Improving Access to Patient Care & Time to Viral Suppression Using HIV Rapid Entry Programs

Implementation of a rapid entry program decreased time to first provider appointment, time to initiation of ART, and time to viral suppression in the Southern United States.

The CDC has reported that 44% of individuals who are living with HIV are residing in the southern region of the United States; HIV diagnosis rates are higher in the South than they are for Americans overall.

At the 25th Conference on Retroviruses and Opportunistic Infections (CROI), research presented by Johnathan Colasanti, MD, MSPH, from the Emory University School of Medicine, suggested that the implementation of rapid entry programs in an economically and socially disenfranchised population in the South significantly improved time to viral suppression for those with HIV.

“Significant resources and effort were needed to implement this program, suggesting that more data are needed to determine which populations will benefit most from the rapid start of ART in the United States,” Dr. Colasanti said in his presentation.

Data from the test and treat or rapid antiretroviral therapy (ART) approaches have improved linkage to care, rates of viral suppression, and time to viral suppression in South Africa, Haiti, and San Francisco; past data suggests that this may lead to better retention in care. Aside from this study, no rapid entry programs have been reported from the Southern United States.

From May 16, 2016, to July 31, 2016, the feasibility and effectiveness of the rapid entry program was assessed in a large Ryan White-funded clinic in Atlanta, Georgia, which serves a predominantly minority and economically disadvantaged population.

Researchers aimed to enroll patients in the clinic, complete a social needs assessment, provider visit, labs and give an opinion to begin ART within 72 hours of presenting to clinic.

To assess the effectiveness of the program, the researchers compared with intervention group with new enrollees of the clinic from the months preceding the rapid entry program January 1, 2016, to May 15, 2016.

Inclusion criteria included HIV-positive patients, new to the clinic — however, not necessarily new to the diagnosis — who were viremic at intake and ≥ 16 years old. Researchers followed up with each group of patients at 6 months.

The primary outcome was the time from presentation to clinic for enrollment to viral suppression, while the secondary outcomes included viral suppression <200 c/mL, attending first scheduled provider visit, time to scheduled provider visit, time to first attended provider visit, and time to ART initiation.

A survival analysis was used to compare viral suppression for the groups, while researchers used linear regression models for secondary outcomes.

The sample size included 118 pre-rapid entry program and 91 post-rapid entry program.

Pre-rapid entry program demographics include age 33, 81% male, 86% Black, 60% men who have sex with men, 58% uninsured, an annual income of $8,808, 67% unstably housed, 9% incarcerated in the last 6 months, 42% active substance use, CD4 141 cells/uL and 59% ART naïve. The post-rapid entry program, however, differed in age at 38-years-old.

The median time to viral suppression decreased from 63 days to 45 days post-rapid entry program.

This is the largest, rapid entry cohort described in the US Time to viral suppression, in an economically and socially disenfranchised population in the South.

The findings concluded that through the implementation of a rapid entry program time to first provider appointment, time to initiation of ART, and time to viral suppression all decreased; however, the proportion of patients achieving viral suppression did not decrease.

Viral suppression, significantly improved through implementation of a rapid entry program, was likely due to shortening the time to initial provider visit and ART prescription, the researchers said.

Rapid entry programs are feasible in areas of the country with the greatest number of new infections.

In an interview with Contagion®, Dr. Colasanti said that he thinks these programs are critically important in areas like the South, where stigma is so strong and there’s leftover systemic racism and mistrust in the medical system — the impact of these programs need to be further studied.

“I think it’s up to us to continue to demand from our health systems, from our other state or federal funding sources, that dollars need to be poured into this, really because it’s the right thing to do,” he said.