart review to
initiation in women are accounted for by same-day ART among assess successful LTC. Linkage to care and ART initiation
pregnant women as part of prevention of mother-to-child required documentation in a file at the same clinic as HIV
transmission (PMTCT); the overall lower engagement in care testing occurred. Patients who initiated ART at other
among men may also have contributed to our findings. 26,27,28 facilities were considered as not having initiated ART.
In contrast to general ART initiation studies and an SDI Furthermore, we also did not abstract a reason for visit at
study from Zimbabwe, we observed that younger patients the time of HIV testing, making it impossible to compare
(men and women) were more likely to have SDI compared ART for PMTCT with other initiation reasons. Finally, time
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with older patients. This is an intriguing finding and contrasts to ART initiation was not randomised. As a result, more
with findings that older individuals are more likely to initiate motivated individuals may have started on the same day.
ART. 30,31 It is plausible that SDI may have an especially It is also plausible that some same-day initiators were
important role in engaging young adult patients in care. just doing what they were told and were not motivated.
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Overall, the most substantial variation in SDI was by facility Comparing early ART (1–7 days after diagnosis) with
(10 – 69% for women and 0 – 45% for men). This variability same-day ART provides a group with motivation
was not associated with the type of health facility or structure, demonstrated by a prompt return to the clinic to
nor daily headcount, suggesting that health facility practice the potentially more heterogeneous same-day group.
and provider discretion were the primary determinants of However, the similar outcomes between these two groups
whether or not a patient received SDI. Further qualitative are reassuring.
research within healthcare facilities to understand facility-
based barriers to SDI is needed to support this initiative.
Conclusion
Studies of retention in care with SDI are limited to studies of This study demonstrates the feasibility of SDI of ART and
PMTCT and research studies. Research studies on SDI have similar outcomes with subsequent initiation. These findings
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reported increased retention in care, whereas some PMTCT are reassuring and should support continued scale-up of SDI
studies have reported a higher loss from care with same-day of ART. The finding of higher SDI of ART among younger
ART. 5,6,32,33,34,35,36,37 Same-day ART may improve outcomes by individuals may suggest that this approach is especially
reducing the cost of care and enhancing the perceived value promising to improve care engagement among this
of ART because of the immediacy of receiving the therapy. 38,39 population. Operational research should be continued to
The findings of our study present a stark contrast to a identify challenges and barriers to inform programmatic
recently published study led by Lilian et al., which presents delivery of same-day ART.
data on the national impact of SDI on retention in care.
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Routinely collected data from TIER.Net (n = 32 290) were Acknowledgements
analysed for HIV-infected adults who were newly initiating
ART in Johannesburg or Mopani districts between October Competing interests
2017 and June 2018. Their study identified a significant The authors have declared that no competing interest exists.
increase in lost to follow-up (LTFU) at 30.1% in the SDI
group compared with 22.4%, 19.8% and 21.9% among
clients initiating ART 1–7 days, 8–21 days and ≥ 22 days Authors’ contributions
after HIV diagnosis, respectively. Although LTFU was N.M-P., T.M., C.H., D.K. and S.C. designed the research
19
similar to our study (overall LTFU was 32.8%, 233/710), the study; T.M., N.M-P, G.K. and S.C. performed the research;
association between the timing of ART initiation and LTFU B.H., C.H. and E.H. analysed the data; B.H., N.M-P., T.M. and
was not found. Although our study was smaller, it benefitted C.H. wrote the article. All authors have read and approved
from the triangulation of multiple data sources that may the final manuscript.
capture individuals missed in the Tier.Net system. This
likely reveals the bias of using a single data source, which
may underestimate LTC. Additionally, it is also possible that Funding information
there is a heterogeneity in the success of SDI by district and The study was funded by Project SOAR (Supporting
even by clinic. Our study within a single district (Ekurhuleni) Operational AIDS Research). Project SOAR (Cooperative
had more promising LTC results than those in the Agreement AID-OAA-A-14-00060) was made possible by the
neighbouring districts of Johannesburg and Mopani. A generous support of the American people through the United
deeper dive into the implementation practices across States President’s Emergency Plan for AIDS Relief (PEPFAR)
districts and their relative LTC outcomes is required to and United States Agency for International Development
understand this phenomenon further. (USAID).

http://www.sajhivmed.org.za 297 Open Access