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Background: High rates of pre-ART attrition are widely reported. Retention may be improved if pre-ART services could be effectively provided in one day.
Methods: We conducted a randomized study comparing standard and same-day ART initiation for adult patients (age >17 years) who presented for HIV testing with WHO stage 1 or 2 disease and CD4 count ≤500 cells/mm3 at GHESKIO in Port-au-Prince, Haiti. All participants received same-day HIV and CD4 count testing, TB screening, and physician evaluation. The standard group initiated ART at the third follow-up visit (day 21); the same-day group initiated ART on the day of presentation. The only difference in services provided was the timing of ART initiation. Participants were followed for 12 months.
Results: Between August 2013 and October 2015, 762 participants were randomized to standard (n=384) or same-day ART (n=378) (see Table 1). Twenty-four participants in the standard and 18 in the same-day ART group transferred during the study period, and were removed from all analyses; this left 360 participants in each group. ART was initiated within 90 days in 329 (91%) of participants in the standard and 100% in the same-day ART group (p< 0.001). 577 participants (80%) have completed 12 months of potential follow-up time (290 in standard; 287 in same-day ART groups). In the standard group, 212 participants (73%) were retained, 17 (6%) died, 56 (19%) were lost to follow-up (LTFU), and 5 (2%) were late returners. In the same-day ART group, 230 participants (80%) were retained, 8 (3%) died, 46 (16%) were LTFU, and 3 (1%) were late returners. Twelve-month retention was higher in the same-day ART group (p=0.046).
Conclusions: Same-day ART is associated with higher rates of ART initiation and retention, compared with standard ART initiation. These findings suggest that immediate ART is feasible in PEPFAR “Test and Start” recommendations.

  Standard Group (n=360)Same-Day Group (n=360)p-value
Baseline CharacteristicsFemale sex - no. (%)183 (51%)169 (47%)0.296
 Age - mean (SD)38 (10)38 (10)0.296
 CD4 count - mean (SD)244 (129)241 (124)0.781
Pre-ART OutcomesCompleted CD4 count - no. (%)360 (100%)360 (100%)---
 Initiated ART within 90 days after HIV testing - no. (%)329 (91%)360 (100%)<0.001
Outcomes 12-Months Post-ART (among participants with 12 months of potential follow-up time)Retained in care - no. (%)212 (73%)230 (80%)0.046
 Late returners - no. (%)5 (2%)3 (1%)0.486
 Lost to follow-up - no. (%)56 (19%)46 (16%)0.302
 Died - no. (%)17 (6%)8 (3%)0.062
[Table 1: Outcomes for Participants in the Standard and Same-day ART Groups]