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Up to 95% virologic response rate with rapid ART in safety-net clinic
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Conference on Retroviruses and Opportunistic Infections (CROI), March 4-7, 2019, Seattle
Mark Mascolini
Up to 95% of people with newly diagnosed HIV and beginning antiretroviral therapy (ART) within a week of diagnosis reached a viral load below 50 copies in the first year of therapy. High proportions of people in this San Francisco safety-net clinic had a substance use disorder, a major mental health diagnosis, or unstable housing.
US and international guidelines recommend starting ART upon HIV diagnosis, regardless of CD4 count. Some clinics have designed programs to offer ART immediately after HIV diagnosis, including Ward 86, the largest public health-funded HIV clinic in San Francisco. In 2013 Ward 86 adopted immediate ART at the first clinic visit after HIV diagnosis. Researchers working with Ward 86 conducted this study to describe demographics and viral load outcomes in people offered immediate ART in the clinic.
The Ward 86 RAPID program accepts people just diagnosed with HIV in the clinic or at San Francisco testing sites. Health workers offer them a same-day or next-day intake appointment, where they receive same-day ART after an evaluation that includes education, support, and insurance help. People who accept ART get a 3- to 5-day ART starter pack, prescriptions, check-in calls, and a follow-up appointment within 1 to 2 weeks.
From July 2013 through December 2017, health workers referred 225 people to the Ward 86 RAPID ART program, of whom 216 (96%) accepted ART and remained in follow-up. Median age stood at 30 years, 7.9% were women, 36.6% white, 26.9% Hispanic, and 11.6% black. This high-risk population included 51% with substance use disorder, 48% with a major mental health diagnosis, and 31% with unstable housing. The group had a median pretreatment CD4 count of 441 and a median initial viral load of 37,011 copies.
A median of 7 days passed between HIV diagnosis and starting ART. Median time from RAPID intake and starting ART was 0 days. Median follow-up lasted 1.09 years, during which participants had a median of 4 viral load measures.
Median time from HIV diagnosis to a viral load below 200 measured 60 days. One year after treatment began, 95.8% of participants had reached a sub-200-copy viral load at least once and 95.1% had reached a viral load below 50 copies at least once. At the last recorded measure, 91.2% of participants had a viral load below 200 copies.
Among participants who reached a viral load below 200 copies, 14.7% had one or more viral rebounds. But 78% of rebounders regained a viral load below 200 copies.
The researchers concluded that immediate ART is highly acceptable and effective in an urban public-health clinic with high rates of substance use, mental illness, and unstable housing. Most uninsured participants in this study had rapid access to health insurance through Medicaid and/or emergency ADAP (AIDS Drug Assistance Program).
Reference
1. Coffey S, Bacchetti P, Sachdev D, et al. High rates of virologic suppression after rapid ART start in safety-net clinic. Conference on Retroviruses and Opportunistic Infections (CROI). March 4-7, 2019. Seattle. Abstract 515.
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