Test to Treat / RAPID in 5 questions
In addition to this blogpost, you can listen to Dr. Bacon’s presentation at CROI 2018 by following the link below.
- So what is RAPID?
RAPID stands for “Rapid ART Program Initiative for new Diagnoses:” an HIV treatment strategy in San Francisco that aims to start antiretroviral therapy (ART) as soon after diagnosis as possible. After a successful pilot program at the HIV clinic at San Francisco General Hospital in 2013-14, the Getting to Zero consortium adapted it for use with all persons newly diagnosed with HIV in the city.
- Why is RAPID an attractive treatment strategy?
Even though it is well known that persons with HIV who are started on ART earlier (at higher CD4 count, and with a lower cumulative period of viremia) have fewer HIV-related and -unrelated complications than those started later, and even though we know that the sooner you achieve a durably undetectable viral load on ART, the shorter your period of HIV transmission, ART initiation following diagnosis (and therefore virologic suppression) is usually delayed by weeks to months. This represents lost opportunities for disease control, preservation of immune function, and prevention. Many of us who favor RAPID also believe that it is psychologically empowering for patients to take control over their HIV infection as soon as they know they have it, and, conversely, that delaying therapy might be associated with self-stigmatization (this is not yet proven, although research is underway to examine these associations). Studies of immediate ART at diagnosis in Haiti, South Africa, and Lesotho have shown that patients starting ART immediately at diagnosis have a higher probability of retention in care and virologic suppression over time, than those whose ART is delayed.
Think about it: If you found out you had a chronic, potentially fatal illness that could be controlled by medication so that you could live a long, healthy life, wouldn’t you want to start treatment right away? What would it do to your trust in the healthcare system or how you feel about your value as a person to be told to wait?
- How does the Citywide RAPID program work in San Francisco?
First, San Francisco is fortunate to have a health department and city government, medical providers, academic and nonacademic medical centers, and community partners who are committed to reducing the impact of HIV on our residents, including but not limited to the SF Getting to Zero Consortium. Second, RAPID isn’t about creating some new technology, but rather studying the existing continuum of HIV diagnosis, linkage, and care, and removing as many barriers and delays as possible. First, we studied our HIV care landscape, identifying the places where San Franciscans test positive for HIV, the organizations that link newly-diagnosed persons to care, the medical sites where they get their care and antiretroviral therapy, and how these entities communicate with each other. Then we drafted a citywide RAPID protocol stipulating that all persons newly-diagnosed with HIV should be linked to care within 5 working days of diagnosis, and started on ART at their first care appointment (the same day they have their intake interview, psychosocial counseling, and medical evaluation including baseline labs). We then disseminated the RAPID protocol to HIV providers using colleague-to colleague conversations, medical grand rounds, in-services, and, later, public health detailing. This is a strategy of having trainers (in our case nurse practitioners), equipped with informational materials, make brief on-on-one visits to clinicians with the goal of helping them to adopt evidence-based medical practices (in our case, RAPID). We also posted the protocol and a quick clinician guide to RAPID on our getting to zero website. As more clinicians signed on to RAPID, we included their names and practice details in a RAPID Provider Directory that linkage navigators could use to quickly refer newly-diagnosed persons to the optimal HIV specialist for their psychosocial needs and insurance coverage. Finally, we collaborated with the HIV surveillance branch in our health department to include a set of RAPID metrics for program evaluation and improvement.
- Is the RAPID initiative working?
We think so. In a recent analysis of our metrics comparing pre-RAPID (2013) to early RAPID (2016), median time from diagnosis to virologic suppression fell 54% from 134 to 61 days. Time from diagnosis to first care visit dropped 38% from 8 to 5 days. Time from first care visit to ART initiation dropped 96% from 27 days to 1 day. What’s really encouraging is that improvements in time to virologic suppression and ART start are significant among all racial and ethnic groups, both sexes, all age categories, and both housed and homeless persons, although small differences remain among some groups.
- What do you think has contributed to the success of citywide RAPID?
Some of the key contributors included (1) Having a few early, committed, influential RAPID champions in key organizations throughout the city: certain key HIV clinics that serve a large number of the newly-diagnosed, including in the safety-net system and the private system; the health department; and academic HIV leadership. (2) Having data from the successful RAPID pilot to convince HIV providers that it could be done (and to create new RAPID champions when we needed them). (3) Having a pre-existing citywide linkage team at the Department of Public Health who could also serve as care and insurance navigators. (4) Being able to enroll eligible patients in emergency ADAP or presumptive Medi-Cal (California’s Medicaid program) on the day of, or day after, diagnosis, to pay for care and medications. (5) Making sure that RAPID training included not just clinicians but the entire healthcare team: eligibility workers, social worker, nurses, counselors, registration staff.