UPDATED Oct 29, 2020 // Editor’s Note: In light of additional information from the Boston Medical Center, a misleading heading has been rewritten and the enrollment procedures for the DAART program, incorrectly described as a study, have been clarified.
Time to enrollment on HIV treatment was reduced by 53% when doctors sent treatment-naïve patients home with a bottle of universal first-line therapy from admission. This was before seeing a doctor.
By immediately initiating antiretroviral treatment (ART) into a comprehensive, team-based HIV program, HIV is treated like a chronic disease and the stigma that can be an obstacle to care reduced, said Dr. Glory Ruiz, Boston Medical Center (BMC) program director of public health.
“Patients are in such good shape by the time they leave ART initiation the same day that they’ll be better by the time they see their doctor,” Ruiz told Medscape Medical News during the US HIV virtual conference / AIDS 2020 (USCHA 2020). “Doctors can confidently say, ‘I don’t have to see you in 4 months.’ “”
Instead, they meet with a doctor after 6 months. In the meantime, they receive all-round services from the staff at the BMC Center for Infectious Diseases. This is helpful because most patients in the clinic are covered by Medicare or Medicaid and have several competing priorities, such as: B. Housing, transportation, insurance navigation, and immigration assistance.
Still, the results represent only 61% of patients in a small cohort complicated by the coronavirus pandemic that changed treatment approaches. However, Ruiz said the results show that instant ART is a great tool to expand the toolbox for HIV care when clinics can support their patients’ other needs as well.
“It’s generalizable to clinics that look like ours,” she said. “Clinics could use doctors, pharmacies, and case management to deliver this tool to patients.”
A backbone for Rapid ART
Prior to the start of the Direct Access to Anti-Retroviral Therapy (DAART) program, the average care enrollment was more than 2 weeks – which was better than the U.S. Centers for Disease Control and Prevention goal of 30 days, but higher than wanted by Ruiz and the team.
So they returned to their community and asked patients, clinicians, nurse navigators, sexually transmitted infection counselors, and outreach workers what issues existed in their program of linking up with care. They also conducted a literature review of other so-called red carpet programs that might provide best practices. One of the main obstacles they identified was the disparity in the prescribing of ART by clinical providers. Some prescribed on the same day. Others waited for the patient’s virus genotyping to come back.
They realized that they needed to standardize ART initiation. So they went back to the pharmacy and checked the virus suppression data for the clinic’s 1,600 patients, focusing on the genotypic profile.
They found that the HIV in their area responded best to a combination of bictegravir, emtracitabine, and tenofovir alafenamide (Biktarvy), which was their first choice. The alternative was darunavir and cobicistat with emtracitabine and tenofovir alafenamide, which were sold as a single pill called Symtuza.
Then they did a chart review to see who might qualify for the program and offered it to them. In doing so, they also conducted a general admission for the patients, including a review of the Massachusetts Department of Public Health’s severity scale and linking the patient to immigration, transportation, housing, and other support activities that might aid medical care.
DAART was introduced in February 2019. Since then, 61 patients have qualified for DAART, which means they have been treated naively – either newly diagnosed or with a known diagnosis of HIV with no history of treatment and concomitant drug use, or otherwise at high risk for the transmission of the virus.
Persons with treatment experience were not suitable for DAART, as were persons with renal insufficiency or co-infections such as opportunistic infections of the active central nervous system.
Of the 61 eligible participants, 37 (61%) were registered with DAART. That number also makes up 45% of the people who were newly diagnosed with HIV at Boston Medical Center during that time.
“The reasons the other patients weren’t enrolled, but eligible, is because they came through the ED, got enrolled, and then they leave [against medical advice] before we can get there, “said Katy Scrudder, MPH, a data quality specialist at BMC.” Another big reason for patients who do not enter is that they have other comorbidities that need to be addressed first. Mental health crises are a major problem for this population. “
Those who were not initially enrolled with DAART were connected to other care facilities and were regularly checked to see how they were doing. Since then, 85% of those who chose not to start ART right away are also on HIV treatment, Diaz said.
Of the 37 patients who chose to start ART immediately – and for whom there is enough data to evaluate follow-up – 36 were permanently on care and use in October 2020, according to Medscape Medical News Drugs busy. The team defined care engagement as at least one follow-up appointment with the doctor and possibly two. Since the program is less than 2 years old and COVID-19 has halted and then changed the way the team works with DAART-qualified people, the team is waiting for more data to see how the results develop.
None of the original 36 DAART patients developed treatment-resistant mutations.
Ruiz attributed the strong commitment to care to the recording team, which reflects the communities they serve in the hospital – the majority are colored people, 20% recover from alcohol or drugs, 5% live with HIV, the staff speak eight total Languages, and many come from the immigrant communities most commonly BMC.
And she added that giving medication to a patient on the day of ingestion is likely to place HIV in the chronic disease category to which it belongs.
“If you have diabetes or high blood pressure, we will prescribe medication – and if we have to titrate them on the way, we will titrate them on the way,” she said. In DAART they do the same with HIV. “It helps the patient feel better and cope with the new diagnosis.”
No pill for Will
The individual original patient who does not receive ART is cared for with their primary care provider. However, according to Ruiz, the patient refuses to have discussions about his or her HIV care or accept HIV prescriptions.
This is where the patient-centered approach in the clinic becomes essential, said Ruiz. The clinic’s multidisciplinary nature includes clinicians who are experts in refugee health and care, escorting patients to the pharmacy, collecting medication for the patient, or guiding them through insurance navigation.
But this one case presents a truth clinicians struggle with: achieving virus suppression is not always a patient’s goal, and even if it does, some patients will never get there, said Larry Scott-Walker , Co-Founder and General Manager of Thrive SS HIV service organization in Atlanta, Georgia.
To combat stigma, clinicians must put the patient’s goals before their own goals for virus suppression.
“Clinicians are trained to focus on virus suppression, but it is a science to engage with a patient in a way that enables them,” he told Medscape Medical News. He pointed to motivating interviews and conversations with his colleague Leisha McKinley-Beach, an HIV counselor. They may not talk about HIV at all in their 15-minute discussions, but they keep him motivated to “eat a bowl of broccoli and take my ARVs”.
As he put it in another USCHA 2020 presentation, there is no pill to increase a person’s will.
“My whole life is important,” said Scott-Walker, not just his viral load. “We vendors need to train ourselves not to make everything dependent on a pill, a magic pill, because the truth is there could be a cure for HIV and some people won’t get it because they are valued or devalued feel.”
“It’s important that we make sure our team reflects the people we serve,” she said. “And that’s why it’s important to do everything possible to establish that human connection very early in the process.”
United States Conference on HIV / AIDS: Workshop Session 4: Evaluating the AART Program: Solutions to Barriers to Rapid HIV Treatment. Workshop Session 4: Viraemia, Vulnerability and Victory: The Black Experience with HIV. Presented on October 21, 2020.
Heather Boerner is a scientific and medical reporter based in Pittsburgh, Pennsylvania.
For more news, follow Medscape on Facebook, Twitter, Instagram and YouTube.