Immediate Antiretroviral Therapy for Better Patient Health and HIV Prevention

Oliver Bacon, MD, MPH2 February 2016

DisclaimerViews expressed in this talk do not necessarily reflect those of the San Francisco Department of Public Health or UCSF

Getting to Zero San Francisco: The Power of Collective Impact—and guided by data

90% fewer HIV infections90% fewer HIV deathsZero stigma and discrimination

By 2020:

Where was San Francisco On Dec 1 2013?

2010:Universal

ART; HIV test scale-up

2012:PrEP-

DEMO

2006: HIV test w/o

written consent

2011: LINCSiPrEx

Linkage, retention, and sustained virologic suppression in San Francisco

HIV Infections by Race/Ethnicity: 2014

Race/Ethnicity No. (%)

White 135 (44.1)

African American

33 (10.8)

Latino 85 (27.8)

API/NA 40 (13.1)

Multiple Races 13 (4.2)

HIV Infections by Transmission Category: 2014

Transmission Category

No. (%)

MSM 231 (75.5)

IDU 20 (6.5)

MSM IDU 33 (10.8)

Heterosexual 8 (2.6)

TFN/Hemophilia 0 (0)

Perinatal 0 (0)

Other/Unknown 14 (4.6)

Demographics of the 306 New HIV Infections in SF in 2014

HIV Semi-Annual Surveillance Report, SFDPH, June 2015

Data Highlight the Gaps• If the goal is virologic suppression, 67% is insufficient• Need better, faster Linkage• Need better Retention• Need something to prevent HIV(-)s from getting infected by unknown

HIV (+)s• Need to decrease stigma, psychosocioeconomic discrimination as a

barrier to care, prevention

Strategic Plan: Signature Initiatives • PrEP: Expand access to pre-exposure prophylaxis for San

Franciscans at-risk for HIV infection • RAPID ART: Early diagnosis, with immediate linkage to care

and treatment of HIV• RETENTION in HIV care• STIGMA reduction interventions

Committee for each initiative is developing action plan, metrics and

milestones, budget

Universal ART…………Faster• Delivering ART as early as possible after a new diagnosis of

HIV: • improves morbidity and mortality in all stages of infection (START

Trial 2015)• reduces transmission by 96% (HPTN052 2011)• in acute HIV infection: limits reservoirs and hyper-infectivity

• Typical interval of weeks to months between diagnosis, ART, and virologic suppression=lost opportunities

• Delayed or dropped linkage, retention• Immunologic dysfunction• Onward Transmission

Why can’t ART be started at diagnosis?

RAPID Implementation: Overview

Step IDay one

New HIV+ Diagnosis 

Step IISame day, expedited referral • Medical/psychosocial

evaluation• Start ART• Partner Services• Linkage to HIV 1° care

 

Step III5-7 days

• Follow-up with HIV 1° care

• Review baseline Labs• Modify ART as needed

The Goal of RAPID is to improve the health of newly diagnosed patients by eliminating delays in ART and access to high-quality HIV care. This means:• Starting ART the same day as someone is newly diagnosed with HIV (or within 2-3 days if same-day start is

impossible) • Their first follow-up visit with HIV 1° care within a week of starting ART• Sometimes RAPID patients will be referred to you at Step III, having already completed Steps I and II.• Sometimes RAPID patients will undergo all Steps I-III or II-III at your clinic (especially if they were your patients when

they were HIV-uninfected)

RAPID Pilot at SFGH: 2013-15• PHAST Team paged with any new confirmed new HIV+ patients on

SFGH campus• PHAST Team paged by testing sites in SF with any new HIV+ with

no/public insurance• Expedited intake at Ward 86 (UCSF HIV Clinic at SFGH)• Comparison of linkage, virologic outcomes, by era:

• CD4-guided ART• Universal ART• RAPID (immediate ART)

561

Referral 1st Clinic Visit

1st PCP Visit

ART Prescribed

Viral load suppressed

Engagement Timeline, SFGH

CD4-guided(2006-9)

Universal(2010-3)

RAPID

0 30 60 90 120 150 180 210 240 270 300 330 360 390

13237

Pilcher, IAS 2015

RAPID

Time to VL suppression by ART initiation strategy: SFGH 2006-2014

RAPID vs. universal ARTP<0.001

Universal ART

CD4-guided ART

Proportion<200 copies

Pilcher, IAS 2015

Qualitative Lessons from Interviews with RAPID Pilot Team Members: Keys to Success1. Single point-of-contact for referrals activates the team (PHAST Pager)2. Committed team is essential (Counseling, Benefits Navigation, Clinical)3. Minimize handoffs: Every handoff is a warm handoff4. Talk about Care first, Insurance later5. Have a plan for medication access

• Emergency ADAP• Presumptive Medi-Cal• Pharma Patient Assistance Cards

6. Check in with patient in the 1-2 days after he/she leaves the appointment

Taking ART Citywide• Develop a RAPID Protocol• Develop a capacity-building strategy

• Clinic-wide education Sessions• Public Health Detailing of Individual Clinicians, with RAPID Guide for Providers

• Target High Prevalence Testing Sites• Target HIV Clinics where newly HIV+ persons are linked (referral sites)• Develop an Evaluation Plan

SFGH (13%)

SF City Clinic (14%)

AHP/Magnet/

Glide/DPH (CHN+

Consortium) (37%)

Private/UCSF/

StM/CPMC (22%)

Kaiser (9%)

Other (5%)

Citywide RAPID (same day as HIV+ if possible)DisclosureCounseling

Partner ServicesMedical Evaluation

Benefits/Insurance Navigation and Rapid EnrollmentLinkage to HIV Primary Care within 5 Days

Immediate ART (Starter Pack or Prescription)

Private/UCSF/StM

(32%)

SFGH (26%)

SFCC/DPH (12%)

Kaiser (14%)

Other/AHP/VA/OOJ/Jail

(9%)

Evaluation

Testing sites

HIV Primary Care Sites

???(7%)

The Goal: Test, Treat, Retain, and PrEPI. Universal, accessible HIV/STI testing-Frequency determined by risk-Testing for acute infection in high-risk populations/settings

II. Immediate ART•Eliminate OIs/AIDS•↓ nonAIDS complications•↓ transmission to partners•Retention in care to maintain suppression

IF(+) IF (-)III. COMBINATION PREVENTION

•Condoms and Risk Reduction coaching•Referrals for Substance use treatment, Mental health care•PEP for occasional exposures•PrEP for Pts with elevated risk:

• Inconsistent condom use• Multiple partners/non-monogamous steady

partnerships• Serodiscordant partners including

periconception• h/o Rectal STIs, PEP

Acknowledgments• G2Z Rapid Committee

• Diane Havlir• Diane Jones• Stephanie Cohen• Chris Pilcher• Hiroyu Hatano• Susa Coffey• Tim Patriarca• Janet Grochowski

• G2Z Steering Committee• Shannon Weber

• PHAST• Clarissa Ospina-Norvell• Sandra Torres• Fabi Calderon

• Kaiser-SF• Brad Hare• Marc Solomon• Ed Chitty

• SFDPH• Jonathan Fuchs• Darpun Sachdev• Andy Scheer• Susan Scheer