Effect of same-day HIV treatment initiation (SDI) on 1-year outcomes in low- and middle-income countries: systematic review and meta-analysis of randomised trials

Introduction Same-day initiation (SDI) of antiretroviral therapy is recommended for people presenting with HIV who have no contraindications. We reviewed the evidence on SDI interventions in low- and middle-income countries (LMICs). Methods We conducted a systematic review and meta-analysis of randomised controlled trials of SDI in adults diagnosed with HIV in LMICs. We searched MEDLINE, Embase and the Cochrane Library up to December 2024. Primary outcomes were viral suppression and retention in care 6–12months after enrolment. Based on a qualitative assessment of the complex trial interventions, we considered two subgroups: (1) interventions newly introducing SDI and (2) interventions improving SDI implementation in settings where it was already routinely available. We conducted random-effects meta-analysis, assessed risk of bias using the ROBUST instrument and used the Grading of Recommendations Assessment, Development and Evaluation approach to assess the certainty of evidence. Results We identified 12 eligible trials, 7 introducing and 5 improving SDI. The trial interventions introducing SDI were sufficiently similar for meta-analysis. Introducing SDI likely has an important benefit for viral suppression (relative risk (RR) 1.18, 95% CI 1.06 to 1.30, moderate certainty) and retention in care (RR 1.12, 95%CI 1.00 to 1.25, low certainty) at 6–12months The five trials improving SDI were too heterogeneous for meaningful meta-analysis. Individually, they showed either low to very low certainty for an important effect or, when implementing SDI in patients with tuberculosis (TB) symptoms, moderate to high certainty for little to no effect on viral suppression and retention in care. Conclusion Newly introducing SDI likely improves viral suppression and retention in care. However, the impact of interventions to improve SDI where already available is less clear. Two studies provided evidence against the concern that SDI may have adverse effects in participants with TB symptoms. PROSPERO registration number CRD42023482522.