Immediate antiretroviral therapy (ART) for vulnerable populations may be successful with the help of a multidisciplinary care team and support structures within the municipality, according to a study published in AIDS.
Offering early ART therapy to people living with HIV has been shown to result in individual-level clinical benefits and to confer a reduced risk for onward HIV transmission. Offering ART immediately after diagnosis of HIV has been shown to result in both earlier ART initiation and higher rates of retention in care and viral suppression at 10 to 12 months compared with standard of care. In the United States, the current standard of care for HIV is to start ART, regardless of CD4 count or clinical stage, but this is not necessarily required at the first clinical care visit. In 2018, the International Antiviral Society-USA recommended immediate ART initiation when HIV is diagnosed and although several clinics and jurisdictions have adopted this, the United States Department of Health and Human Services Adult and Adolescent ART Guidelines refer to this practice as an “investigational” approach. Therefore, this study endeavored to describe virologic outcomes from the San Francisco-based Ward 86 RAPID‑ART program.
In 2013, Ward 86 adopted immediate ART at the first visit after HIV diagnosis. Patients were referred from testing sites, offered same- or next-day intakes, and received multidisciplinary evaluation, support, and insurance enrollment and optimization. Patients were provided with a 3- to 5-day supply of ART, with full prescription sent to the patient’s pharmacy, and subsequent close follow-up. Between 2013 and 2017, 225 patients were referred to RAPID-ART. Medical records were used to extract demographic and laboratory data. Subsequent viral loads were obtained from public health surveillance data. Distributions of time to first measurement of viral suppression were summarized with Kaplan-Meier curves, and viral suppression at time of most recent viral load measurement was also calculated.
Of the 225 patients referred to RAPID-ART, 216 (96%) were started on immediate ART, the remaining patients started a median period of 71 days after HIV diagnosis. Characteristics of these 216 patients included a median age of 30 years, 7.9% were women, 11.6% were African American, 26.9% were Hispanic, 36.6% were white, 51.4% had substance abuse, 48.1% had a mental health-related diagnosis, and 30.6% were unstably housed. Further, the baseline median CD4 count was 441 cells/mm3 and the median viral load was 37,011 copies/mL. One year after intake, 95.8% of patients achieved viral suppression to ≤200 copies/mL at least once. Over a median follow-up of 1.09 years (range 0 to 3.92 years), only 14.7% of patients had a viral rebound; 78% of these patients later attained viral suppression again. Finally, viral suppression rates were 92.1% at least recorded viral load. The median time from the start of ART to suppression of HIV RNA to <200 copies/mL was 41 days in the whole cohort.
Overall, the study authors concluded that, “Our results should inform other clinical care programs on the clear benefits of and strategies to achieve near same-day ART start for those newly diagnosed with HIV.”
Coffey S, Bacchetti P, Sachdev D, et al. RAPID ART: high virologic suppression rates with immediate ART initiation in a vulnerable urban clinic population [published online December 21, 2018]. AIDS. doi: 10.1097/QAD.0000000000002124