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Evidence supporting the current World Health Organization recommendations ofearly antiretroviral therapy (ART) initiation for adolescents is inconclusive.We leverage a large observational data and compare, in terms of mortality andCD4 cell count, the dynamic treatment initiation rules for HIV-infectedadolescents. Our approaches extend the marginal structural model for estimatingoutcome distributions under dynamic treatment regimes (DTR), developed inRobins et al. (2008), to allow the causal comparisons of both specific regimesand regimes along a continuum. Furthermore, we propose strategies to addressthree challenges posed by the complex data set: continuous-time measurement ofthe treatment initiation process; sparse measurement of longitudinal outcomesof interest, leading to incomplete data; and censoring due to dropout anddeath. We derive a weighting strategy for continuous time treatment initiation;use imputation to deal with missingness caused by sparse measurements anddropout; and define a composite outcome that incorporates both death and CD4count as a basis for comparing treatment regimes. Our analysis suggests thatimmediate ART initiation leads to lower mortality and higher median values ofthe composite outcome, relative to other initiation rules.

Causal comparative effectiveness analysis of dynamic continuous-time treatment initiation rules with sparsely measured outcomes and death