Little is known about long-term viral suppression outcomes for patients initiating antiretroviral therapy (ART) the same day as or shortly after HIV diagnosis (RAPID ART).
The Ward 86 HIV Clinic in San Francisco is a public health funded clinic that adopted immediate ART for persons newly diagnosed with HIV in 2013. Patients were referred from San Francisco testing sites or the hospital to Ward 86, offered same or next-day intake appointments, and received multidisciplinary evaluation, with education, support, and insurance enrollment/optimization. Patients were offered same-day ART and provided 3-5-day starter packs and prescriptions of ART, check-in calls, and follow-up appointments within 1-2 weeks. Demographic characteristics, baseline CD4 counts, and viral loads (VL) were extracted from the medical record. Subsequent VLs were obtained from public health surveillance data, regardless of testing site. Kaplan-Meier curves summarized distribution of times to 1st virologic suppression and suppression at the last VL measurement.
Of 225 patients referred to the Ward 86 RAPID ART program from 2013-17, 4 declined ART, 3 were not offered ART and 2 were lost to follow-up before the RAPID visit. Of the 216 patients (96%) started on immediate ART, median age was 31 years; 7.9% women; 11.6% African American, 26.9% Hispanic, 36.6% white; 51.4% with substance use disorder; 48.1% with major mental health diagnosis; 30.6% unstably housed; median baseline CD4 441; median VL 37,011 copies/mL. Median time from HIV diagnosis to ART start: 7 days; from RAPID intake to ART start: 0 days; from HIV diagnosis to VL <200: 60 days. The median follow-up time for the sample was 1.09 years (0-3.92). By 1 year after follow-up, 95.8% had achieved VL suppression to <200 at least once. Among patients who initially suppressed, 15% experienced one or more episodes of viral rebound, but most (75%) resuppressed to <200 copies/mL. The median number of VL measures for the cohort over the period of follow-up was 4 (1-22). At the last recorded VL result, 92.1% of all patients were suppressed.
In an urban HIV clinic with high rates of mental illness, substance use and housing instability, immediate ART initiation after HIV diagnosis resulted in virologic suppression in >90% at last VL measurement at a median of 1.09 years after ART start. Rapid ART implementation within safety-net populations is acceptable, feasible, and successful with a multidisciplinary care team and municipal support.