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

In April 2020, South Africa adopted the World Health Organization revised eligibility for differentiated service delivery, which changed from requiring virologically suppressed clients to be on antiretroviral therapy (ART) for 12 months to 6 months. To evaluate the uptake of early community-based ART (ec-ART) and subsequent clinical outcomes, we performed a retrospective cohort study using routine, de-identified data from 124 public clinics in KwaZulu-Natal, 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 ec-ART among people initiating ART between January 2020 and December 2022, and clinical outcomes of retention in care, death, and viremia at 12 months among those initiating ART between January 2020 and March 2022 . We used multivariable Poisson regression models with robust standard errors to compare outcomes. Among 27,855 people eligible for ec-ART, 61% were women, median age was 33 years. 12.3% received ec-ART, at a median of 223 days after ART initiation. Rates of ec-ART increased from 7.0% in Q1 2020 to 20% in Q4 2022. Among 21,106 participants with outcome data, 9.5% received ec-ART. The proportion not retained-in-care/died at 12 months was 3.9% for those with and 7.9% for those without ec-ART (RR 0.48; 95% CI 0.38-0.60; p < 0.05). Among those retained-in-care, a 12-month viral load result was available for 83.4% patients, of these 9.0% with and 10.5% without ec-ART had viraemia (not significantly different). Uptake of ec-ART was low but associated with better retention and similar clinical outcomes.