One Pill, Once a Day: Simplified Treatment Regimens and Retention in HIV Care

For individuals diagnosed with HIV, the prospect of starting treatment can be daunting. Antiretroviral therapy (ART), the main method of treating HIV in order to reduce patients’ viral loads and alleviate symptoms, typically involves a combination of three or more medications taken on a daily basis. However, new evidence suggests HIV treatment need not be so complex.

Beginning in April 2013, South Africa–the country with the world’s largest HIV epidemic–adopted a once-daily single-pill HIV treatment regimen as standard-of-care, replacing a multiple-pill regimen. Because the single-pill and multi-pill regimens have similar biological efficacy, the shift to single-pill therapy offers a real-world test of the impact of simplified drug delivery mechanisms on patient behavior.

In a new journal article published in the American Journal of Epidemiology, Jacob Bor and seven coauthors assess retention in care among 4,484 South African patients starting HIV treatment just before and just after the single-pill treatment became standard practice. The authors find that initiating ART after the policy change was associated with 11.7 percentage points higher patient retention at 12 months. In particular, being a prescribed a single-pill regimen instead of multiple pills led to:

• a 21.7 percentage point decrease in four-month gaps in care
• a 19.9-percentage point decrease in absence from care at one year
• a 21.6-percentage point decrease in long-term attrition by one year
• and a 27.7-percentage point decrease in missed six-month viral load measures.

Bor and coauthors’ study provides strong evidence that simplified treatment regimens can benefit patients in meaningful ways, perhaps due to the lower burden they place on those seeking care. Additionally, the study illustrates that simplified regimens can be scaled up very quickly through changes in guidelines and centralized procurement, without requiring changes in patient or provider behavior. While further research is needed to identify the exact reasons why retention improved with the simplified regimen, the study nonetheless indicates that policy changes aimed at streamlining treatment can improve the real-world management of chronic diseases in low-resource settings.