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Clin Infect Dis. 2019 Nov 29. pii: ciz1126. doi: 10.1093/cid/ciz1126. [Epub ahead of print]

Engagement in care, viral suppression, drug resistance and reasons for non-engagement after home-based same-day ART initiation in Lesotho: a two-year follow-up of the CASCADE trial.

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Swiss Tropical and Public Health Institute, Socinstrasse, Basel, Switzerland.
University of Basel, Basel, Switzerland.
Division of Infectious Diseases and Hospital Epidemiology, University Hospital Basel, Basel, Switzerland.
Molecular Virology, Department of Biomedicine, University of Basel, Basel, Switzerland.
SolidarMed, Swiss Organization for Health in Africa, Lesotho.



The CASCADE trial showed that compared to usual care (UC), offering same-day (SD) ART during home-based HIV testing improved engagement in care and viral suppression 12 months after diagnosis. However, open questions remain regarding long-term outcomes and the risk of propagating drug resistance.


After completion of the primary endpoint at 12 months, participants not in care in both arms were traced and encouraged to access care. At 24 months, the following outcomes were assessed in both arms: Engagement in care, viral suppression, and reasons for non-engagement. Furthermore, we explored among SD arm non-linkers the acquisition of drug resistance mutations (DRMs).


At 24 months, 64% (88/137) in the SD vs 59% (81/137) in the UC arm were in care (absolute difference 5%; 95%CI -6-16; p=0.38) and 57% (78/137) vs 54% (74/137) had documented viral suppression (3%; -9-15; p=0.28). Among 36 participants alive and not in care at 24 months with ascertained status, the majority rejected contact with the health system or were unwilling to take ART. Among eight interviewed SD arm non-linkers, six had not initiated ART upon enrolment and no acquired DRMs were detected. Two had taken the initial 30-day ART supply and acquired DRMs.


SD ART resulted in higher rates of engagement in care and viral suppression at 12 but not 24 months. Levelling off between both arms was driven by linkage beyond 12 months in the UC arm. We did not observe compensatory long-term disengagement in the SD arm. These long-term results endorse SD ART initiation policies.


HIV infection; Lesotho; Same-day ART; rapid ART initiation; retention in care


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