The average time from HIV diagnosis to treatment initiation in San Francisco shrank from 35 days to six days between 2013 and 2016 as the city implemented its RAPID programme to speed up treatment starts, Oliver Bacon of San Francisco Department of Public Health reported at the Conference on Retroviruses and Opportunistic Infections (CROI 2018) in Boston on Tuesday.
The time from HIV diagnosis to having viral load suppressed below 200 copies/ml halved during the same period, from 134 days to 61 days.
A consortium of San Francisco public health officials, healthcare workers and community organisations agreed in 2015 to implement a new rapid treatment initiation protocol across the city, as part of the city’s Getting to Zero initiative, designed to eliminate new HIV infections. A pilot in 2013-14 had demonstrated the feasibility and acceptability of rapid treatment initiation.
Rapid treatment initiation benefits patients by preventing disease progression and by improving engagement with care. It benefits the wider community by reducing the number of people who can pass on HIV, especially if a person with high viral load starts treatment. Increasing the proportion of people who are on treatment and virally suppressed should, over time, reduce the incidence of new HIV infections.
The RAPID protocol aims to link everyone diagnosed with HIV to care within five days and, unless there are clinical indications that the patient is at risk of fatal immune reconstitution inflammatory syndrome (IRIS), treatment should be initiated at the first care visit using the most potent regimen available. The first-line treatment regimen should consist of tenofovir/emtricitabine and either an integrase inhibitor or boosted darunavir. Newly diagnosed people are linked to care by navigators who identify the most appropriate clinic based on insurance coverage and psychosocial needs.
San Francisco Department of Public Health carried out a review of City surveillance data, to monitor performance during the piloting and introduction of the RAPID protocol from 2013 to 2016. HIV diagnoses declined markedly during this period, from 399 in 2013 to 265 in 2016. There was little change in the demographics of those diagnosed between the years 2013 and 2016: around 90% were male, around a third were aged 13-29 years, and around one in ten were homeless. There was a slight decline in the proportion of newly diagnosed persons who were white (from 45% to 37%) and a corresponding increase in the proportion of newly diagnosed persons who were Hispanic or Asia-Pacific Islander.
Considering all the people diagnosed with HIV in the city, 93% of those diagnosed in that year were in care in 2013 compared to 97% in 2016, and 78% of all diagnosed people started antiretroviral therapy (ART) in 2013, compared to 81% in 2016. The proportion who started ART that contained an integrase inhibitor increased from 47% in 2013 to 74% in 2016. The proportion of HIV-diagnosed people who met all the criteria for a RAPID protocol-compliant treatment start – linkage within five days, and immediate treatment start – rose from 6% in 2013 to 30% in 2016.
Thirty-nine per cent of people who started ART did so at a 'safety net' public clinic and 60% did so at clinics that accepted Medicaid or uninsured patients in 2016, indicating the importance of Medicaid availability to ensuring rapid ART initiation in San Francisco.
Time from diagnosis to viral load suppression decreased significantly for all groups, but especially for Asian and Pacific Islanders and Latino persons (p < 0.0001. Speed of treatment initiation also improved significantly in homeless persons (p = 0.0132).
There was no significant demographic difference between those who started treatment and those who did not in 2016.
The results show that multisectoral collaboration can shorten the time from HIV diagnosis to virologic suppression, said Oliver Bacon, but routine surveillance data and case reviews are essential for mapping the care pathway and identifying opportunities for improvement.