Earlier referral to differentiated antiretroviral therapy delivery at six months after initiation: a retrospective cohort study in KwaZulu-Natal, South Africa

Preprint

The World Health Organization revised eligibility for differentiated service delivery to requiring clients to be on antiretroviral therapy (ART) from 12 to six months with one suppressed viral load. South Africa adopted “early community-based ART” referral from April 2020. We aimed to evaluate the uptake and subsequent clinical outcomes through a retrospective cohort study using routine, de-identified data from 124 public clinics in KwaZulu-Natal province, South Africa. We included people with HIV aged ≥16 years, newly initiated on ART and virally suppressed (≤50 copies/mL) at 6 months. We assessed uptake of early community-based ART (referral < 270 days from ART initiation) among people initiating ART between 1 January 2020 and 1 December 2022, and clinical outcomes of not retained-in-care or died, and viraemia at 12 months. We used multivariable Poisson regression models with robust standard errors to compare outcomes between ‘early community-based ART referral’ versus ‘no early referral’. Among 27,855 people eligible for early community-based ART, 61% were women and the median age was 33 years. 3,427 (12.3%) received early community-based ART, at a median of 223 days after ART initiation. Rates of early community-based ART increased from 7.0% of those initiated in Q1 2020 to 20% in Q4 2022. Among 21,106 participants with outcome data, 9.5% received early community-based ART. The proportion not retained-in-care or died at 12 months was 3.9% for those with and 17.9% for those without early community-based ART (RR 0.49; 95% CI 0.39-0.61; p < 0.05). Among those retained-in-care, a 12-month viral load result was available for 83.4% patients, and of these 9.0% with and 10.5% without early community-based ART had viraemia (RR 0.88; 95% CI 0.75-1.04; p = 0.128). In conclusion: uptake of early community-based ART was low but associated with better retention and similar clinical outcomes.

Authors: van der Molen, J; Tlhaku, K; Lewis, L; Sookrajh, Y; Hobe, L

• Publication status: Published
• Preprint server: VeriXiv
• Volume: 2
• Article number: 361
• Publication date: 2025-11-04
• DOI: 10.12688/verixiv.2341.1
• Server owner: Taylor & Francis
• Language: English
• Keywords: HIV; antiretroviral therapy; differentiated service delivery; retention in care; viral suppression; South Africa