Same-Day Diagnosis, Treatment a Hit Among HIV Patients

Pam Harrison

July 27, 2015

VANCOUVER, British Columbia — Antiretroviral therapy initiated on the day of an HIV diagnosis is well liked by patients and providers and leads to more rapid suppression of viral loads than standard approaches, according to researchers involved in the RAPID program.

Of the patients offered antiretrovirals on the day they received their HIV diagnosis, 90% agreed to start on the spot, Christopher Pilcher, MD, from the University of California at San Francisco, and colleagues report.

"It was impressive how much they wanted it; 35 out of 39 patients who were offered this same-day antiretroviral therapy took the pill in the clinic," Dr Pilcher said. "And all of the patients were on therapy within a few weeks."

"Anecdotally, the reactions of the patients leaving the clinic already on antiretroviral therapy on the day they were diagnosed were universally positive and, frankly, quite moving to those of us who were taking care of these patients," he added. "This engendered an extreme level of enthusiasm among the providers and really facilitated the adoption of this strategy by our clinic."

The RAPID program, conducted at the San Francisco General Hospital, was designed to compress a number of key steps after a diagnosis of HIV. Results were presented here at the 8th International AIDS Society Conference.

RAPID Program

On the day of their HIV diagnosis, patients undergo a brief medical evaluation; however, antiretroviral therapy is initiated before laboratory results, including genotype results, are available.

Initially, only patients with acute HIV infection were enrolled in the program, but the RAPID criteria were expanded to include patients with newly diagnosed HIV who had been infected for more than 6 months and patients with an urgent need for antiretroviral therapy.

Still, about 70% of patients enrolled in the program had acute HIV infection, Dr Pilcher reported.

Practical strategies were used to facilitate the same-day initiation of therapy, such as providing patients with taxi vouchers so they could get to the clinic on the day of their diagnosis.

Patients received a 5-day starter pack of their antiretroviral regimen, which gave staff time to sort out insurance benefits for these patients. About one-quarter of the patients enrolled in the RAPID program were homeless, and none had health insurance when they presented to the clinic.

"We recommended that patients open their starter pack and take the first dose in the clinic in the presence of the provider for support," Dr Pilcher said.

The median time to initiation of antiretrovirals from diagnostic disclosure was 24 hours. "And the mean viral suppression effect in the RAPID program was quite striking," Dr Pilcher pointed out.

Universal Antiretrovirals

From 2006 to 2009, when CD4-guided treatment was in force, the average time between diagnosis and the initiation of antiretroviral therapy at San Francisco General Hospital was 128 days, he reported. And it took an average of 218 days for patients to achieve the WHO threshold of less than 200 copies/mL.

"After 2010, when San Francisco moved to universal antiretroviral therapy ahead of national guidelines, the average time to the initiation of antiretrovirals was 37 days," he said. "And time to viral suppression was 132 days."

The 39 RAPID patients, treated from July 2013 to December 2014, were compared with 149 patients treated from 2010 to 2013 under the universal antiretroviral program.

Median time to viral suppression was significantly lower in the RAPID group than in the universal group (56 vs 132 days; P < .001).

This shortened interval was, in part, related to the immediate start of antiretrovirals, Dr Pilcher explained. However, it might also reflect the fact that two-thirds of patients in the RAPID cohort received integrase inhibitors, and the fact that the practice of giving starter medications in the clinic eliminated the need for patients to find a pharmacy, pick up their prescription, and then make the decision to take their medications, he added.

"We did note an increase in the number of antiretroviral therapy modifications in the RAPID group, although these were predominantly the simplification of regimens after HLA testing," he explained. "But there was no evidence of increased drug toxicity or treatment failure in RAPID patients compared with those in the universal group," he said.

On the basis of our results, "we are working now to expand RAPID citywide in San Francisco," Dr Pilcher reported.

Acute-Phase Infection

If patients are in the acute phase of HIV infection — as about 70% of RAPID patients were — putting them on antiretroviral agents quickly is very important because patients are highly infectious in the acute phase of the infection, said session comoderator Melissa Marx, PhD, from the Johns Hopkins Bloomberg School of Public Health in New Haven, Connecticut.

"Getting them on treatment reduces the chance that they will transmit the virus to other people," she told Medscape Medical News.

Initiating treatment on diagnosis of HIV also reduces the risk that patients will be lost to follow-up, Dr Marx added.

"Especially in high-risk communities, you run the risk of diagnosing patients and then never seeing them again. So not only could they be transmitting the disease to others, they are getting sicker and sicker themselves," she said.

"I took note of the fact that these patients wanted to do something about the diagnosis; they wanted to act on what they had just found out about, rather than waiting around for various appointments to see different specialists," Dr Marx explained. "It just makes sense to me."

Dr Pilcher and Dr Marx have disclosed no relevant financial relationships.

8th International AIDS Society (IAS) Conference: Abstract WEAD0105LB. Presented July 22, 2015.


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