Implementation of a Rapid Entry Program Decreases Time to Viral Suppression Among Vulnerable Persons Living With HIV in the Southern United States

Nurse-led sequential multiple assignment randomized trial of nudging intervention for early antiretroviral therapy initiation among patients with HIV/AIDS: Implementation study protocol

AIMS

In China, more than 30% of patients have not initiated treatment within 30 days of HIV diagnosis. Delayed initiation has a detrimental influence on disease outcomes and increases HIV transmission. The study aims to evaluate the effectiveness of a nurse-led antiretroviral therapy initiation nudging intervention for people newly diagnosed with HIV in China to find the optimal intervention implementation strategy.

METHODS

A Hybrid Type II sequential multiple assignment randomized trial will be conducted at four Centers for Disease Control and Prevention in Hunan, China. This study will recruit 447 people newly diagnosed with HIV aged ≥18 years and randomly assign them into two intervention groups and one control group. On top of the regular counselling services and referrals, intervention groups will receive a 4-week, 2-phase intervention based on the dual-system theory and the nudge theory. The control group will follow the currently recommended referral procedures. The primary outcomes are whether treatment is initiated, as well as the length of time it takes. The study outcomes will be measured at the baseline, day 15, day 30, week 12, week 24 and week 48. Generalized estimating equations and survival analysis will be used to compare effectiveness and explore factors associated with antiretroviral therapy initiation. Both qualitative and quantitative information will be collected to assess implementation outcomes.

DISCUSSION

Existing strategies mostly target institutional-level factors, with little consideration given to patients' decision-making. To close this gap, we aim to develop an effective theory-driven nudging strategy to improve early ART initiation.

IMPACT

This nurse-led study will help to prevent delayed initiation by employing implementation science strategies for people newly diagnosed with HIV. This study contributes to the United Nations' objective of ending the AIDS pandemic by 2030.

TRIAL REGISTRATION

Chinese Clinical Trial Registry ChiCTR2300070140. The trial was prospectively registered before the first participant was recruited.

PATIENT AND PUBLIC INVOLVEMENT

The nudging intervention was finalized through the Nominal Group Technique where we invited five experts in the related field and five people living with HIV to participate.

Pharmacist-Driven Rapid Initiation of Antiretroviral Therapy Decreases Time to Viral Suppression in People With HIV

Background

Rapid initiation of antiretroviral therapy (rapid ART) improves clinical outcomes in people with HIV and is endorsed by clinical guidelines. However, logistical challenges limit widespread implementation. We describe an innovative rapid ART model led by pharmacists and its impact on clinical outcomes, including time to viral suppression (TVS).

Methods

On 1 January 2019, we implemented Pharmacist-Driven Rapid ART (PHARM-D RAPID ART), including rapid ART initiation by pharmacists. Our retrospective cohort study compared TVS, using a Cox proportional hazards model, and clinical outcomes among individuals with a new HIV diagnosis before (1 January 2017 to 31 December 2017) and after (1 January 2019 to 31 December 2019) implementation.

Results

A total of 108 individuals were included. TVS was significantly shorter (P < .001) for the PHARM-D RAPID ART group (n = 51) compared with the preimplementation group (n = 57) (median: 30 days and 66 days, respectively). Those in the PHARM-D RAPID ART group were significantly more likely to achieve VS at any given time during the study period (adjusted hazard ratio: 3.47 [95% confidence interval, 2.25-5.33]). A total of 94.1% (48/51) of patients in the PHARM-D RAPID ART group were retained in care at 1 year. With a median follow-up of 2.4 years in the PHARM-D RAPID ART group, 98% remained suppressed at last recorded viral load.

Conclusions

A pharmacist-driven model for rapid ART delivery decreases TVS with high rates of retention in care and durable VS. This model could improve clinical outcomes and increase program feasibility and sustainability.

Reducing time to differentiated service delivery for newly-diagnosed people living with HIV in Kigali, Rwanda: a pilot, unblinded, randomized controlled trial

BACKGROUND

Differentiated service delivery (DSD) programs for people living with HIV (PWH) limit eligibility to patients established on antiretroviral therapy (ART), yet uncertainty exists regarding the duration on ART necessary for newly-diagnosed PWH to be considered established. We aimed to determine the feasibility, acceptability, and preliminary impact of entry into DSD at six months after ART initiation for newly-diagnosed PWH.

METHODS

We conducted a pilot randomized controlled trial in three health facilities in Rwanda. Participants were randomized to: (1) entry into DSD at six months after ART initiation after one suppressed viral load (DSD-1VL); (2) entry into DSD at six months after ART initiation after two consecutive suppressed viral loads (DSD-2VL); (3) treatment as usual (TAU). We examined feasibility by examining the proportion of participants assigned to intervention arms who entered DSD, assessed acceptability through patient surveys and by examining instances when clinical staff overrode the study assignment, and evaluated preliminary effectiveness by comparing study arms with respect to 12-month viral suppression.

RESULTS

Among 90 participants, 31 were randomized to DSD-1VL, 31 to DSD-2VL, and 28 to TAU. Among 62 participants randomized to DSD-1VL or DSD-2VL, 37 (60%) entered DSD at 6 months while 21 (34%) did not enter DSD because they were not virally suppressed. Patient-level acceptability was high for both clinical (mean score: 3.8 out of 5) and non-clinical (mean score: 4.1) elements of care and did not differ significantly across study arms. Viral suppression at 12 months was 81%, 81% and 68% in DSD-1VL, DSD-2VL, and TAU, respectively (p = 0.41).

CONCLUSIONS

The majority of participants randomized to intervention arms entered DSD and had similar rates of viral suppression compared to TAU. Results suggest that early DSD at six months after ART initiation is feasible for newly-diagnosed PWH, and support current WHO guidelines on DSD.

TRIAL REGISTRATION

Clinicaltrials.gov NCT04567693; first registered on September 28, 2020.

Exploring the willingness toward HIV immediate test and treat among MSM in Nairobi and its environs: a cross-sectional study

Background

In the test and treat initiative, high-risk populations are screened for human immunodeficiency virus (HIV) infection and start early treatment if diagnosed positive. This study explores factors associated with willingness to initiate testing and immediate treatment among men who have sex with men (MSM) in Nairobi and its environs. The study was informed by a conceptual framework combining the AIDS Risk Reduction Model (ARRM) and the Modified Social Ecological Model.

Methods

This cross-sectional exploratory study targeted MSM (aged 18-60 years) reporting active engagement in anal or oral sex with men in Nairobi and its surrounding areas. Purposive sampling was used to identify data collection sites, and then snowballing was employed to reach the respondents. Data analysis was performed using SPSS version 23, and binary logistics regression was used for inferential analysis.

Results

Between July 2018 and June 2019, 391 MSM were recruited to fill out a self-administered questionnaire, out of which 345 complete questionnaires were analyzed. Never been tested for HIV, private/NGO as the facility of the last HIV test, and had unprotected anal sex were listed as the reasons for taking the most recent test, and the results of the most recent HIV test and seeking a post self-test confirmation were associated with a higher likelihood of accepting the immediate HIV test and treat initiative. Additionally, a preference for a health provider as the first source of support, belief in the efficacy of ARVs, and disclosure about being on ART were the other reasons. Additionally, being aged 25+ years, having more than 60 USD monthly income, and having inconsistent condom use during sex were associated with a higher likelihood of accepting the immediate HIV test and treat initiative. Barriers to the immediate test and treat strategy included stigma from healthcare providers and concerns about disruptions in lifestyle through antiretroviral therapy (ART) use.

Conclusion

Interventions aimed at increasing the HIV test and treat initiative in Kenya may need to take into account the demographic and social characteristics of MSM, including age, lack of habitual HIV testing, and lifestyle changes before and upon enrollment in ART. Projects should also consider working closely with healthcare facilities to strengthen treatment preparation, especially for asymptomatic MSM and those who may not be immediately willing to choose the test and treat strategy.

Rapid Start of Antiretroviral Therapy in a Large Urban Clinic in the US South: Impact on HIV Care Continuum Outcomes and Medication Adherence

Rapid start of antiretroviral therapy (ART) has been associated with improvement in several HIV-related outcomes in clinical trials as well as demonstration projects, but how regional and contextual differences may affect the effectiveness of this intervention necessitates further study. In this study of a large, urban, Southern US clinic-based retrospective cohort, we identified 544 patients with a new diagnosis of HIV during 2016 to 2019 and compared HIV care continuum outcomes for the first 12 months of care before and after rapid start implementation. Kaplan-Meier time-to-event curves were used to summarize time to virologic suppression, and stepwise Cox, linear, and logistic regression models were used to create multivariate models to evaluate the association between rapid start and time to virologic suppression, medication adherence, and retention in care and sustained virologic suppression, respectively. We found that rapid start was significantly associated with improved medication adherence scores (+15.37 points, 95% confidence interval [CI] 9.36-21.39, P < .01) and retention in care (adjusted odds ratio = 1.51, 95% CI 1.05-2.19, P = .03). Time to virologic suppression (median 2.46 months before, 2.56 months after rapid start) and sustained virologic suppression were not associated with rapid start in our setting. Though rapid start was associated with improved medication adherence and retention in care, more support may be needed to achieve the same outcomes seen in other studies and sustained over the entire HIV care continuum, especially in settings with significant patient and systemic barriers to care such as unstable housing, lack of Medicaid expansion, and frequent coverage interruptions.

The Capacity of HIV Care Facilities to Implement Strategies Recommended by the Ending the HIV Epidemic Initiative: The Medical Monitoring Project Facility Survey

BACKGROUND

Data are needed to assess the capacity of HIV care facilities to implement recommended Ending the HIV Epidemic activities.

SETTING

US HIV care facilities.

METHODS

We analyzed 2021 survey data from 514 facilities that were recruited from a census of facilities providing care to a national probability sample of US adults with HIV. We present weighted estimates of facility characteristics, services, and policies and estimates of the proportion of all US HIV patients attending these facilities.

RESULTS

Among HIV care facilities, 37% were private practices, 72% were in areas with population >1 million, and 21% had more than 1000 HIV patients. Most provided preexposure prophylaxis (83%) and postexposure prophylaxis (84%). More than 67% of facilities provided HIV-specific stigma or discrimination training for all staff (covering 70% of patients) and 66% provided training on cultural competency (covering 74% of patients). A majority of patients attended facilities that provided on-site access to HIV/sexually transmitted infection (STI) transmission risk reduction counseling (89%); fewer had on-site access to treatment for substance use disorders (35%). We found low provision of on-site assistance with food banks or meal delivery (14%) and housing (33%). Approximately 71% of facilities reported using data to systematically monitor patient retention in care. On-site access to adherence tools was available at 58% of facilities; 29% reported notifying patients of missed prescription pickups.

CONCLUSION

Results indicate some strengths that support Ending the HIV Epidemic-recommended strategies among HIV care facilities, such as high availability of preexposure prophylaxis/postexposure prophylaxis, as well as areas for improvement, such as provision of staff antistigma trainings and adherence supports.

Impact of the COVID-19 pandemic on routine HIV care and antiretroviral treatment outcomes in Kenya: A nationally representative analysis

BACKGROUND

The COVID-19 pandemic adversely disrupted global health service delivery. We aimed to assess impact of the pandemic on same-day HIV diagnosis/ART initiation, six-months non-retention and initial virologic non-suppression (VnS) among individuals starting antiretroviral therapy (ART) in Kenya.

METHODS

Individual-level longitudinal service delivery data were analysed. Random sampling of individuals aged >15 years starting ART between April 2018 -March 2021 was done. Date of ART initiation was stratified into pre-COVID-19 (April 2018 -March 2019 and April 2019 -March 2020) and COVID-19 (April 2020 -March 2021) periods. Mixed effects generalised linear, survival and logistic regression models were used to determine the effect of COVID-19 pandemic on same-day HIV diagnosis/ART initiation, six-months non-retention and VnS, respectively.

RESULTS

Of 7,046 individuals sampled, 35.5%, 36.0% and 28.4% started ART during April 2018 -March 2019, April 2019 -March 2020 and April 2020 -March 2021, respectively. Compared to the pre-COVID-19 period, the COVID-19 period had higher same-day HIV diagnosis/ART initiation (adjusted risk ratio [95% CI]: 1.09 [1.04-1.13], p<0.001) and lower six-months non-retention (adjusted hazard ratio [95% CI]: 0.66 [0.58-0.74], p<0.001). Of those sampled, 3,296 (46.8%) had a viral load test done at a median 6.2 (IQR, 5.3-7.3) months after ART initiation. Compared to the pre-COVID-19 period, there was no significant difference in VnS during the COVID-19 period (adjusted odds ratio [95% CI]: 0.79 [95%% CI: 0.52-1.20], p = 0.264).

CONCLUSIONS

In the short term, the COVID-19 pandemic did not have an adverse impact on HIV care and treatment outcomes in Kenya. Timely, strategic and sustained COVID-19 response may have played a critical role in mitigating adverse effects of the pandemic and point towards maturity, versatility and resilience of the HIV program in Kenya. Continued monitoring to assess long-term impact of the COVID-19 pandemic on HIV care and treatment program in Kenya is warranted.

Outcomes and Predictors of Rapid Antiretroviral Therapy Initiation for People With Newly Diagnosed HIV in an Integrated Health Care System

Background

Rapid antiretroviral therapy (ART) is the recommended treatment strategy for patients newly diagnosed with HIV, but the literature supporting this strategy has focused on short-term outcomes. We examined both long-term outcomes and predictors of rapid ART among patients newly diagnosed with HIV within an integrated health care system in Northern California.

Methods

This observational cohort study included adults newly diagnosed with HIV between January 2015 and December 2020 at Kaiser Permanente Northern California. Rapid ART was defined as ART initiation within 7 days of HIV diagnosis. We collected demographic and clinical data to determine short-term and long-term outcomes, including viral suppression, care retention, medication adherence, and cumulative viral burden. Logistic regression models were used to identify predictors of rapid ART initiation.

Results

We enrolled 1409 adults; 34.1% initiated rapid ART. The rapid ART group achieved viral suppression faster (48 vs 77 days; P < .001) and experienced lower cumulative viral burden (log10 viremia copy-years, 3.63 vs 3.82; P < .01) but had slightly reduced medication adherence (74.8% vs 75.2%; P < .01). There was no improvement in long-term viral suppression and care retention in the rapid group during follow-up. Patients were more likely to initiate rapid ART after 2017 and were less likely if they required an interpreter.

Conclusions

Patients who received rapid ART had an improved cumulative HIV burden but no long-term improvement in care retention and viral suppression. Our findings suggest that rapid ART should be offered but additional interventions may be needed for patients newly diagnosed with HIV.

The Rapid interaction: a qualitative study of provider approaches to implementing Rapid ART

BACKGROUND

Offering antiretroviral therapy (ART) to patients directly following an HIV diagnosis ("Rapid ART") improves clinical outcomes and is feasible and acceptable for patients and providers. Despite this, implementation of Rapid ART is not yet standard practice in the USA. Structural-level implementation guidance is available, but research at the individual provider level that explores the patient-provider interaction itself remains scarce. The Consolidated Framework for Implementation Research (CFIR) provides a nuanced guide to investigating the less visible, more social elements of implementation like the knowledge and feelings of people, and the influences of culture and resources on individual approaches.

METHODS

We conducted a multi-site qualitative study, exploring intervention commonalities across three HIV clinic environments: an HIV primary care clinic; an HIV/STI testing, treatment, and prevention clinic; and a large federally qualified health center (FQHC). Qualitative data were gathered from 27 provider informants-Rapid ART program staff and clinicians-using an interview guide developed using the CFIR. An experienced qualitative team conducted a comprehensive thematic analysis and identified cross-cutting themes in how providers approach and engage in the Rapid interaction, as well as longer-form narratives from providers that describe more fully what this interaction looks like for them.

RESULTS

Three main themes represent the range and content of individual provider approaches to the Rapid interaction: (1) patient-centeredness; (2) emotional support and partnership; and (3) correcting misperceptions about HIV. Each theme encompassed both conceptual approaches to offering Rapid ART and concrete examples of messaging to the patient that providers used in the Rapid interaction. We describe and show examples of these themes, offer key take-aways for implementation, and provide expanded narratives of providers' personal approaches to the Rapid interaction.

CONCLUSIONS

Exploration of provider-level approaches to Rapid ART implementation, as carried out in the patient-provider Rapid interaction, contributes a critical layer of evidence for wider implementation. It is our hope that, together with existing research showing positive outcomes and core components of systems-level implementation, these findings add to an instructive body of findings that facilitates the implementation of Rapid ART as an enhanced model of HIV care.

Rapid start antiretroviral therapies for improved engagement in HIV care: implementation science evaluation protocol

BACKGROUND

In 2020, the Health Resources and Services Administration's HIV/AIDS Bureau funded an initiative to promote implementation of rapid antiretroviral therapy initiation in 14 HIV treatment settings across the U.S. The goal of this initiative is to accelerate uptake of this evidence-based strategy and provide an implementation blueprint for other HIV care settings to reduce the time from HIV diagnosis to entry into care, for re-engagement in care for those out of care, initiation of treatment, and viral suppression. As part of the effort, an evaluation and technical assistance provider (ETAP) was funded to study implementation of the model in the 14 implementation sites.

METHOD

The ETAP has used implementation science methods framed by the Dynamic Capabilities Model integrated with the Conceptual Model of Implementation Research to develop a Hybrid Type II, multi-site mixed-methods evaluation, described in this paper. The results of the evaluation will describe strategies associated with uptake, implementation outcomes, and HIV-related health outcomes for patients.

DISCUSSION

This approach will allow us to understand in detail the processes that sites to implement and integrate rapid initiation of antiretroviral therapy as standard of care as a means of achieving equity in HIV care.

Access to a novel first-line single-tablet HIV antiretroviral regimen in Affordable Care Act Marketplace plans, 2018-2020

BACKGROUND

A pillar of the United States' Ending the HIV Epidemic (EHE) initiative is to rapidly provide antiretroviral therapy (ART) in order to achieve HIV viral suppression. However, insurance benefit design can impede ART access. The primary objective of this study is to understand how Affordable Care Act (ACA) Marketplace qualified health plan (QHP) formularies responded to two new ART single tablet regimens (STRs): dolutegravir/abacavir/lamivudine (DTG/ABC/3TC; approved in 2014) and bictegravir/emtricitabine/tenofovir alafenamide (BIC/FTC/TAF; approved in 2018).

METHODS

We conducted a descriptive study of individual and small group QHPs to assess coverage, cost sharing (coinsurance vs. copay), specialty tiering, prior authorization, and out-of-pocket (OOP) costs for DTG/ABC/3TC and BIC/FTC/TAF. All individual and small group QHPs offered in state ACA Marketplaces from 2018-2020 were identified using plan-level formulary data from Ideon linked to end-of-year data from Robert Wood Johnson Foundation's Individual Market Health Insurance Exchange (HIX).

RESULTS

For 2018, 2019, and 2020, respectively, we identified 19,533, 17,007, and 21,547 QHPs. While DTG/ABC/3TC coverage was above 91% from 2018-2020, BIC/FTC/TAF coverage improved from 60 to 86%. Coverage of BIC/FTC/TAF improved in EHE priority jurisdictions from 73 to 90% driven by increased coverage with coinsurance. Although BIC/FTC/TAF had a higher wholesale acquisition cost than DTG/ABC/3TC, monthly OOP cost trends differed regionally in the Midwest but did not differ by EHE priority jurisdiction status.

CONCLUSIONS

QHP coverage of STRs is heterogeneous across the US. While coverage of BIC/FTC/TAF increased over time, many QHPs in EHE priority jurisdictions required coinsurance. Access to new ART regimens may be slowed by delayed QHP coverage and benefit design.

Immediate ART and clinical outcomes in New York City among patients newly diagnosed with HIV

Immediate antiretroviral therapy (iART) has been shown to decrease time to viral suppression. Our center underwent significant practice transformation to support iART, including a same-day Open Access (OA) model and enhanced care coordination. We examined whether same-day ART at linkage was associated with favorable proximate and long-term HIV care outcomes. From 2018 to 2019, patients newly diagnosed with HIV, linked to care at our institution, and iART eligible were included. We evaluated the association between iART and time to viral suppression, and between iART and initial/sustained viral suppression and retention in care. We also evaluated the association between use of OA and frequency of care coordination with the same outcomes. Of the 107 patients included, 72 initiated same-day ART at linkage and 35 did not. There was no statistically significant differences in whether patients were ever suppressed, had sustained viral suppression, or were retained in care between those who received same-day ART and those who did not. More care coordination was associated with retention in care (RR 1.21 [1.01-1.5]; p = 0.05). Organizing vital services and ensuring implementation strategies that facilitate iART, while tailoring the approach to the patient's comfort level, is likely optimal for longitudinal HIV care engagement.

Comparison of Immunological and Virological Recovery with Rapid, Early, and Late Start of Antiretroviral Treatment in Naive Plwh: Real-World Data

Background

Rapid initiation of antiretroviral therapy (ART) reduces the transmission of HIV infection in the community. This study aimed to determine whether rapid ART initiation is effective compared to standard ART treatment in our country.

Methods

Patients were grouped based on time to treatment initiation. HIV RNA levels, CD+4 T cell count, CD4/CD8 ratio, and ART regimens were recorded at baseline and follow-up visits for 12 months.

Results

There were 368-ART naive adults (treatment initiated at the time of HIV diagnosis; 143 on the first day, 48 on the second-seventh day, and 177 after the seventh day). Although virological suppression rates at 12^th months were higher in all groups, over 90% on average, there were no statistically significant differences in HIV-1 RNA suppression rates, CD+4 T cell count, and CD4/CD8 ratio normalization in the studied months but in multivariate logistic regression analysis; showed a significant correlation between both virological and immunological response and those with CD4+ T <350 cells/mL at 12th month in total patients.

Conclusion

Our findings support the broader application of recommendations for rapid ART initiation in HIV patients.

A Qualitative Study Exploring Factors Associated with Retention in HIV Care among Women with HIV in a Large HIV Clinic in Lagos, Nigeria, after Implementing the Test and Treat Policy

Background

In Nigeria, various sociocultural and economic factors may prevent women from being retained in HIV care. This study explores the factors associated with retention in care among women with HIV in a large HIV clinic in Lagos, Nigeria, under the Test and Treat policy.

Methods

Women living with HIV/AIDS (n = 24) enrolled in an HIV study at the AIDS Prevention Initiative in Nigeria (APIN) clinic in Lagos, Nigeria, were interviewed from April 1 to October 31, 2021, using a semistructured interview guide. Interviews were audio-taped, transcribed verbatim, and the themes were analyzed using the framework of Andersen and Newman's Behavioural Model for Healthcare Utilization.

Results

The mean age of the respondents was 37.4 ± 9.27 years. The identified themes were as follows: being aware of the antiretroviral medications and their benefits, the household's awareness of the respondents' HIV status, and the presence of social support. Other themes were the presence of a dependable source of income and the ability to overcome the challenges encountered in obtaining income, ease of travel to and from the clinic (length of travel time and transportation costs), securing support from the clinic, challenges encountered in the process of accessing care at the clinic, and the ability to overcome these challenges. Also mentioned were self-perception of being HIV positive, motivation to remain in care, linkage to care, and intention to stay in care.

Conclusion

Several deterring factors to retention in HIV care, such as nondisclosure of status, absence of social support, and clinic barriers, persist under the Test and Treat policy. Therefore, to achieve the "treatment as prevention" for HIV/AIDS, especially in sub-Saharan Africa, it is essential to employ strategies that address these barriers and leverage the facilitators for better health outcomes among women with HIV/AIDS.

A Call to Action: Integration of Buprenorphine Prescribing into the Care of Persons with HIV and Opioid Use Disorder

During the coronavirus disease 2019 (COVID-19) pandemic, we also experienced a worsening opioid overdose epidemic. Untreated opioid use disorder (OUD) in persons with human immunodeficiency virus (HIV) is associated with worse HIV-related outcomes. Buprenorphine is a safe, evidence-based medication for OUD and is effective in reducing opioid craving and overdose and improving outcomes along the HIV care continuum. Despite the longstanding evidence supporting the benefits of buprenorphine, there remains an implementation gap in the uptake of buprenorphine prescribing in HIV care settings. To improve integration of OUD care and HIV primary care, we recommend (1) all HIV clinicians obtain a buprenorphine waiver, (2) teaching on OUD should be integrated into infectious diseases and HIV continuing medical education, and (3) previously validated models of integrated care should be leveraged to urgently expand access to buprenorphine for persons with HIV and OUD.

Status-Neutral Interventions to Support Health Equity for Black Sexual Minority Men

PURPOSE OF REVIEW

Status-neutral care, a person-centered approach to healthcare not predicated on HIV serostatus, may improve health equity among Black sexual minority men (BSMM). We reviewed current status-neutral, HIV, and Pre-Exposure Prophylaxis (PrEP) interventions, and coded each for social-ecological focus and use of six approaches: (1) person-centered, (2) anti-stigma, (3) social support, (4) the social determinants of health (SDOH), (5) community engagement, and (6) multi-sectoral partnerships.

RECENT FINDINGS

We reviewed 25 studies, of which 3 were status-neutral. Nineteen studies utilized person-centered approaches, with several employing BSMM peers. For SDOH, financial incentives and reducing clinic-level barriers to care improved cascade outcomes. Direct text messaging, anti-stigma, social support, community-engagement, and multi-sectoral partnerships also improved outcomes in some studies. Few status-neutral programs exist and additional research is needed to identify key intervention components and mechanisms of influence. Programs targeting SDOH and multiple social-ecological levels offer promise for providing holistic care to BSMM, while addressing HIV prevention and treatment and health equity.

The Impact of Churn on HIV Outcomes in a Southern United States Clinical Cohort

Background

Persons with human immunodeficiency virus (PWH) may experience a cycle of engaging and disengaging in care referred to as “churn.” While human immunodeficiency virus (HIV) churn is predicted to be more prevalent in the southern United States (US), it has not been well characterized in this region.

Methods

We conducted a retrospective cohort study involving PWH newly establishing care at a large urban clinic in Atlanta, Georgia, from 2012 to 2017, with follow-up data collected through 2019. The primary exposure was churn, defined as a ≥12-month gap between routine clinic visits or viral load (VL) measurements. We compared HIV metrics before and after churn and assessed the risk of future churn or loss to follow-up.

Results

Of 1303 PWH newly establishing care, 81.7% were male and 84.9% were Black; 200 (15.3%) experienced churn in 3.3 years of median follow-up time. The transmissible viremia (TV) rate increased from 28.6% prechurn to 66.2% postchurn (P < .0001). The 122 PWH having TV on reengagement had delayed time to subsequent viral suppression (adjusted hazard ratio, 0.59 [95% confidence interval {CI}, .48–.73]), and PWH returning to care contributed disproportionately to the community viral load (CVL) (proportion of CVL/proportion of patients, 1.96). Churn was not associated with an increased risk of subsequent churn (adjusted odds ratio [aOR], 1.53 [95% CI, .79–2.97]) or loss to follow-up (aOR, 1.04 [95% CI, .60–1.79]).

Conclusions

The rate of churn in a southern US clinic was high, and those who experienced churn had increased TV at reentry and disproportionately contributed to the CVL and likely contributing to ongoing HIV transmission.

Multilevel Determinants of Rapid Antiretroviral Treatment Implementation and Demand in Miami-Dade County

BACKGROUND

Rapidly linking newly diagnosed HIV patients to antiretroviral treatment (ART) is the best practice for achieving optimal treatment outcomes, including viral suppression. However, rapid ART implementation varies throughout the United States, highlighting the importance of identifying rapid ART implementation determinants in US HIV epicenters, such as Miami-Dade County (MDC).

METHODS

Clinic focus groups (N = 4 clinics) and patient interviews (N = 31 recently diagnosed patients) systematically and qualitatively assessed rapid ART implementation determinants in MDC. Independent coders analyzed focus groups and interviews using a directed content analysis approach guided by the Consolidated Framework for Implementation Research.

RESULTS

For clinic stakeholders, key rapid ART implementation determinants included the following: complexity and adaptability (innovation characteristics); networks between clinics and patient needs rooted in structural inequities (outer setting); leadership and available resources (inner setting); staff/provider flexibility (characteristics of individuals); and appointing patient navigators and champions (process). For patients, key determinants included complexity and relative advantage of rapid treatment (innovation characteristics); patient needs and clinic networks (outer setting); provider knowledge and skills (inner setting); provider warmth and affirmation (characteristics of individuals); and need for improved outreach (process).

CONCLUSIONS

Multilevel factors impact clinic implementation and patient demand for rapid ART in MDC. Informed by these factors, we identified potential implementation strategies to enhance rapid ART implementation throughout MDC. These implementation strategies can be tested in an implementation trial, enhancing the toolkit of strategies to ensure that evidence-based tools, particularly rapid ART, are readily available to the most impacted communities.

Comprehensive Process Mapping and Qualitative Interviews to Inform Implementation of Rapid Linkage to HIV Care Programs in a Mid-Sized Urban Setting in the Southern United States

BACKGROUND

Rapid antiretroviral therapy (ART) initiation, in which people living with HIV start ART within days of diagnosis, is a key component of the US Ending the HIV Epidemic initiative.

SETTING

The Memphis Metropolitan Statistical Area ranked fourth in the United States for the highest HIV incidence per 100,000 population in 2018. Rapid ART programs are limited in the Memphis Metropolitan Statistical Area, and our objective was to identify local implementation barriers.

METHODS

We conducted participatory process mapping and in-depth interviews to detail steps between HIV testing at the municipal health department's Sexually Transmitted Infections Clinic and ART prescription from a nearby high-volume Ryan White-funded HIV Clinic.

RESULTS

Process mapping identified 4 modifiable, rate-limiting rapid ART barriers: (1) requiring laboratory-based confirmatory HIV results, (2) eligibility documentation requirements for Ryan White-funded services, (3) insufficient HIV Clinic medical provider availability, and (4) variability in ART initiation timing among HIV Clinic providers. Staff at both sites highlighted suboptimal communication and sense of shared management between facilities, limited resources to address important social determinants of health, and lack of Medicaid expansion in Tennessee as key barriers. In-depth interview themes negatively affecting rapid ART initiation included clinic burden; provider knowledge, attitudes, and beliefs; and client psychosocial needs.

CONCLUSIONS

Our preimplementation work identified modifiable and systemic barriers to systems flow and patient-level outcomes. This work will inform the design and implementation of a locally relevant rapid ART program in Memphis, a community disproportionately affected by the HIV epidemic.

Rapid Antiretroviral Therapy Program: Development and Evaluation at a Veterans Affairs Medical Center in the Southern United States

Early HIV viral suppression (VS) improves individual health outcomes and decreases onward transmission. We designed an outpatient clinic protocol to rapidly initiate antiretroviral therapy (ART) in a large Veterans Health Administration (VA) HIV clinic. A pre-post evaluation was performed using a retrospective cohort study design for new diagnoses of HIV infection from January 2012 to February 2020. Time-to-event analyses were performed using the Cox proportional hazards model with the intervention group as the main exposure adjusted for integrase inhibitor usage, baseline viral load, age, gender, and race. Most of the patients were men (historical control: 94.8%, n = 55; Rapid Start: 94.8%, n = 55) and Black or African American persons (historical control: 87.9%, n = 51; Rapid Start: 82.8%, n = 48). More patients initiated treatment with an integrase inhibitor-based regimen in the Rapid Start group (98.3%, n = 57) compared with the historical control group (39.7%, n = 23). Compared with controls, the Rapid Start patients were significantly more likely to achieve VS at any given time during the study period (hazard ratio 2.65; p < 0.001). Median days (interquartile range) from diagnosis to VS decreased from 180.5 (102.5-338.5) to 62 (40-105) (p < 0.001), first appointment to VS decreased from 123 (68.5-237.5) to 45 (28-82) (p < 0.001), referral to first visit decreased from 20 (10-43) to 1 (0-3) (p < 0.001), and from first visit to ART dispense date decreased from 27.5 (3-50) to 0 (0-0) (p = 0.01). Prioritizing immediate ART initiation can compress the HIV care continuum from diagnosis to linkage to VS. Implementation of the Rapid Start Protocol should be considered at all VA facilities providing HIV care.

Longitudinal Improvements in Viral Suppression for Persons With New HIV Diagnosis Receiving Care in the Ryan White Program: A 10-Year Experience in New Haven, CT (2009-2018)

Background

The Ryan White (RW) program funds medical and other support services for low-income persons with HIV, significantly improving progress along the HIV care continuum. Although the program has shown overall improvements in achievement of viral suppression, the relative contributions of changes in clinical practice and RW service components to the optimization of the HIV care continuum, particularly for those with new HIV diagnoses, remain unknown.

Methods

The target population was patients with recent HIV diagnoses who received care at RW-funded clinics in the greater New Haven area between 2009 and 2018. Client data were extracted from the RW-funded database, CAREWare, and the electronic medical record. Primary outcomes included time between HIV diagnosis and first HIV primary care (PC) visit, antiretroviral therapy (ART) initiation, and viral suppression (VS).

Results

There were 386 eligible patients. Between 2009 and 2018, the median number of days from HIV diagnosis to first PC visit decreased from 58.5 to 8.5 days, and ART initiation decreased from 155 to 9 days. In 2018, 86% of participants achieved viral suppression within 1 year, compared with 2.5% in 2009. Patients who initiated single-tablet ART and integrase inhibitor-containing regimens were more likely to reach viral suppression within 1 year (P < .001). Receipt of medical case management services was also associated with achieving viral suppression (P < .001).

Conclusions

Longitudinal improvements over 10 years in ART initiation and viral suppression were observed due to clinical advances and their effective implementation through the RW comprehensive care model. Further study of the essential components promoting these outcomes is needed.

Essential elements of and challenges to rapid ART implementation: a qualitative study of three programs in the United States

BACKGROUND

Antiretroviral therapy (ART) initiation on the day of an HIV diagnosis or as soon as possible after diagnosis, known as rapid ART (henceforth "RAPID"), is considered to be a safe and effective intervention to quickly reduce viral load and potentially improve engagement in care over time. However, implementation of RAPID programming is not yet widespread. To facilitate broader dissemination of RAPID, we sought to understand health care worker experiences with RAPID implementation and to identify essential programmatic elements.

METHODS

We conducted 27 key informant interviews with medical providers and staff involved in RAPID service delivery in three distinct clinical settings: an HIV clinic, a Federally Qualified Health Center and a sexual health and wellness clinic. Interviews were structured around domains associated with the Consolidated Framework for Implementation Research and were audio-recorded, transcribed, and thematically analyzed.

FINDINGS

We identified seven (7) essential elements across settings associated with successful RAPID program implementation. These high-impact elements represent essential components without which a RAPID program could not function. There was no one requisite formation. Instead, we observed a constellation of essential elements that could be operationalized in various formations and by various people in various roles. The essential elements included: (1) presence of an implementation champion; (2) comfort and competence prescribing RAPID ART; (3) expedited access to ART medications; (4) expertise in benefits, linkage, and care navigation; (5) RAPID team member flexibility and organizations' adaptive capacity; (6) patient-centered approach; and (7) strong communication methods and culture.

CONCLUSIONS

The RAPID model can be applied to a diverse range of clinical contexts. The operational structure of RAPID programs is shaped by the clinical setting in which they function, and therefore the essential elements identified may not apply equally to all programs. Based on the seven essential elements described above we recommend future implementers identify where these elements currently exist within a practice; leverage them when possible; strengthen them when necessary or develop them if they do not yet exist; and look to these elements when challenges arise for potential solutions.

A province-wide HIV initiative to accelerate initiation of treatment-as-prevention and virologic suppression in British Columbia, Canada: a population-based cohort study

BACKGROUND

In 2010, HIV treatment as prevention (TasP), encompassing widespread HIV testing and immediate initiation of free antiretroviral treatment (ART), was piloted under the Seek and Treat for Optimal Prevention of HIV/AIDS initiative (STOP) in British Columbia, Canada. We compared the time from HIV diagnosis to treatment initiation, and from treatment initiation to first virologic suppression, before (2005-2009) and after (2010-2016) the implementation of STOP.

METHODS

In this population-based cohort study, we used longitudinal data of all people living with an HIV diagnosis in BC from 1996 to 2017. We included those aged 18 years or older who had never received ART and had received an HIV diagnosis in the 2005-2016 period. We defined the virologic suppression date as the first date of at least 2 consecutive test results within 4 months with a viral load of less than 200 copies/mL. Negative binomial regression models assessed the effect of STOP on the time to ART initiation and suppression, adjusting for confounders. All p values were 2-sided, and we set the significance level at 0.05.

RESULTS

Participants who received an HIV diagnosis before STOP (n = 1601) were statistically different from those with a diagnosis after STOP (n = 1700); 81% versus 84% were men (p = 0.0187), 30% versus 15% had ever injected drugs (p < 0.0001), and 27% versus 49% had 350 CD4 cells/μL or more at diagnosis (p < 0.0001). The STOP initiative was associated with a 64% shorter time from diagnosis to treatment (adjusted mean ratio 0.36, 95% confidence interval [CI] 0.34-0.39) and a 21% shorter time from treatment to suppression (adjusted mean ratio 0.79, 95% CI 0.73-0.85).

INTERPRETATION

In a population with universal health coverage, a TasP intervention was associated with shorter times from HIV diagnosis to treatment initiation, and from treatment initiation to viral suppression. Our results show accelerating progress toward the United Nations' 90-90-90 target of people with HIV who have a diagnosis, those who are on antiretroviral therapy and those who are virologically suppressed, and support the global expansion of TasP to accelerate the control of HIV/AIDS.

A Qualitative Study of the Experience of Immediate Antiretroviral Therapy Among Urban Persons With Newly Diagnosed Human Immunodeficiency Virus

Background

Guidelines recommend immediate antiretroviral therapy (ART) at or shortly after human immunodeficiency virus (HIV) diagnosis, yet little is known about how people living with HIV (PLWH) experience this treatment strategy, including racial/ethnic minorities, cisgender/transgender women, and those with housing instability.

Methods

To assess the acceptability of immediate ART offer among urban PLWH, understand how this approach affects the lived experience of HIV diagnosis, and explore reasons for declining immediate ART, we conducted a cross-sectional qualitative study using semi-structured interviews with individuals who had been offered immediate ART after HIV diagnosis at a safety-net HIV clinic in San Francisco and a federally qualified health center in Chicago. Interviews were analyzed using thematic analysis.

Results

Among 40 participants with age range 19-52 years, 27% of whom were cisgender/transgender women or gender-queer, 85% racial/ethnic minority, and 45% homeless/unstably housed, we identified 3 major themes: (1) Individuals experienced immediate ART encounters as supportive; (2) individuals viewed immediate ART as sensible; and (3) immediate ART offered emotional relief by offsetting fears of death and providing agency over one's health. Reasons for declining immediate ART ranged from simply needing a few more days to complex interactions of logistical and psychosocial barriers.

Conclusions

Immediate ART was highly acceptable to urban persons with newly diagnosed HIV infection. Immediate ART was viewed as a natural next step after HIV diagnosis and provided a sense of control over one's health, mitigating anxiety over a decline in physical health. As such, immediate ART somewhat eased but in no way obviated the psychosocial challenges of HIV diagnosis.

Development of a Citywide Rapid Antiretroviral Therapy Initiative in San Francisco

INTRODUCTION

Ending the HIV epidemic in the U.S. holds rapid antiretroviral therapy as a key strategy to improve the health of those with HIV and to decrease transmission. In 2015, Getting to Zero San Francisco, a multisector consortium, expanded rapid antiretroviral therapy citywide.

METHODS

A Getting to Zero San Francisco Rapid ART Program Initiative for HIV Diagnoses Committee (academic, community, service delivery, health department partners) designed the program, protocol, dissemination plan, and monitoring strategy. Newly diagnosed patients were linked to an HIV medical home or Rapid ART Program Initiative for HIV Diagnoses initiation hub to best deliver rapid antiretroviral therapy across a diverse patient mix, with a goal of ≤5 working days from diagnosis to care and ≤1 day from care to antiretroviral therapy. Stakeholders were trained on rapid antiretroviral therapy via Getting to Zero San Francisco meetings, in-services, public health detailing, and peer-to-peer recruiting, prioritizing HIV clinics serving patients of color, Latinx ethnicity, youth, and the uninsured or publicly insured. Rapid ART Program Initiative for HIV Diagnoses-specific metrics were derived from surveillance data; stratified by sex/gender, age, race/ethnicity, and housing status; and presented at public meetings. Data were analyzed between January and April 2021.

RESULTS

From 2014 to 2018, median time from diagnosis to care decreased 71% (7 to 2 days), care to antiretroviral therapy decreased from 19 to 0 days, and diagnosis to virologic suppression decreased 51% (94 to 46 days). Improvements occurred regardless of age, race/ethnicity, sex/gender, exposure, or housing status.

CONCLUSIONS

During a citywide initiative to optimize antiretroviral therapy initiation, time from HIV diagnosis to care, antiretroviral therapy, and virologic suppression decreased across all affected groups to varying degrees. The Rapid ART Program Initiative for HIV Diagnoses Committee continues to address challenges to retention and expand implementation.

The HIV Treat Pillar: An Update and Summary of Promising Approaches

The Treat pillar of the Ending the HIV Epidemic in the U.S. plan calls for comprehensive strategies to enhance linkage to, and engagement in, HIV medical care to improve viral suppression among people with HIV and achieve the goal of 95% viral suppression by 2025. The U.S. has seen large increases in the proportion of people with HIV who have a suppressed viral load. Viral suppression has increased 41%, from 46% in 2010 to 65% in 2018. An additional increase of 46% is needed to meet the Ending the HIV Epidemic in the U.S. goal. The rate of viral suppression among those in care increased to 85% in 2018, highlighting the need to ensure sustained care for people with HIV. Greater increases in all steps along the HIV care continuum are needed for those disproportionately impacted by HIV, especially the young, sexual and racial/ethnic minorities, people experiencing homelessness, and people who inject drugs. Informed by systematic reviews and current research findings, this paper describes more recent promising practices that suggest an impact on HIV care outcomes. It highlights rapid linkage and treatment interventions; interventions that identify and re-engage people in HIV care through new collaborations among health departments, providers, and hospital systems; coordinated care and low-barrier clinic models; and telemedicine-delivered HIV care approaches. The interventions presented in this paper provide additional approaches that state and local jurisdictions can use to reach their local HIV elimination plans' goals and the ambitious Ending the HIV Epidemic in the U.S. Treat pillar targets by 2030.

HIV care continuum interventions for Black men who have sex with men in the USA

Disparities persist along the HIV care continuum among Black men who have sex with men (MSM) in the USA. As part of an initiative funded by the Health Resources and Services Administration's HIV/AIDS Bureau (US Department of Health and Human Services), we searched for recently published interventions focused on improving HIV care continuum outcomes among Black MSM with HIV in the USA. Our search identified 14 interventions, all of which were associated with at least one statistically significant outcome. Medication adherence was the most common outcome of interest, and linkage to care was the least common. More than half of the interventions focused on younger populations and took place in the US South. Interventions used a range of strategies to increase cultural relevance and address common barriers to optimal HIV outcomes for Black MSM. Several interventions harnessed social media, text messaging, and smartphone apps to facilitate social support, deliver HIV education, and encourage medication adherence. Interventions were delivered mostly at the individual or interpersonal level, although three made system-level changes to address structural barriers. Notably missing were interventions focused on minimising behavioural health barriers, and interventions directly addressing social determinants of health such as housing. To accelerate the pace of implementation and scale-up of interventions for Black MSM with HIV, public health entities can pilot emerging interventions in real-world settings, and use an implementation science approach to evaluate outcomes and assess the implementation strategies that drive or hinder effectiveness.

Initiation of Antiretroviral Therapy in the Hospital Is Associated With Linkage to Human Immunodeficiency Virus (HIV) Care for Persons Living With HIV and Substance Use Disorder

BACKGROUND

Studies have demonstrated benefits of antiretroviral therapy (ART) initiation on the day of human immunodeficiency virus (HIV) testing or at first clinical visit. The hospital setting is understudied for immediate ART initiation.

METHODS

CTN0049, a linkage-to-care randomized clinical trial, enrolled 801 persons living with HIV (PLWH) and substance use disorder (SUD) from 11 hospitals across the United States. This secondary analysis examined factors related to initiating (including reinitiating) ART in the hospital and its association with linkage to HIV care, frequency of outpatient care visits, retention, and viral suppression.

RESULTS

Of 801 participants, 124 (15%) initiated ART in the hospital, with more than two-thirds of these participants (80/124) initiating ART for the first time. Time to first HIV care visit among those who initiated ART in the hospital and those who did not was 29 and 54 days, respectively (P = .0145). Hospital initiation of ART was associated with increased frequency of HIV outpatient care visits at 6 and 12 months. There was no association with ART initiation in the hospital and retention and viral suppression over a 12-month period. Participants recruited in Southern hospitals were less likely to initiate ART in the hospital (P < .001).

CONCLUSIONS

Previous research demonstrated benefits of immediate ART initiation, yet this approach is not widely implemented. Research findings suggest that starting ART in the hospital is beneficial for increasing linkage to HIV care and frequency of visits for PLWH and SUD. Implementation research should address barriers to early ART initiation in the hospital.

Factors associated with adherence to guideline-recommended cardiovascular disease prevention among HIV clinicians

Integrating cardiovascular disease (CVD) prevention in routine HIV care remains a challenge. This study aimed to identify factors associated with adherence to guideline-recommended CVD preventive practices among HIV clinicians. Clinicians from eight HIV clinics in Atlanta were invited to complete an online survey. The survey was informed by the Consolidated Framework for Implementation Research and assessed the following: clinician CVD risk screening and advice frequency (never to always), individual characteristics (clinician beliefs, self-efficacy, and motivation), inner setting factors (clinic culture, learning climate, leadership engagement, and resources available), and outer setting factors (peer pressure and patient needs). Bivariate correlations examined associations between these factors and guideline adherence. Thirty-eight clinicians completed the survey (82% women, mean age 42 years, 50% infectious disease physicians). For risk screening, clinicians always check patient blood pressure (median score 7.0/7), while they usually ask about smoking or check their blood glucose (median score 6.0/7). For advice provision, clinicians usually recommend quitting smoking, controlling cholesterol or controlling blood pressure (median score 6.0/7), while they often recommend controlling blood glucose, losing weight, or improving diet/physical activity (median score 5.5/7). Clinician beliefs, motivation and self-efficacy were positively correlated with screening and advice practices (r = .55−.84), while inner setting factors negatively correlated with lifestyle-related screening and advice practices (r = −.51 to −.76). Peer pressure was positively correlated with screening and advice practices (r = .57–.89). Clinician psychosocial characteristics and perceived peer pressure positively influence adherence to guideline-recommended CVD preventive practices. These correlates along with leadership engagement could be targeted with proven implementation strategies.

Redefining therapeutic success in HIV patients: an expert view

Thanks to advances in the field over the years, HIV/AIDS has now become a manageable chronic condition. Nevertheless, a new set of HIV-associated complications has emerged, related in part to the accelerated ageing observed in people living with HIV/AIDS, the cumulative toxicities from exposure to antiretroviral drugs over decades and emerging comorbidities. As a result, HIV/AIDS can still have a negative impact on patients' quality of life (QoL). In this scenario, it is reasonable to believe that the concept of therapeutic success, traditionally associated with CD4 cell count restoration and HIV RNA plasma viral load suppression and the absence of drug resistances, needs to be redefined to include other factors that reach beyond antiretroviral efficacy. With this in mind, a group of experts initiated and coordinated the RET Project, and this group, using the available evidence and their clinical experience in the field, has proposed new criteria to redefine treatment success in HIV, arranged into five main concepts: rapid initiation, efficacy, simplicity, safety, and QoL. An extensive review of the literature was performed for each category, and results were discussed by a total of 32 clinicians with experience in HIV/AIDS (4 coordinators + 28 additional experts). This article summarizes the conclusions of these experts and presents the most updated overview on the five topics, along with a discussion of the experts' main concerns, conclusions and/or recommendations on the most controversial issues.

Decreased Time to Viral Suppression After Implementation of Targeted Testing and Immediate Initiation of Treatment of Acute Human Immunodeficiency Virus Infection Among Men Who Have Sex With Men in Amsterdam

BACKGROUND

Men who have sex with men (MSM) with acute human immunodeficiency virus (HIV) infection (AHI) are a key source of new infections. To curb transmission, we implemented a strategy for rapid AHI diagnosis and immediate initiation of combination antiretroviral therapy (cART) in Amsterdam MSM. We assessed its effectiveness in diagnosing AHI and decreasing the time to viral suppression.

METHODS

We included 63 278 HIV testing visits in 2008-2017, during which 1013 MSM were diagnosed. Standard of care (SOC) included HIV diagnosis confirmation in < 1 week and cART initiation in < 1 month. The AHI strategy comprised same-visit diagnosis confirmation and immediate cART. Time from diagnosis to viral suppression was assessed for 3 cART initiation periods: (1) 2008-2011: cART initiation if CD4 < 500 cells/μL (SOC); (2) January 2012-July 2015: cART initiation if CD4 < 500 cells/μL, or if AHI or early HIV infection (SOC); and (3a) August 2015-June 2017: universal cART initiation (SOC) or (3b) August 2015-June 2017 (the AHI strategy).

RESULTS

Before implementation of the AHI strategy, the proportion of AHI among HIV diagnoses was 0.6% (5/876); after implementation this was 11.0% (15/137). Median time (in days) to viral suppression during periods 1, 2, 3a, and 3b was 584 (interquartile range [IQR], 267-1065), 230 (IQR, 132-480), 95 (IQR, 63-136), and 55 (IQR, 31-72), respectively (P < .001).

CONCLUSIONS

Implementing the AHI strategy was successful in diagnosing AHI and significantly decreasing the time between HIV diagnosis and viral suppression.

Decreased Time From Human Immunodeficiency Virus Diagnosis to Care, Antiretroviral Therapy Initiation, and Virologic Suppression during the Citywide RAPID Initiative in San Francisco

BACKGROUND

Early virologic suppression (VS) after human immunodeficiency virus (HIV) infection improves individual health outcomes and decreases onward transmission. In San Francisco, immediate antiretroviral therapy (ART) at HIV diagnosis was piloted in 2013-2014 and expanded citywide in 2015 in a rapid start initiative to link all new diagnoses to care within 5 days and start ART at the first care visit.

METHODS

HIV providers and linkage navigators were trained on a rapid start protocol with sites caring for vulnerable populations prioritized. Dates of HIV diagnosis, first care visit, ART initiation, and VS were abstracted from the San Francisco Department of Public Health HIV surveillance registry.

RESULTS

During 2013-2017, among 1354 new HIV diagnoses in San Francisco, median days from diagnosis to first VS decreased from 145 to 76 (48%; P < .0001) and from first care visit to ART initiation decreased from 28 to 1 (96%; P < .0001). By 2017, 28% of new diagnoses had a rapid start, which was independently associated with Latinx ethnicity (AOR, 1.73; 95% CI, 1.15-2.60) and recent year of diagnosis (2017; AOR, 16.84; 95% CI, 8.03-35.33). Persons with a rapid ART start were more likely to be virologically suppressed within 12 months of diagnosis than those with a non-rapid start (RR, 1.17; 95% CI, 1.10-1.24).

CONCLUSIONS

During a multisector initiative to optimize ART initiation, median time from diagnosis to VS decreased by nearly half. Immediate ART at care initiation was achieved across many, but not all, populations, and was associated with improved suppression rates.

Diagnosis and Management of HIV-Associated Pulmonary Diseases in a Ryan White-Funded Primary Care Setting

Despite widespread use of antiretroviral therapy (ART), people with HIV (PWH) continue to suffer substantial morbidity and mortality from pulmonary diseases. We sought to evaluate the prevalence of pulmonary symptoms, evaluations, and diagnoses (both infectious and noninfectious) among PWH receiving care at one of the largest HIV clinics in the United States. All PWH seen at the Infectious Disease Program in Atlanta, Georgia, from July 2013 to June 2018 were included. Multivariable logistic regression was used to assess the odds of all-cause mortality. Among 8387 patients, median age was 48 years, 35% had documented smoking, 74% were male, and the 47% with ≥1 pulmonary symptom or diagnosis were older and had higher rates of smoking compared to those without any symptoms or diagnoses (p-values <0.0001). Percent on ART was 97% and 81% for individuals with and without symptoms or diagnoses, respectively (p-value <0.0001). Patients with an infectious diagnosis were more likely to have a diagnostic test ordered than those with a noninfectious diagnosis (p-value <0.0001). After adjustment for demographic and clinical risk factors, odds of death were 2.1 times greater [95% confidence interval (CI) = 1.3-3.5] among those with a pulmonary symptom or diagnosis compared to those without. Despite a high prevalence of pulmonary symptoms and diagnoses in this large cohort of PWH, many did not have a complete diagnostic evaluation, particularly those with noninfectious diagnoses. Greater awareness of evaluation and treatment of noninfectious pulmonary diseases among HIV care providers will be critical to improving long-term outcomes for PWH.

Time between diagnosis and achievement of virologic suppression in people living with HIV

PURPOSE

Data support the individual and public health advantages of shortened time intervals between HIV diagnosis, initiation of antiretroviral therapy (ART), and virologic suppression. The time from HIV diagnosis to linkage to care, initiation of ART, and virologic suppression was evaluated in newly diagnosed, ART-naive individuals after structured programmatic changes were implemented to reduce time to virologic suppression (TVS).

METHODS

The retrospective cohort included newly diagnosed, ART-naive adult patients receiving care in a Midwestern Ryan White Clinic. Study periods were between January 1, 2015, and December 31, 2015 (delayed treatment group) and January 1, 2017, and December 31, 2017 (rapid treatment group). Changes during the intervention time period were related to access to care and ART. The primary outcome of time from HIV diagnosis to virologic suppression was compared between the groups. Secondary outcomes included the time from diagnosis to linkage to care and the time to initiation of ART.

RESULTS

Twenty-four and 35 individuals were included in the control and intervention groups, respectively. Median (interquartile range) time from diagnosis to viral suppression was 137 (77-318) days in the delayed treatment group vs 76.5 (51-151) days in the rapid treatment group (P = 0.021). Time from diagnosis to first clinic visit remained similar (median of 13.5 vs 15 days, P = 0.859), while time from first clinic visit to initiation of ART decreased significantly (median of 15 vs 0 days, P < 0.001).

CONCLUSION

Time from first clinic visit to ART initiation was significantly shortened in this intervention and was the driving force to decreasing TVS. Additional research into barriers impacting time from diagnosis to linkage to care are needed to further shorten TVS.

Care Facilitation Advances Movement Along the Hepatitis C Care Continuum for Persons With Human Immunodeficiency Virus, Hepatitis C, and Substance Use: A Randomized Clinical Trial (CTN-0064)

Background

Direct-acting antivirals can cure hepatitis C virus (HCV). Persons with HCV/HIV and living with substance use are disadvantaged in benefiting from advances in HCV treatment.

Methods

In this randomized controlled trial, participants with HCV/HIV were randomized between February 2016 and January 2017 to either care facilitation or control. Twelve-month follow-up assessments were completed in January 2018.

Care facilitation group participants received motivation and strengths-based case management addressing retrieval of HCV viral load results, engagement in HCV/HIV care, and medication adherence. Control group participants received referral to HCV evaluation and an offer of assistance in making care appointments. Primary outcome was number of steps achieved along a series of 8 clinical steps (eg, receiving HCV results, initiating treatment, sustained virologic response [SVR]) of the HCV/HIV care continuum over 12 months postrandomization.

Results

Three hundred eighty-one individuals were screened and 113 randomized. Median age was 51 years; 58.4% of participants were male and 72.6% were Black/African American. Median HIV-1 viral load was 27 209 copies/mL, with 69% having a detectable viral load. Mean number of steps completed was statistically significantly higher in the intervention group vs controls (2.44 vs 1.68 steps; χ ² [1] = 7.36, P = .0067). Men in the intervention group completed a statistically significantly higher number of steps than controls. Eleven participants achieved SVR with no difference by treatment group.

Conclusions

The care facilitation intervention increased progress along the HCV/HIV care continuum, as observed for men and not women. Study findings also highlight continued challenges to achieve individual-patient SVR and population-level HCV elimination.

Clinical Trials Registration

NCT02641158.

Implementing Rapid Initiation of Antiretroviral Therapy for Acute HIV Infection Within a Routine Testing and Linkage to Care Program in Chicago

Growing evidence suggests that rapid initiation of antiretroviral therapy for HIV improves care continuum outcomes. We evaluated process and clinical outcomes for rapid initiation in acute HIV infection within a multisite health care–based HIV testing and linkage to care program in Chicago. Through retrospective analysis of HIV testing data (2016-2017), we assessed linkage to care, initiation of antiretroviral therapy, and viral suppression. Of 334 new HIV diagnoses, 33 (9.9%) individuals had acute HIV infection. Median time to linkage was 11 (interquartile range [IQR]: 5-19.5) days, with 15 days (IQR 5-27) to initiation of antiretroviral therapy. Clients achieved viral suppression at a median of 131 (IQR: 54-188) days. Of all, 69.7% were retained in care, all of whom were virally suppressed. Sites required few additional resources to incorporate rapid initiation into existing processes. Integration of rapid initiation of antiretroviral therapy into existing HIV screening programs is a promising strategy for scaling up this important intervention.

Rapid initiation of darunavir/cobicistat/emtricitabine/tenofovir alafenamide in acute and early HIV-1 infection: a DIAMOND subgroup analysis

BACKGROUND

Treatment during acute or early human immunodeficiency virus (HIV)-1 infection is associated with immunologic and virologic benefits.

OBJECTIVE

To evaluate darunavir/cobicistat/emtricitabine/tenofovir alafenamide (D/C/F/TAF) efficacy/safety among patients with acute or early HIV-1 infection who rapidly initiate treatment.

METHODS

DIAMOND (ClinicalTrials.gov Identifier: NCT03227861), a phase 3 study, evaluated the efficacy/safety of D/C/F/TAF 800/150/200/10 mg in rapid initiation. Adults aged ≥18 years began D/C/F/TAF within 14 days of diagnosis, prior to the availability of screening/baseline laboratory results. In this subgroup analysis, virologic response (HIV-1 RNA <50 copies/mL) was assessed at Week 48 by intent-to-treat FDA snapshot (ITT-FDA snapshot) and observed (excluding patients with missing data) analyses in patients with acute (HIV-1 antibody negative and HIV-1 RNA positive/p24 positive) or early (HIV-1 antibody positive and suspected infection ≤6 months before screening/baseline) infection.

RESULTS

Among 109 patients, 13 had acute and 43 had early HIV-1 infection. High rates of virologic response were demonstrated at Week 48 by ITT-FDA snapshot (acute: 10/13 [76.9%]; early: 37/43 [86.0%]) and observed (acute: 10/11 [90.9%]; early: 37/38 [97.4%]) analyses. No patients discontinued or required regimen change due to baseline resistance or lack of efficacy, or developed protocol-defined virologic failure. Through Week 48, 7 (53.8%) acute and 22 (51.2%) early infection patients had a D/C/F/TAF-related adverse event (AE); none had a D/C/F/TAF-related grade 4 or serious AE.

CONCLUSIONS

High rates of viral suppression during acute/early infection were achieved with D/C/F/TAF rapid initiation, no treatment-emergent resistant mutations were observed, and D/C/F/TAF was safe and well tolerated.

Darunavir/Cobicistat/Emtricitabine/Tenofovir Alafenamide in a Rapid-Initiation Model of Care for Human Immunodeficiency Virus Type 1 Infection: Primary Analysis of the DIAMOND Study

Background

Most guidelines recommend rapid treatment initiation for patients with newly diagnosed human immunodeficiency virus type 1 (HIV-1) infection, but prospective US data are limited. The DIAMOND (NCT03227861) study using darunavir/cobicistat/emtricitabine/tenofovir alafenamide (D/C/F/TAF) 800/150/200/10 mg is a phase 3 prospective study evaluating efficacy/safety of a single-tablet regimen in a rapid-initiation model of care.

Methods

Adults aged ≥18 years began D/C/F/TAF ≤14 days from diagnosis without screening/baseline results; as results became available, participants not meeting predefined safety/resistance stopping rules continued. Primary endpoint was virologic response (HIV-1 RNA <50 copies/mL; intent-to-treat; US Food and Drug Administration [FDA] snapshot) at week 48; participant satisfaction was measured via the HIV Treatment Satisfaction Questionnaire status version (HIVTSQs).

Results

Of 109 participants, 87% were male, 32% black/African American, median (range) age was 28 (range, 19–66) years, 25% of participants had HIV-1 RNA ≥100 000 copies/mL, 21% had CD4⁺ cell count <200 cells/µL, and 31% enrolled ≤48 hours from diagnosis. At week 48, 97 (89%) participants completed the study and 92 (84%) achieved HIV-1 RNA <50 copies/mL (FDA snapshot). There were no protocol-defined virologic failures; incidences of adverse events (AEs) and adverse drug reactions (33%) were low, no serious AEs were study drug related, and 1 (<1%) participant discontinued due to study drug related AE(s). The overall HIVTSQs score at week 48 was 58 (maximum: 60).

Conclusions

At week 48, a high proportion of participants starting D/C/F/TAF achieved HIV-1 RNA <50 copies/mL and very few discontinued therapy. D/C/F/TAF was well tolerated, no participants discontinued due to baseline resistance stopping criteria, and high treatment satisfaction among participants was recorded.

Clinical Trials Registration

NCT03227861.

Primary Care Guidance for Persons With Human Immunodeficiency Virus: 2020 Update by the HIV Medicine Association of the Infectious Diseases Society of America

Advances in antiretroviral therapy (ART) have made it possible for persons with human immunodeficiency virus (HIV) to live a near expected life span, without progressing to AIDS or transmitting HIV to sexual partners or infants. There is, therefore, increasing emphasis on maintaining health throughout the life span. To receive optimal medical care and achieve desired outcomes, persons with HIV must be consistently engaged in care and able to access uninterrupted treatment, including ART. Comprehensive evidence-based HIV primary care guidance is, therefore, more important than ever. Creating a patient-centered, stigma-free care environment is essential for care engagement. Barriers to care must be decreased at the societal, health system, clinic, and individual levels. As the population ages and noncommunicable diseases arise, providing comprehensive healthcare for persons with HIV becomes increasingly complex, including management of multiple comorbidities and the associated challenges of polypharmacy, while not neglecting HIV-related health concerns. Clinicians must address issues specific to persons of childbearing potential, including care during preconception and pregnancy, and to children, adolescents, and transgender and gender-diverse individuals. This guidance from an expert panel of the HIV Medicine Association of the Infectious Diseases Society of America updates previous 2013 primary care guidelines.

Antiretroviral Drugs for Treatment and Prevention of HIV Infection in Adults: 2020 Recommendations of the International Antiviral Society-USA Panel

Importance

Data on the use of antiretroviral drugs, including new drugs and formulations, for the treatment and prevention of HIV infection continue to guide optimal practices.

Objective

To evaluate new data and incorporate them into current recommendations for initiating HIV therapy, monitoring individuals starting on therapy, changing regimens, preventing HIV infection for those at risk, and special considerations for older people with HIV.

Evidence Review

New evidence was collected since the previous International Antiviral (formerly AIDS) Society-USA recommendations in 2018, including data published or presented at peer-reviewed scientific conferences through August 22, 2020. A volunteer panel of 15 experts in HIV research and patient care considered these data and updated previous recommendations.

Findings

From 5316 citations about antiretroviral drugs identified, 549 were included to form the evidence basis for these recommendations. Antiretroviral therapy is recommended as soon as possible for all individuals with HIV who have detectable viremia. Most patients can start with a 3-drug regimen or now a 2-drug regimen, which includes an integrase strand transfer inhibitor. Effective options are available for patients who may be pregnant, those who have specific clinical conditions, such as kidney, liver, or cardiovascular disease, those who have opportunistic diseases, or those who have health care access issues. Recommended for the first time, a long-acting antiretroviral regimen injected once every 4 weeks for treatment or every 8 weeks pending approval by regulatory bodies and availability. For individuals at risk for HIV, preexposure prophylaxis with an oral regimen is recommended or, pending approval by regulatory bodies and availability, with a long-acting injection given every 8 weeks. Monitoring before and during therapy for effectiveness and safety is recommended. Switching therapy for virological failure is relatively rare at this time, and the recommendations for switching therapies for convenience and for other reasons are included. With the survival benefits provided by therapy, recommendations are made for older individuals with HIV. The current coronavirus disease 2019 pandemic poses particular challenges for HIV research, care, and efforts to end the HIV epidemic.

Conclusion and Relevance

Advances in HIV prevention and management with antiretroviral drugs continue to improve clinical care and outcomes among individuals at risk for and with HIV.

Sobieszczyk M, Olender S, Gordon P, Zucker J, Tross S, Castor D, H. Remien R. Immediate Antiretroviral Therapy: The Need for a Health Equity Approach

Immediate antiretroviral therapy (iART), defined as same-day initiation of ART or as soon as possible after diagnosis, has recently been recommended by global and national clinical care guidelines for patients newly diagnosed with human immunodeficiency virus (HIV). Based on San Francisco’s Rapid ART Program Initiative for HIV Diagnoses (RAPID) model, most iART programs in the US condense ART initiation, insurance acquisition, housing assessment, and mental health and substance use evaluation into an initial visit. However, the RAPID model does not explicitly address structural racism and homophobia, HIV-related stigma, medical mistrust, and other important factors at the time of diagnosis experienced more poignantly by African American, Latinx, men who have sex with men (MSM), and transgender patient populations. These factors negatively impact initial and subsequent HIV care engagement and exacerbate significant health disparities along the HIV care continuum. While iART has improved time to viral suppression and linkage to care rates, its association with retention in care and viral suppression, particularly in vulnerable populations, remains controversial. Considering that in the US the HIV epidemic is sharply defined by healthcare disparities, we argue that incorporating an explicit health equity approach into the RAPID model is vital to ensure those who disproportionately bear the burden of HIV are not left behind.

Rapid Antiretroviral Therapy (ART) Initiation at a Community-Based Clinic in Jackson, MS

Background

Rapid antiretroviral therapy (ART), ideally initiated within twenty-four hours of diagnosis, may be crucial in efforts to increase virologic suppression and reduce HIV transmission. Recent studies, including demonstration projects in large metropolitan areas such as Atlanta, Georgia; New Orleans, Louisiana; San Francisco, California; and Washington D.C., have demonstrated that rapid ART initiation is a novel tool for expediting viral suppression in clinical settings. Here we present an evaluation of the impact of a rapid ART initiation program in a community-based clinic in Jackson, MS.

Methods

We conducted a retrospective chart review of patients who were diagnosed with HIV at Open Arms Healthcare Center or were linked to the clinic for HIV care by the Mississippi State Department of Health Disease Intervention Specialists from January 1, 2016 to December 31, 2018. Initial viral load, CD4+ T cell count, issuance of an electronic prescription (e-script), subsequent viral loads until suppressed and patient demographics were collected for each individual seen in clinic during the review period. Viral suppression was defined as a viral load less than 200 copies/mL. Rapid ART initiation was defined as receiving an e-script for antiretrovirals within seven days of diagnosis.

Results

Between January 1, 2016 and December 31, 2018, 70 individuals were diagnosed with HIV and presented to Open Arms Healthcare Center, of which 63 (90%) completed an initial HIV counseling visit. Twenty-seven percent of patients were provided with an e-script for ART within 7 days of diagnosis. The median time to linkage to care for this sample was 12 days and 5.5 days for rapid ART starters (p < 0.001). Median time from diagnosis to viral suppression was 55 days for rapid ART starters (p = 0.03), a 22 day decrease from standard time to viral suppression.

Conclusion

Our results provide a similar level of evidence that rapid ART initiation is effective in decreasing time to viral suppression. Evidence from this evaluation supports the use of rapid ART initiation after an initial HIV diagnosis, including same-day treatment.

I wanted it as soon as possible: a qualitative exploration of reactions to access to same-day ART start among participants in San Diego's ART-NET project

Rapid start of antiretroviral therapy (ART) is quickly becoming best practice around the world. In the US, programs exist to facilitate rapid ART start, but little is known about the experiences of newly diagnosed individuals receiving these recommendations and services. Twenty participants (19 men who have sex with men and 1 transgender woman) from an early ART start program were interviewed to better understand these experiences. Interviews were analyzed for main themes in three general areas: reasons to start, reasons to delay, and factors influencing early ART adherence. Participants reported starting anywhere from right away (same visit as diagnosis) to within a few weeks (median 10.5 days). Reasons to start right away included fear of what could happen if not treated, personal health, influence of people/resources at the clinic, and study participation. Most had small delays in ART start because of structural (insurance, costs) and intentional delays (getting additional medical consultations). Adherence facilitators included desires to improve CD4/viral load and positive beliefs in benefits of suppression. Participants were largely supportive of rapid ART start and appeared to rely on CD4/viral load as "proof" of need for ART, which may be particularly helpful for asymptomatic, newly diagnosed individuals starting ART.

Falling Through the Cracks: Risk Factors for Becoming Lost to HIV Care After Incarceration in a Southern Jail

Using a retrospective cohort analysis of inmates released from Dallas County Jail between January 2011 and November 2013, this study characterizes people living with HIV/AIDS (PLWHA) who are lost to care after release from jail. We used Kaplan-Meier analysis to estimate the risk of becoming lost to post-release HIV care and a Cox proportional hazards regression model to identify associated factors. The majority of individuals (78.2%) were men and 65.5% were black. Of the incarcerations that ended with release to the community, approximately 43% failed to link to community HIV care. Non-Hispanic Whites were more likely than Hispanics or Blacks to drop out of care after release. Individuals with histories of substance use or severe mental illness were more likely to become lost, while those under HIV care prior to incarceration and/or who had adhered to antiretroviral therapy (ART) were more likely to resume care upon release. Targeted efforts such as rapid linkage to care and re-entry residence programs could encourage formerly incarcerated individuals to re-engage in care.