Enhancing Antiretroviral Therapy Initiation for Hospitalized and Recently Discharged People Living With HIV in Johannesburg, South Africa

Despite increased antiretroviral therapy (ART) access in South Africa, HIV testing and ART initiation are suboptimal in hospital settings. Key gaps include in-hospital case finding, ART initiation support, and primary health care (PHC) facility linkage after discharge. We identified weaknesses in hospital processes by comparing them with PHC HIV services and developed a quality improvement model for implementation in 5 Johannesburg hospitals. We introduced dedicated teams of HIV testing counselors for structured case finding and ART-trained nurses and linkage officers to provide in-hospital or post-discharge ART initiation and support to strengthen PHC facility linkage. Monitoring data (May 2020-March 2021) was used to measure initiation rates. Over 11 months, despite COVID-19 pandemic-related disruptions, our model achieved 74% (5,201/7,025) ART linkage within 28 days post-discharge and 87% (6,087/7,025) overall, including all initiations (i.e., all newly diagnosed, known not on ART and reinitiating individuals). The 2 highest-performing hospitals achieved 97% (2,096/2,170) linkage overall, demonstrating the potential of implementing this quality improvement model with fidelity. Over half (58%, 4,092/7,025) of patients initiated ART within 7 days, with 39% (2,748) initiating on the same day. Women and men achieved similar initiation rates (3,010/4,015, 75%; 2,186/3,003, 73%, respectively). Combining rapid (