Populations considered hard to treat or engage in care can benefit from same-day antiretroviral treatment as part of a clinic offering social safety-net interventions.
High rates of viral suppression are possible in vulnerable populations starting antiretroviral treatment (ART) immediately after they are referred to a clinic for treatment. One year after treatment uptake, 95.8% of patients in the Ward 86 ‘RAPID’ programme in San Francisco had achieved viral suppression, defined as a viral load below 200 copies per ml, despite high levels of substance abuse, housing instability and mental health problems.
The Ward 86 RAPID programme is a ‘safety-net’ clinic that has adopted immediate ART after diagnosis, ideally at the first clinic visit. In the USA, standard of care is to start ART as soon as possible, regardless of CD4 count or any other clinical data – but not necessarily on the first visit after referral. In 2013, the Ward 86 clinic became the first programme in the USA to do this via their RAPID (Rapid ART Program for Individuals with an HIV Diagnosis) pilot. It later became the clinic’s standard of care in 2014.
To facilitate a swift initiation of care, the RAPID model includes intervention components such as same-day access to a medical provider after diagnosis, including taxi vouchers from testing sites to the clinic. The same-day medical appointments last three to four hours and include information and education on HIV, risk-reduction, sexual health and the benefits of ART. Baseline tests are also taken at this point. It also includes additional support with health insurance, including processes for accelerated approval.
The clinic uses pre-approved treatment regimens with a high barrier to resistance that don’t require immediate genotypic testing (namely, dolutegravir and tenofovir). They also provide five-day ART starter-packs where needed while insurance benefits are arranged. Patients are observed while taking their first dose and are later followed-up with a call and given ongoing counselling and psychosocial support.
Until now, little was known about the long-term viral suppression rates in this group of vulnerable people who start treatment immediately.
Researchers retrospectively analysed sociodemographic characteristics and viral outcomes of all patients referred to RAPID within 6 months of diagnosis, between July 2013 and December 2017. 216 patients were included in the analysis, of which women made up just 7.6%. Race/ethnicity was 11.6 African American, 26.9% Hispanic, 12.5% Asian, 4.2% Native American and 36.6% White.
Over half (51.4%) had a substance misuse disorder, 48.1% had a major mental health disorder, and 30.6% were homeless or unstably housed. In the subset of patients who had delayed attending the RAPID clinic after their initial HIV-positive diagnosis – more than 30 days – these rates were significantly higher.
The study found that immediate ART was both acceptable to this vulnerable safety net population (fewer than 2% declined RAPID ART) and feasible in the context of a busy, urban public health practice.
In their conclusion, the authors note that “successful care of RAPID patients involved the skills of a multidisciplinary care team as well as the support of structures within the municipality. 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.”