By Siyakudumisa Nontamo (Walter Sisulu University)
In recognition of World AIDS Day 2025
A new dawn in HIV care
South Africa, home to the world’s largest HIV treatment program, has achieved remarkable gains in testing and access to life-saving antiretroviral therapy (ART). Yet, behind these successes lies a persistent challenge: how do we ensure that people who start treatment on the same day as diagnosis remain in care and achieve viral suppression?
Since the commencement of the Universal Test and Treat initiative in 2016 in the Eastern Cape, South Africa, I have consistently observed an unsettling pattern. Patients were initiated on HIV treatment as soon as they were tested HIV positive. However, many patients drop out of their treatment journey within weeks or months. The main purpose of the same-day initiation of the ART policy was to save lives through timely treatment, yet without the support, it would sometimes overwhelm people who were still trying to come to terms with their diagnosis. This observation led our research team at Walter Sisulu University to ask a difficult but important question: how could same-day initiation be strengthened so that treatment outcomes could be improved?
Why we needed a new approach
The Fast-Track Initiation and Counselling (FTIC) protocol was endorsed by the World Health Organization in 2016 to speed up the ART initiation, reducing the barriers to care. Despite its sound clinical justification, retention and viral load suppression remain suboptimal. In South Africa, clinics report that half of the patients were lost in care within the six months of treatment. Nurses, counselors, and patients stated that a rush into starting ART compromises the emotional readiness, adherence, and disclosure, among others.
To address this, we developed a new protocol called ART Same-day Counselling and Initiation (ASCI). However, this approach does not replace the current same-day initiation policy; it improves it. ASCI introduces structured follow-up, psychosocial support, and community integration. Patients are seen regularly and receive personalized navigation. When patients miss their appointments, they get contacted through phone calls and home visits. To sum up, ASCI is a patient-centered standard operating procedure for helping people who start ART on the day they are diagnosed.
Testing the ASCI model
Our team conducted a randomized controlled trial between January and August 2023 in three high-volume clinics in the O.R. Tambo, Eastern Cape, South Africa. We enrolled 179 individuals aged 12 and up who were clinically stable (WHO Stage 1 or 2) and had recently received an HIV diagnosis.
The participants were randomly assigned to either the FTIC or the ASCI group:
- FTIC group: This group received the standard fast-track counselling and initiation procedure
- ASCI group: This group received the procedure, integrated follow-up on day 5, social worker support and counselling at day 14, structured monthly visits with continuous navigation.
All the participants were started on ART on the same day of their HIV diagnosis, utilizing a first-line treatment regimen as recommended by the Department of Health. What differed was the level of follow-up after treatment initiation. Patients were assigned to navigators for extra support outside the facility, which included phone calls, WhatsApp messages, and home visits for those who missed their clinic appointments. This personal connection was a game-changer.
What we found
After six months of treatment, the results were inspiring and uplifting.
- Retention in care with viral load suppression (<50 copies/mL) was 64% (45 out of 70 participants) in the ASCI group compared to 39% (28 out of 72 participants) in the FTIC group.
- Retention in care with low viremia (>1000 copies/mL) was 74% (52 out of 70 participants) in the ASCI compared to 50% (36 out of 72 participants) in the FTIC group.
- Overall retention regardless of viral load uptake was 79% (55 out of 70 participants) in the ASCI compared to 63% (46 out of 72 participants) in the FTIC group.
- Loss to follow-up was 17% (12 out of 70 participants) in the ASCI compared to 28% (20 out of 72 participants) in the FTIC group.
In a nutshell, participants who were supported through ASCI were more likely to be retained in care and achieve suppressed viral load, which is an important step in stopping the spread of HIV.
One participant said the following:
“The nurse phoned to check my well-being after having initiated ART. Following that, I received a call from a social worker asking to assist in addressing barriers to treatment adherence and disclosing my status to my loved ones. I was touched to see how valuable my life is.”
Behind the numbers: the human story
More than just numbers, the study exposes the tough truths about HIV in rural areas, providing a view into the daily lives of people living with HIV in South Africa. The HIV diagnosis still carries a burden of stigma for many people, particularly young people. After receiving the HIV-positive test results, anxiety, disbelief, and hurt overwhelm the body. Despite the daunting emotions, starting ART immediately is essential, yet without mental readiness, it can be devastating.
ASCI highlighted the importance of a structured support system, combining clinical and psychosocial support, helping to address challenges experienced by people living with HIV. The navigators and social workers became the pillar of ongoing counselling, assuring that patients not only start ART but also understand it is important to adhere to it. Nurses highlighted that using the clear SOP helped them to deliver quality care. Meanwhile, patients welcomed the frequent communication and follow-up. Our work highlights that compassion, communication, and reliability are as pivotal as clinical protocols in attaining 95-95-95 targets.
Lessons for HIV programmes
The achievement of ASCI’s mission has crucial implications for South Africa and any other country that strives to improve HIV services in settings with scarce resources. In South Africa, same-day ART initiation remains a fundamental part of HIV policy. However, we need to evolve from only being fast to being smart and supportive.
The ASCI SOP highlights the following:
- Adherence improves through structured follow-up and ongoing counselling
- Loss to follow-up can be easily prevented through timely reminders and outreach implemented by a patient navigator.
- Retention and viral load suppression can be enhanced through integrating community-based psychosocial support.
- Healthcare teams seamlessly track progress by using the clear, easy-to-follow SOP to intervene early.
National programs aiming to improve same-day ART initiation policy could be guided by these lessons, particularly in South Africa, which supports the decentralization of healthcare services closer to communities.
Looking ahead: Sustaining gains and equity in care
For ASCI to succeed, resources and training are essential, but it's a model that can help mitigate the growing pressures on health systems. Thus, even small steps, such as patient navigation targeting adherence, can yield enormous benefits.
A message for World AIDS Day
This study tells a story of resilience, the story of people living with HIV and the healthcare workers who serve them with commitment and compassion. This means that every person who remains in care with an undetectable viral load is a step forward in our mission to end the HIV epidemic.
"It's not enough to start treatment quickly anymore. We need to help people stay healthy, hopeful, and connected for life."
Author: Siyakudumisa Nontamo, Walter Sisulu University, South Africa
Study registration: ISRCTN99248870
Funding: Chemical Industries Education and Training Authority (CHIETA) and Strategic Health Innovation Partnerships (SHIP) of the South African Medical Research Council.