RAPID Program Leads to Faster HIV Suppression
San Francisco General Hospital’s RAPID program, which offers antiretroviral treatment starting the same day people are diagnosed with HIV, was well received and led to more rapid viral load suppression than the standard treatment schedule, according to a study presented on Wednesday at the 8th International AIDS Society Conference in Vancouver. Participants in the RAPID program achieved undetectable viral load in a median of 56 days, compared with 119 days for those in a universal ART standard-of-care group and 283 days in people starting ART based on CD4 count. The RAPID program is now being implemented city-wide as part of the “Getting to Zero” initiative, which aims to reach zero new HIV transmission and zero AIDS-related deaths, and eliminate stigma.
Studies have shown that early antiretroviral treatment improves the health of people living with HIV and has the added public health benefit of reducing HIV transmission. But getting people into care can be challenging and some are lost at each stage of the HIV care cascade.
Christopher Pilcher, MD, presented results from a feasibility study of the UCSF/SFGH RAPID program.
In 2010 San Francisco was the first city to recommend universal antiretroviral therapy (ART) for everyone diagnosed with HIV regardless of CD4 cell count. A similar recommendation was included in U.S. treatment guidelines in 2013 and will soon be incorporated into the World Health Organization’s global guidelines.
San Francisco has a well-financed HIV care system with highly experienced and culturally competent providers. Yet even with these advantages, the process of getting tested, addressing other issues that may be barriers to treatment (such as substance use or unstable housing), then figuring out how to pay for medication can take a lot of time. This delay can lead to disease progression and continued HIV transmission.
When treatment was based on CD4 count in the late 2000s, it took 128 days on average for people to get a prescription for ART and 218 days to achieve viral suppression. After the standard of care shifted to universal treatment in 2010, it took a mean of 37 days to get ART and 132 days to reach viral suppression.
The RAPID program was designed to speed up this process by collapsing some of the steps of the care continuum, Pilcher explained. Instead of HIV diagnosis, initial assessment and counseling, medical evaluation, and ART prescription being done over multiple visits, these are all consolidated into a single visit.
Pilcher’s team analyzed outcomes in a demonstration project assessing this rapid approach. They looked at 39 people newly diagnosed with HIV who participated in the RAPID program between July 2013 and December 2014. This group was compared to people who historically received standard care with universal ART during 2010-2013 or CD4-guided treatment during 2006-2009.
RAPID was initially designed to offer prompt treatment for people with acute HIV infection (within the past six months), as research has shown that very early ART can limit the size of the viral reservoir. It was later expanded to include newly diagnosed people who had been infected longer, and people with indications for urgent treatment because of an opportunistic illness or CD4 count below 200. In this analysis, 70% of RAPID participants had been infected with HIV in the past six months.
Overall, Pilcher described the RAPID participants as a “high needs” population at risk of falling through the cracks of the healthcare system. All were men, 59% were people of color, more than a quarter were homeless, and none had health insurance. The average CD4 count was 474 cells/mm3 and viral load was generally high. This analysis included only people who came in as outpatients, not those who started as inpatients or transferred from jail or another clinic.
People are typically referred to the RAPID program by one of the city’s public HIV testing sites, which routinely do HIV RNA testing. Patients are generally referred to the program the same day they receive their HIV diagnosis (which can be days or weeks after they actually take the test).
Newly diagnosed people are offered multidisciplinary services including social support, HIV education, and mental health counseling, and have samples collected for laboratory tests. RAPID participants also receive same-day medical appointments and access to an on-call provider, along with taxi vouchers if needed to get to the clinic. They are given a five-day starter pack of antiretroviral medication and encouraged to take the first dose on the spot.
Pilcher reported that 90% of eligible patients opted to start ART on the day of the first visit, with another 5% starting the next day. On average, it took people about one day from the time they receive their HIV test result to take their first pill. In contrast, in the historical standard-of-care groups only about one-quarter started therapy within the first week and about 60% did so within the first month.
Treatment is usually offered after a brief medical evaluation, but before lab test results including drug-resistance data are available. Providers choose from a list of pre-approved regimens based on local patterns of transmitted drug resistance, as resistance is common in this population.
Meanwhile, program counselors helped participants establish on-going insurance coverage. Most RAPID participants qualified for publicly funded coverage such as Medicaid or Healthy San Francisco program, but some were eligible for private insurance (for example, through Kaiser Permanente). The program serves undocumented immigrants who might not be eligible for federal or state coverage but can use Healthy San Francisco, Pilcher told BETA.
After three months on treatment, 75% of RAPID participants achieved viral suppression, compared with 38% in the standard-of-care groups. After six months the corresponding response rates were 95% vs 70%.
Among the 39 participants who received treatment through the RAPID program and were followed for up to 18 months, only two changed their ART regimen due to side effects and none stopped therapy. Most participants (90%) were still engaged in care at the end of follow-up.
“It was feasible to implement same-day ART initiation for outpatients with newly diagnosed HIV in a well resourced, public health clinic setting,” the researchers concluded.
Pilcher said that participants had “extremely positive” reactions to the program. Although he had expected some resistance from providers reluctant to start treating people so early, but this did not occur and the program was met with “extreme enthusiasm.”
The RAPID program is now considered one of the three prongs of the city’s Getting to Zero effort, which also includes pre-exposure prophylaxis (PrEP) and efforts to retain people with HIV in care.
Earlier this year Diane Havlir, chief of SFGH’s division of HIV/AIDS, said the city wants to expand same-day HIV treatment from SFGH and Department of Public Health clinics to all public and private providers citywide.
Liz Highleyman is a freelance medical writer and editor-in-chief of HIVandHepatitis.com.