Toward Universal HIV Treatment in Haiti: Time Trends in ART Retention After Expanded ART Eligibility in a National Cohort From 2011 to 2017

Background: The World Health Organization (WHO) recommends universal antiretroviral therapy (ART) for persons living with HIV (PLWH), but evidence about effects of expanded ART access on ART retention in low-resource settings is limited. Setting: Haiti's Ministry of Health endorsed universal ART for pregnant women in March 2013 (Option B+) and for all PLWH in July 2016. This study included 51,579 ART patients from 2011 to 2017 at 94 hospitals and clinics in Haiti. Methods: This observational, retrospective cohort study described time trends in 6-month ART retention using secondary data, and compared results during 3 periods using an interrupted time series model: pre-Option B+ (period 1: 1/11-2/13), Option B+ (period 2: 3/13-6/16), and Test and Start (T&S, period 3: 7/16-9/17). Results: From the pre-Option B+ to the T&S period, the monthly count of new ART patients increased from 366/month to 877/month, and the proportion with same-day ART increased from 6.3% to 42.1% (P< 0.001). The proportion retained on ART after 6 months declined from 78.4% to 75.0% (P< 0.001). In the interrupted time series model, ART retention improved by a rate of 1.4% per quarter during the T&S period after adjusting for patient characteristics (adjusted incidence rate ratio = 1.014; 95% confidence interval: 1.002 to 1.026,P< 0.001). However, patients with same-day ART were 14% less likely to be retained compared to those starting ART >30 days after HIV diagnosis (adjusted incidence rate ratio = 0.86; 95% confidence interval: 0.84-0.89,P< 0.001). Conclusions: Achieving targets for HIV epidemic control will require increasing ART retention and reducing the disparity in retention for those with same-day ART.