Providing same day, observed ART to newly diagnosed HIV+ outpatients is associated with improved virologic suppression
Background: Despite known clinical and prevention benefits, ART is typically delayed by weeks-to-months after HIV diagnosis to allow linkage to care, HIV education, social stabilization and laboratory evaluation. The UCSF/San Francisco General Hospital (SFGH) RAPID program aimed to eliminate this delay by providing same-day/observed ART even as HIV care was being established. We investigated consequences of the RAPID treatment initiation strategy.
Methods: RAPID eligibility included new HIV diagnosis with acute/recent infection, active opportunistic infection or CD4< 200/mm3. At referral, all RAPID-eligible or -ineligible patients with new diagnosis received a standard package of multidisciplinary services for social support, education, risk and stigma reduction; labs were drawn; and regular provider follow-up was arranged. The RAPID intervention consisted of 1) same-day access to an on-call provider; 2) a 5-day ART supply facilitated by 3) an accelerated process for insurance benefits. Focusing on a July 2013-Dec 2014 program period, survival analysis was used to compare time to achieving VL< 200 copies/mL between patients receiving or not receiving the RAPID intervention, and also between these patients and historical controls from two eras of ART provision at SFGH: pre-RAPID universal (2010-2013) and CD4-guided (2006-2009).
Results: We studied 227 newly diagnosed outpatients receiving RAPID (n=39), universal (n=149) or CD4-guided (n=39) ART. No patients had private insurance and 27% were homeless; mean(range) CD4 was 381(2-1031)/mm3 and VL 4.6(1.6-7.0)log10cp/mL. Time to VL< 200 cp/mL was significantly faster in RAPID patients vs. both contemporaneous and historical controls (p< 0.001; see Figure).
[Viral suppression over time by ART initiation strategy]
Median(IQR) time to VL< 200 for RAPID ART was 56(40-87) days vs. 119(58-201) days for universal and 283(128-777) days for CD4-guided ART. After 3 months of ART, 75% RAPID vs. 38% non-RAPID patients achieved a VL< 200 cp/mL; after 6 months, 95% RAPID vs. 70% non-RAPID patients achieved VL< 200 cp/mL. Among the first 39 patients receiving RAPID ART and followed for 5-18 months, only 2 (5%) of had toxicity-related regimen changes, none discontinued ART and 35 (90%) remain engaged in care.
Conclusions: Combined with patient education and psychosocial support, same day-observed initiation of ART at the time of HIV diagnosis was feasible and associated with substantially faster sustained viral suppression.
C. Pilcher1, H. Hatano1, A. Dasgupta2, D. Jones1, S. Torres1, F. Calderon1, C. Ospina-Norvell1, W. Hartogensis1, E. Demicco1, E. Geng1, M. Gandhi1, D. Havlir1
1UCSF, HIV/AIDS Division, Medicine, San Francisco, United States, 2Tulane University Medical School, New Orleans, United States