Time to enrollment in HIV treatment dropped by 53% when clinicians sent people new to HIV treatment home from intake with a bottle of universal first-line therapy before they even saw a physician.
Doing so treats HIV like the chronic condition it is and reduces the stigma that can be a barrier to care, said Glory Ruiz, MD, public health programs director at Boston Medical Center (BMC), in Massachusetts.
“The patients are in such good shape when they leave from that same-day ART [antiretroviral therapy] initiation that by the time they get to the first MD visit, they’re already doing better,” Ruiz told Medscape Medical News during the virtual United States Conference on HIV/AIDS 2020 (USCHA 2020). “The doctors are able to confidently say, ‘I don’t need to see you in 4 months.’ “
Instead, patients come in at 6 months. This is helpful because most of them are covered by Medicare or Medicaid and have multiple competing priorities, such as housing, transportation, insurance navigation, and immigration support.
Still, the results represent only 37 patients of the 61 enrolled in the study — a small sample that was complicated by the coronavirus pandemic, which altered approaches to care. But Ruiz added that underpinning the new ART program with a patient-centered and multidisciplinary model within BMC’s Center for Infectious Diseases means that despite the small sample size, their findings could be instructive to others.
“It is generalizable for clinics that look like ours,” she said. “Clinics could leverage the pharmacy and case-management resources to provide this tool for patients.”
A Backbone for Rapid ART
Before launching the Direct Access to Anti-Retroviral Therapy (DAART) program, average enrollment in care took more than 2 weeks — better than the US Centers for Disease Control and Prevention goal of 30 days but higher than Ruiz and the team wanted.
So they went back to their community and asked patients, clinicians, care navigators, sexually transmitted infection counselors, and outreach workers what the holdups were in having their patients enter care programs. One of the main barriers they identified was lack of consistency in how different clinic providers prescribed ART. Some prescribed on the same day. Others waited for genotyping of the patient’s virus to come back.
“The younger generation of HIV doctors are a lot bolder,” Ruiz said. “They were more gung-ho, like, ‘Yeah, let’s try rapid ART, as long as we have a backbone and a logic as to why we’re going to choose the regimen we choose.’ “
That backbone — the scaffold from which most HIV combination therapy hangs — typically includes two nucleoside/nucleotide reverse transcriptase inhibitors and one or more medications that target other aspects of the HIV life cycle. But that backbone needs to be based on the genetic variation of each patient’s HIV strain.
To address the concerns of clinicians hesitant to prescribe before genotype testing, the team went back to the pharmacy and reviewed viral suppression data for the Center for Infectious Diseases’ 1600 patients, focusing on genotypic profile.
They discovered that the HIV in their area responded best to a combination of bictegravir, emtracitabine, and tenofovir alafenamide (Biktarvy), which became the their first-line option. The alternative was darunavir and cobicistat with emtracitabine and tenofovir alafenamide (Symtuza).
Then they revisited the Massachusetts Department of Public Health’s 14-item acuity scale. They conducted a chart review to see who might qualify for the program and offered it to them.
In February 2019, DAART rolled out. Since then, 61 patients have qualified for the program, meaning they were treatment naive — either newly diagnosed or with a known HIV diagnosis but with no history of treatment and co-occurring injection drug use or other factors that placed them at high risk for transmitting the virus.
People with treatment experience were ineligible for DAART, as were those with renal insufficiency or coinfections such as active central nervous system opportunistic infections.
Of the 61 eligible patients, 37 (61%) were enrolled in DAART. That number also accounts for 45% of people newly diagnosed with HIV at BMC during that time.
“The reasons the other patients haven’t been enrolled but are eligible is because they came in through the ED [emergency department], have been admitted, and then leave [against medical advice] before we’re able to get to them,” said Katy Scrudder, MPH, a data quality specialist at BMC. “Another big reason for patients not entering is because they have other comorbidities that are needing to be addressed first. A big one for this population is mental health crises.”
Despite all this, “they were excited to start medication for same-day ART,” she said.
Of those 37 patients, 36 were had been in long-term care and were taking medication in October 2020, according to data shared with Medscape Medical News. The team defined engagement in care as having had at least one follow-up appointment with the physician, and potentially two. The program is not yet 2 years old. COVID-19 put the program on hold and then led to changes in how the team worked with people eligible for DAART. The team is currently awaiting more data to see how well the program is working.
They have kept track of the 39% of people who were eligible for DAART but who did not enroll. Currently, 85% of those patients are in HIV treatment, too.
Ruiz attributed this to their strong intake team, which reflects the communities they serve at the hospital: the majority are people of color, 20% are in recovery for alcohol or drugs, and 5% are living with HIV. They speak a combined total of eight languages, and many are from the immigrant communities that most frequent BMC.
The high level of patient engagement probably comes from categorizing HIV as a chronic disease — which it is — and by handing medications to a patient on the day of intake, Ruiz said.
“If you have diabetes or hypertension, we’re going to prescribe you medicine — and if we need to titer it along the way, we will titer it along the way,” she said. In DAART, they do the same with HIV. “It helps the patient feel better and cope with the new diagnosis.”
None of the 36 DAART patients have developed treatment-resistant mutations.
No Pill for Will
The single patient in the study who is not receiving ART is engaged in care with their primary care provider. But according to Ruiz, the patient “refuses to engage in any conversations about his HIV care and refuses to accept any HIV prescriptions.”
This is where the patient-centered approach at the clinic becomes essential, Ruiz said. The multidisciplinary nature of the clinic includes clinicians expert in refugee healthcare and care navigators who accompany patients to the pharmacy, pick up the medications for the patient, or walk them through insurance navigation.
But that single patient represents a truth that clinicians often struggle with: It’s not always a patient’s goal to achieve viral suppression, and even if it is, some patients will never get there, said Larry Scott-Walker, cofounder and executive director of the HIV service organization Thrive SS, in Atlanta, Georgia.
To battle stigma, clinicians need to put the patient’s goals ahead of their own goals for viral suppression.
“Clinicians are trained to focus on viral suppression, but there’s a science to engaging with a patient in a way that empowers them,” he told Medscape Medical News. He pointed to motivational interviewing and to the conversations he has with his colleague Leisha McKinley-Beach, an HIV consultant. They may not talk at all about HIV in their 15-minute discussions, but they leave the patient feeling motivated to “eat a bowl of broccoli and take my ARVs.”
As he put it during another presentation at USCHA 2020, there is no pill to increase a person’s will.
“My whole life matters,” not just the viral load, Scott-Walker said. “We providers have to train ourselves not to hinge everything on a pill, a magical pill, because the truth is that there could be a cure to HIV, and some people will not get it because of how valued vs devalued they feel.”
“It’s important that we make sure our team reflects the population we serve,” she said. “And it’s why it’s important to do everything we possibly can to make that human connection very early on in the process.”
United States Conference on HIV/AIDS: Workshop Session 4: AART Program Evaluation: Solutions to Barriers in Rapid HIV Treatment. Workshop Session 4: Viremia, Vulnerability and Victory: The Black Experience Living With HIV. Presented October 21, 2020.
Heather Boerner is a science and medical reporter based in Pittsburgh, Pennsylvania.