Rapid HIV care cuts time to viral suppression in half
With the help of his local health department in New Orleans, Jason Halperin, MD, and colleagues are starting patients on ART within 72 hours of their HIV diagnosis — most of them within 24 hours. A recent study showed that the intervention cut the median time to viral suppression by more than half, and he believes its success can be replicated in other clinics around the country.
“I want to demonstrate to people that this can be done in the resource-poor areas of this country, like the South,” Halperin told Infectious Disease News.
“We really are on the frontlines of the HIV epidemic in the United States,” Halperin said.
Halperin oversees HIV services at CrescentCare, federally qualified health center that runs a large pre-exposure prophylaxis clinic in the city with almost 900 active patients. They conduct approximately 10,000 HIV tests in the community each year. The disease predominantly affects young black men who have sex with men, and the core of their work is committed to this population, he said.
Before the intervention, patients with an HIV diagnosis had to wait 4 to 5 weeks before starting ART, which Halperin suggested is “better than average,” but the lapse still increases the risk for HIV transmission. There are several reasons for the delay, he said. First, it can take up to 2 weeks or more to sort out patients’ insurance, which is often provided through the Ryan White HIV/AIDS program. Second, providers frequently choose to postpone treatment until they know the status of their kidney and liver functions and their CD4 cell counts. HIV drug-resistance testing is also recommended for patients with HIV before selecting an ART regimen, tacking on even more time. Finally, the price of the medication and whether payers will even cover the expense is yet another challenge.
“I really had to lay out all these barriers to start dismantling them,” Halperin said.
With the expansion of Medicaid in Louisiana in 2016 — “a gift from the heavens,” according to Halperin — the clinic could enroll patients in Medicaid services on the same day as their HIV diagnosis. In December of that year, they started a test-and-start strategy called the CrescentCare Start Initiative (CCSI), which links newly diagnosed patients with a treating provider and starts them on ART within 72 hours, ideally within 24. But first, they needed help from the city’s health department.
“So, I got in touch with the Office of Public Health (OPH), and I said, ‘This is our plan: I guarantee that we are going to have a higher rate of linkage and an impact on our time to viral suppression and hopefully 2-year data that show retention and sustained viral repression,’” Halperin said. “‘What I need from you is that when I fax you the form for Ryan White services, you fax it back within an hour. I don’t care how you figure it out, but if you can do it, I can see these patients [within 24 hours].’”
CrescentCare proposed to use Ryan White funds to cover the first 30 days of patients’ medication, giving them 4 weeks to figure out how to refill the prescriptions. The OPH agreed.
“So now, within an hour of a diagnosis I can get patients Ryan White services,” he said. “I can get them signed up for Medicaid if they meet criteria, and 4 weeks of medication are provided.”
Halperin argued that knowing the genotype was unnecessary before starting patients on ART because evidence suggests there is a low risk for resistance to the integrase inhibitor Tivicay (dolutegravir, ViiV Healthcare), which is used in combination with Descovy (tenofovir alafenamide/emtricitabine, Gilead Sciences). In addition, if lab work comes back within 24 hours and indicates that a patient has kidney damage, they can be switched to a new regimen.