Implementation Lessons and Policy Implications of Same-Day Antiretroviral Therapy Initiation: Insights from the ART Same-Day Counselling and Initiation (ASCI) SOP in South Africa

Abstract

Same-day antiretroviral therapy (ART) initiation (SDI) is globally recommended to improve ART uptake. However, retention in care and viral suppression in South Africa remain suboptimal. This study evaluated the experiences of healthcare providers, patients, and community stakeholders in implementing the ART Same-day Counselling and Initiation (ASCI) Standard Operating Procedure (SOP), focusing on facilitators, barriers, and policy implications for improving HIV treatment outcomes. Using implementation frameworks, qualitative data from providers, patients, and community structures were analyzed alongside findings from a randomized controlled trial involving 142 newly diagnosed individuals initiated on ART on the same day as diagnosis. Evaluation of the ASCI SOP demonstrated improved six-month outcomes compared with standard initiation: retention in care (83% vs. 72%), viral suppression (81% vs. 69%, <i>p</i> = 0.04), and reduced loss to follow-up (17% vs. 28%, <i>p</i> = 0.05), with no significant mortality difference. These gains were linked to structured psychosocial support, patient navigation, and community follow-up. Key facilitators included multidisciplinary collaboration, psychosocial support, and community engagement, while major barriers involved healthcare system overload, patient-level challenges, and lack of standardized tools to assess treatment readiness. Policy reform to scale up the ASCI SOP should emphasize interdisciplinary support, consistent monitoring, and integration within national health systems. Overall, the preliminary evidence suggests that implementing the ASCI SOP model improved same-day ART uptake, retention, and viral suppression. Expanding this model to other provinces could strengthen HIV program performance and accelerate progress toward South Africa's treatment goals.