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In areas of the world where HIV is highly prevalent, such as Africa, home-based testing programs hold out the prospect of diagnosing more people with HIV and, through widespread treatment, preventing transmission to others. Investigators evaluated whether offering antiretroviral therapy (ART) on the day of HIV diagnosis in rural Lesotho improved outcomes.
A total of 274 people diagnosed with HIV through home-based testing were randomized to same-day ART or usual care. Participants in the same-day group were counseled and given a 30-day supply of ART on the day of diagnosis, with instructions to follow up at a health facility within 2 to 4 weeks. Those in the usual-care group were referred to a health facility for preparatory counseling (at least 2 sessions) followed by ART initiation.
At 3 months, 68.6% of the same-day group and 43.1% of the usual-care group had linked to care. At 12 months, 50.4% of the same-day group and 34.3% in the usual-care group had viral suppression. Both differences were significant.
Labhardt ND et al. Effect of offering same-day ART vs usual health facility referral during home-based HIV testing on linkage to care and viral suppression among adults with HIV in Lesotho: The CASCADE randomized clinical trial. JAMA 2018 Mar 20; 319:1103. (https://doi.org/10.1001/jama.2018.1818)
Katz IT et al. The global HIV epidemic: What will it take to get to the finish line? JAMA 2018 Mar 20; 319:1094. (https://doi.org/10.1001/jama.2018.2093)
Comment
Like previous trials in South Africa and Haiti, this study supports offering ART on the day of HIV diagnosis — a strategy now endorsed by the World Health Organization. However, linkage and virologic suppression rates were low even in the same-day group, highlighting the need for enhanced efforts to engage people in care.
Should same-day initiation of ART be standard in the U.S.? We face different challenges here — e.g., securing insurance coverage for visits and medications. Still, the lesson of studies such as this one is that each care setting should develop programs based on local circumstances to deliver ART as quickly as possible. Our patients — and the public's health — deserve no less.