Programming Connection

Rapid ART Program for Individuals with an HIV Diagnosis (RAPID) 

CATIE

2017

A study1 has shown that 95% of participants in a rapid HIV treatment initiation program start antiretroviral treatment (ART) within 24 hours of being diagnosed with HIV. The Rapid ART Program for Individuals with an HIV Diagnosis, known as RAPID, was established at the San Francisco General Hospital in 2013.

There are seven components to RAPID:

  1. Same-day access to an HIV provider. When diagnosed with HIV, people are offered a same-day appointment with an HIV specialist. Taxi vouchers are provided to get from the testing site to the hospital.
  2. Same-day medical visit. People diagnosed with HIV spend time with an HIV healthcare provider who educates them on HIV infection, risk reduction, sexual health, and the benefits of treatment. People are offered same-day treatment and patients can decline if they are not ready. Baseline tests are ordered, including CD4 cell count, HIV viral load, kidney and liver function tests, drug hypersensitivity and resistance testing, and hepatitis testing.
  3. Accelerated health insurance approval process. Pre-existing, available protocols for emergency drug assistance are used for clients without health insurance.  
  4. Pre-approved treatment regimens. Drug regimens that can be used without the results of genotyping or laboratory testing have been pre-approved by a local HIV expert committee and are based on known local drug-resistant strains of HIV.
  5. Five-day starter pack. Starter packs are available for patients who are waiting for insurance coverage.
  6. Observed first dose of treatment. Patients who want to start treatment are offered the opportunity to take their first dose during the medical visit.
  7. Telephone follow-up. Nurses contact patients within seven days to review laboratory results, ask about adherence, pharmacy/prescription issues, and any side effects.

The study

The study compared patients who were managed through the RAPID protocol to those who were managed according to the standard of care between July 2013 and December 2014. The study also compared the RAPID patients to a historical cohort of HIV-positive patients referred to the hospital between 2006 and 2013, before RAPID was developed. People were targeted for the RAPID protocol if they had an acute or recent infection, or had a CD4 count below 200 copies/ml, an active opportunistic infection, or an HIV-negative partner at the time of diagnosis.

Among 86 patients referred for HIV treatment initiation between July 2013 and December 2014, 39 were managed through RAPID and 47 were managed according to the standard of care. The characteristics of the 86 patients in the study were as follows:

  • 97% male
  • 66% were people of colour
  • 42% reported major mental health disorders
  • 42% reported illicit substance use
  • 28% reported homelessness

Referrals to the RAPID program took a median of six days after the HIV test was performed and typically happened the day the patient was diagnosed with HIV. Following their referral, intake into the RAPID program and prescribing of treatment happened a median of one day later.

Among patients who received the standard of care, the intake time into the clinic and time to prescription of treatment were significantly longer, 10 days and 22 days respectively. There was no significant difference in loss to follow-up between RAPID and standard of care patients (10% vs. 15%).

Using the RAPID protocol for HIV treatment initiation:

  • 90% of patients started HIV treatment at the clinic
  • 95% of patients started HIV treatment within 24 hours of clinic visit

The median time to an undetectable viral load (below 200 copies/ml) was significantly faster for RAPID patients than for standard of care patients (56 days vs. 79 days).

When time to undetectable viral load was also compared to the historical group of patients, the study found that median time to undetectable viral load was significantly shorter among RAPID patients. In RAPID patients, the median time was 1.8 months, compared to 4.3 months during the period 2010–2013 in San Francisco when treatment was offered to everyone that was diagnosed with HIV, and 7.2 months during the period 2006–2009 in San Francisco when treatment was offered to patients who had a CD4 count less than 500 cells/mm3.

What does this mean for Canadian service providers?

People with HIV who start treatment as soon as possible after diagnosis achieve better health outcomes than those who wait to start treatment.2 Once a person is on treatment and has achieved an undetectable viral load, the risk of transmitting HIV to others is negligible.3–10

This study demonstrates that a RAPID protocol, which helps people living with HIV access the benefits of treatment as soon as possible, is feasible in a hospital setting and is acceptable to people just diagnosed with HIV. In Canada, a similar approach is being used to treat people with acute HIV infection in two clinics in British Columbia.

Resources

CATIE statement on the use of antiretroviral treatment (ART) to maintain an undetectable viral load to prevent the sexual transmission of HIV

Prevention Access Campaign

References

  1. Pilcher C, Ospina-Norvell C, Dasgupta A, 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. Journal of Acquired Immune Deficiency Syndromes. 2016;74(1):44–51.
  2. The INSIGHT START Study Group. Initiation of antiretroviral therapy in early asymptomatic HIV infection. New England Journal of Medicine. 2015 Aug 27; 373:795–807.
  3. Cohen M, Chen YQ, Macauley M, et al. Prevention of HIV-1 infection with early antiretroviral therapy. New England Journal of Medicine. 365(6):493–505.
  4. Reynolds SJ, Makumbi F, Nakigozi G, et al. HIV-1 transmission among HIV-1 discordant couples before and after the introduction of antiretroviral therapy. AIDS. 2011 Feb 20;25(4):473–7.
  5. Melo MG, Santos BR, De Cassia Lira R, et al. Sexual transmission of HIV-1 among serodiscordant couples in Porto Alegre, southern Brazil. Sexually Transmitted Diseases. 2008 Nov;35(11):912–5.
  6. Donnell D, Baeten JM, Kiarie J, et al. Heterosexual HIV-1 transmission after initiation of antiretroviral therapy: a prospective cohort analysis. Lancet. 2010 Jun 12;375(9731):2092–8.
  7. Rodger A. HIV Transmission risk through condomless sex if HIV+ partner on suppressive ART: Partner STUDY. Oral presentation at: Conference on Retroviruses and Opportunistic Infections; 2014 Mar 3; Boston, MA. Available from: http://www.croiwebcasts.org/console/player/22072
  8. Eshleman SH, Hudelson SE, Redd AD, et al. Treatment as Prevention: Characterization of partner infections in the HIV Prevention Trials Network 052 trial. Journal of Acquired Immune Deficiency Syndromes. 2017 Jan 1;74(1):112–6.
  9. Rodger A, Cambiano V, Braun T. Sexual activity without condoms and risk of HIV transmission in serodifferent couples when the HIV-positive partner is using suppressive antiretroviral therapy. Journal of the American Medical Association. 2016;316(2):171–81.
  10. Grulich AE, Bavinton B, Jin F. HIV Transmission in male serodiscordant couples in Australia, Thailand and Brazil. Late breaker poster 1019 LB presented at: 22nd Conference on Retroviruses and Opportunistic Infections; 2015 Feb 23; Seattle, WA.