The Rapid ART Program Initiative for HIV Diagnoses (RAPID) in San

Francisco

Oliver Bacon, Jennie Chin, Ling Hsu, Stephanie Cohen, Darpun Sachdev, Susan Scheer, Susan Buchbinder, Susa Coffey, Diane Havlir

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Background

• 2017 WHO Guidelines: On basis of international randomized trials1-6, immediate (within 7 days of diagnosis) ART initiation endorsed for all willing persons diagnosed with HIV7

• 2017 United States Treatment guidelines: Immediate ART initiation an investigational approach8

• 2015 San Francisco Getting to Zero (SFG2Z) Consortium: Citywide RAPID (accelerated ART initiation for newly HIV-diagnosed persons) prioritized, after a successful pilot9.

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SFG2ZS. Buchbinder

Abstract 87Tues 10 am

Objectives

• Describe ART initiation in all persons newly diagnosed with HIV in San Francisco before and during early implementation of the RAPID initiative

• Examine RAPID outcomes stratified by gender, race/ethnicity, age, and housing status

• Examine RAPID uptake by different HIV care providers

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Methods

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Program Design and Implementation

Citywide RAPID Protocol:

All new confirmed HIV diagnoses linked to care ≤ 5 working days;

At 1st care visit: Baseline labs collected, counseling, medical/psychosocial assessment, ART started unless risk for fatal IRIS

[TFV+FTC] + [INSTI or DRV/r] with option for 4-drug regimen if HIV infection suspected on PrEP

Dissemination:

HIV clinics identified using HIV surveillance data, trained on RAPID procedures by in-service (2015) and individual provider detailing (2016)

Linkage navigators used RAPID Provider Directory to identify optimal HIV clinic for each newly-diagnosed patient, by insurance coverage, psychosocial needs.

Full protocol and RAPID detailing brochure for clinicians disseminated electronically at http://www.gettingtozerosf.org/rapid-committee/ and at open quarterly SFGTZ consortium meetings

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Linkage:S. ScheerAbstract

1100Tues 2:30pm

Pre-specified Outcomes, 2013-2016

Using HIV Case Registry Data from Surveillance Unit at SFDPH, including sex, age, race/ethnicity, housing status:

• Time (median days) from Diagnosis to VL<200 c/mL• Diagnosis to 1st Care Visit• 1st Care Visit to ART Initiation• ART to VL<200 c/mL• Kruskal-Wallis test for differences in medians 2013-2016

• Proportion of new cases linked ≤ 5 days AND started ART ≤ 1 day

• Rapid ART initiation by Care Site (public vs. private)

• INSTI use in 1st ART

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Results

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Study Population: New HIV Diagnoses 2016 -2013

Category 2013 N (%) 2016 N (%)

All 399 (100) 265

Male 361 (90) 229 (86)

Female 27 (7) 29 (11)

13-29 years old 130 (33) 96 (36)

White 178 (45) 97 (37)

Black 51 (13) 34 (13)

Latino 100 (25) 73 (28)

Asian/Pacific Islander 51 (13) 47 (18)

Homeless 30 (8) 29 (11)8

Linkage to Care and ART Initiation Following HIV Diagnosis

Metric 2013 2014 2015 2016

Diagnosed (%) 399 329 295 265

In Care (%) 372 (93) 318 (97) 282 (96) 258 (97)

Started ART (%) 311 (78) 276 (84) 244 (83) 215 (81)

ART included INSTI (%) 145 (47) 203 (74) 195 (80) 159 (74)

Met RAPID definition (%)* 23 (6) 45 (14) 50 (17) 80 (30)

9*Both diagnosis to care w/in 5 days AND ART w/in 1 day

Median Time to Care, ART, and Virologic Suppression

Metric 2013 2014 2015 2016 %Δ 2013-16

In Care within 1 year (%) 372 (93) 318 (97) 282 (96) 258 (97)

Diagnosis to care (days) 8 7 7 5 -38%

1st Care Visit to ART (days) 27 17 6 1 -96%

ART to VL<200c/mL (days) 70 53 50 38 -46%

Diagnosis to VL<200 c/mL (days) 134 92 77 61 -54%

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• Time from diagnosis to VL<200 decreased significantly in all groups• Time from diagnosis to first care visit decreased significantly for males, whites, Latinos, youth (13-29) and the

housed• Time from first care visit to ART decreased significantly in all groups• Time from ART to VL<200 decreased significantly for males, under 40 y.o., whites, Latinos, Asian/Pacific

Islanders, and the housed

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ART Initiation Within 5 days of 1st visit, by Care Site

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ART Initiation Within 5 days of 1st visit, by Care Site

2013 2014 2015 2016

Proportion of ART starts by Site, 2016

Site ART Starts(%)

All 215

HCO/Univ 24 (11)

HMO 35 (16)

PMD 29 (13)

STD 18(8)

Safety Net 83(39)

Other Public 17(8)

Out of Jurisdiction 9 (4)

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2013 2014 2015 2016

All 134 92 77 61

White 134 94 82 69

Black 135 131 100 66

Latino 126 80 70 57

Asian/PI 145 106 62 43

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Year Diagnosed

Time from Diagnosis to VL<200 c/mL, by Race/Ethnicity

P<.0001 for White, Latino, Asian/PIP=.015 for Black

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2013 2014 2015 2016

All 27 17 6 1

White 27 21 7 5

Black 34 42 7 6

Latino 25 14 5 0

Asian/PI 30 22 6 0

0

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45

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Year of Diagnosis

Time from First Care Visit to ART Initiation, by Race/Ethnicity

P<.0001 for White, Latino, Asian/PIP=.0008 for Black

2013 2014 2015 2016

All 8 7 7 5

White 9 7 8 5

Black 15 9 9 6

Latino 7 7 7 4

Asian/PI 5 5 4 4

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Year of Diagnosis

Time from Diagnosis to First Care Visit, by Race/Ethnicity

P=.01 for WhiteP=.37 for BlackP=.03 for LatinoP=.73 for API

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2013 2014 2015 2016

All 134 92 77 61

Housed 133 91 75 57

Homeless 154 187 148 71

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200

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Year of Diagnosis

TIme from Diagnosis to VL<200, by Housing Status

P<.0001 for housedP=.04 for homeless

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2013 2014 2015 2016

All 8 7 7 5

Housed 8 7 7 5

Homeless 7 5 6 5

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Year of Diagnosis

Time from Diagnosis to First Care Visit, by Housing Status

P<.0001 for housedP=.85 for homeless

2013 2014 2015 2016

All 27 17 6 1

Housed 27 16 6 0

Homeless 25 63 21 6

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Year of Diagnosis

First Care Visit to ART Initiation, by Housing Status

All Housed Homeless

P<.0001 for housedP=.0132 for homeless

Summary and Limitations

• During a citywide, multisector initiative to optimize ART initiation, time to first virologic suppression was cut by more than half from 134 days to 61 days.

• Median time from care to ART cut 96% from 27 days to 1 day.

• Significant improvement in time to ART initiation and first virologic suppression in traditionally vulnerable populations, including racial and ethnic minorities and the homeless. Disparities remain in some groups.

• 30% of new HIV diagnoses in 2016 met strictest RAPID start definition, vs. 6% in 2013.

• RAPID uptake by care providers improved in the public and private health care sectors.

• 16% of persons diagnosed with HIV in 2016 were not started on ART; no notable sociodemographic differences vs. ART starters (data not shown).

• Durability of virologic suppression not addressed in this analysis.

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Conclusions and Future Directions

• Time from HIV diagnosis to first virologic suppression can be shortened citywide using collaborative multisector approach

• Routinely collected HIV surveillance data, plus case-based review (ART start date), central to map care pathway and identify areas for improvement

• Increase individual detailing to make immediate ART standard of care among all HIV providers

• Role of ARV choice in longer time to suppression in certain groups?

• Ongoing studies evaluating the impact of RAPID initiation of ART on retention and durable viral suppression

• Need different data to understand ART non-starters

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Acknowledgments

SF G2Z Consortium and RAPID CommitteeHiroyu HatanoVirginia CafaroChris PilcherSusa CoffeyBrad HareDiane JonesJanet Growchowski

SFDPH LINCS Team and SF City ClinicErin AntunezSharon PennPatrick KinleyJason ChadderdonIvette Vazquez-LopezAndy Scheer

PHAST and RAPID Teams at the UCSF Division of HIV, ID, and Global Health at ZSFGHSandra TorresLizzie LynchChristy CampFabiola CalderonClarissa Ospina-NorvellMonica Gandhi

SFDPH Center for Learning and Innovation:Jonathan FuchsZachary PopeGary Naja-RieseWesley DaytonMehroz BaigJonathan Van Nuys 19

References

1. Lundgren J and the START INSIGHT Study Team. Initiation of Antiretroviral Therapy in Early Asymptomatic HIV Infection. New Engl J Med. Aug 27 2015;373(9):795-807.

2. TEMPRANO ANRS 12136 Study Group. A Trial of Early Antiretrovirals and Isoniazid Preventive Therapy in Africa. New Engl J Med. 2015 Aug 27;373(9):808-22.

3. Cohen MS, Chen YQ, McCauley M, et al. Antiretroviral Therapy for the Prevention of HIV-1 Transmission. New Engl J Med. 2016 Sep 1;375(9):830-9.

4. Rodger AJ, et al. Sexual Activity Without Condoms and Risk of HIV Transmission in Serodifferent Couples When the HIV-Positive Partner Is Using Suppressive Antiretroviral Therapy. JAMA. 2016;316(2):171-181.

5. Rosen S, Maskew M, Fox MP, Nyoni C, Mongwenyana C, Malete G, et al. (2016) Initiating Antiretroviral Therapy for HIV at a Patient’s First Clinic Visit: The RapIT Randomized Controlled Trial. PLoS Med 13(5).

6. Koenig SP, Dorvil N, Dévieux JG, Hedt-Gauthier BL, Riviere C, Faustin M, et al. (2017) Same-day HIV testing with initiation of antiretroviral therapy versus standard care for persons living with HIV: A randomized unblinded trial. PLoS Med 14(7).

7. Guidelines for managing advanced HIV disease and rapid initiation of antiretroviral therapy, July 2017. Geneva: World Health Organization; 2017.

8. Panel on Antiretroviral Guidelines for Adults and Adolescents. Guidelines for the Use of Antiretroviral Agents in Adults and Adolescents Living with HIV. Department of Health and Human Service, October 2017. Available at http://www.aidsinfo.nih.gov/ContentFiles/AdultandAdolescentGL.pdf.

9. Pilcher et al. The Effect of Same-Day Observed Initiation of Antiretroviral Therapy on HIV Viral Load and Treatment Outcomes in a US Public Health Setting. J Acquir Immune Defic Syndr 2017;74:44–51)

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Extra Slides

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2013 2014 2015 2016

All 134 92 77 61

Female 205 87 85 66

Male 133 91 77 60

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Med

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Time from Diagnosis to VL<200, by SexP<.0001 for malesP=.0035 for females

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2013 2014 2015 2016

All 27 17 6 1

Male 27 16 6 0

Female 49 16 17 2

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40

50

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Year of Diagnosis

First Care Visit to ART Initiation, by Sex

P<.0001 for malesP=.0006 for females

2013 2014 2015 2016

All 8 7 7 5

Housed 8 6 7 5

Homeless 14 7 10 5

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Year of Diagnosis

Time from Diagnosis to First Care Visit, by Sex

P=.39 for femalesp=<.0001 for males

2013 2014 2015 2016

All 8 7 7 5

13-29 9 8 7 3

30-39 8 6 11 6

>40 8 7 6 6

0

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Year of Diagnosis

Time from Diagnosis to First Care Visit, by Age (years)

P<.05 for 13-29P=.08 for 30-39P=.05 for 40+

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2013 2014 2015 2016

All 134 92 77 61

13-29 153 91 76 56

30-39 123 102 74 50

>40 133 89 79 69

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Time from Diagnosis to VL<200, by Age

P<.0001 for all groups

2013 2014 2015 2016

All 27 17 6 1

13-29 26 18 6 0

30-39 27 14 5 0

>40 28 21 7 3

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25

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Year of Diagnosis

First Care Visit to ART Initiation, by Age (Years)

P<.0001 for all groups

Milestones in Citywide HIV Diagnosis and Care, pre-RAPID

Written consent for HIV testing dropped: 2006

Expansion of HIV testing and universal ART: 2010

Citywide Navigation-to-Care Team (LINCS): 2011

SFGH/UCSF RAPID Pilot: 2013-14

Diagnosed site (2013): % Linked to Care by Linked to Care at (2013): %

Community Site(DPH) 28 Internal/LINCS backup SFGH and Network Clinics: 29

SFGH and Network Clinics 15 Internal/LINCS backup Private MD: 24

City STD Clinic 14 LINCS KP-Large HMO: 14

Private MD 13 Internal/ LINCS backup University/Private Hospital: 10

University/Private Hospital 9 Internal/LINCS backup City STD Clinic: 4

KP- Large HMO 9 Internal/LINCS backup Other: 8

Community site (non-DPH) 9 Internal/LINCS backup Not in Care: 324

Citywide RAPID built on existing resources (2015)

Testing Sites• 57% send samples

to SFDPH• HIV+ tests from

outside labs reported to City HIV surveillance

DPH Linkage Navigators• Notified immediately of all

HIV+ results from SFDPH• Notified by HIV Surveillance of

all new HIV + results from outside labs

• Link patients to care based on insurance, needs

• Back-up linkage for non-DPH testing sites

(33% of new HIV+)Safety Net Hospital and

satellite clinics for uninsured/publicly insured

(48% of new HIV+)Private MDs, University,

Large Group Health Plans (HMOs) for commercially

insured

(8% of new HIV+)Community Clinics

specializing in certain populations: Youth,

Monolingual Spanish Speaking, Asian/PI,

Homeless)

Written consent for HIV testing waived: 2006

Expansion of HIV testing and universal ART: 2010

Citywide Navigation-to-Care Team (LINCS): 2011

SFGH/UCSF RAPID Pilot: 2013-14

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