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Selected Presentations from CROI 2018
San Francisco RAPID ART Program Halves Span From HIV Diagnosis to Suppression
25th Conference on Retroviruses and Opportunistic Infections (CROI), March 4-7, 2018, Boston
Mark Mascolini

RAPID, a citywide San Francisco program, greatly cut time from HIV diagnosis to (1) HIV care, (2) antiretroviral therapy (ART), and (3) HIV suppression [1]. After RAPID began, overall time from diagnosis to suppression dropped by 54%, from 134 to 61 days.

Because starting ART soon after diagnosis has personal and population-level benefits, in 2015 San Francisco Getting to Zero (SFG2Z) prioritized the Rapid ART Program Initiative for HIV Diagnoses (RAPID). RAPID aims to link all newly diagnosed people to a first care appointment within 5 working day and to start ART at that visit. Public health officials trained staff of HIV clinics in the program, detailed online at http://www.gettingtozerosf.org/rapid-committee/. Researchers used San Francisco Department of Public Health data to record demographics of people newly diagnosed with HIV, time from diagnosis to first care visit, time from first visit to starting ART, and time from diagnosis to viral suppression, defined as a viral load below 200 copies.

The investigators compared findings from 2013 (before RAPID began) to 2016 (after RAPID began). In 2013 and 2016 most study participants were men (90% and 86%) and about one third (33% and 36%) were 13 to 29 years old. Respective racial/ethnic proportions in 2013 and 2016 were 45% and 37% white, 13% and 13% black, 25% and 28% Hispanic, and 13% and 18% Asian/Pacific Islander. Homeless people represented 8% of the 2013 group and 11% of the 2016 group.

From 2013 to 2016, median time to starting care fell from 8 to 5 days (-38%), time from first care to starting ART plunged from 27 days to 1 (-96%), and time from diagnosis to a viral load below 200 copies sunk from 134 to 61 days (-54%). The proportion of people in care within 1 year of diagnosis climbed from 93% in 2013 to 97% in 2016.

With RAPID underway in 2016, clinical sites with the highest proportions of people starting ART within 5 days of starting care were the Municipal STD clinic (78%), Kaiser San Francisco, a large health maintenance organization (71%), the county hospital, and safety net clinics (69%). In 2016 about 40% of people who entered care with newly diagnosed HIV did so at a site that accepted commercial insurance, while about 60% started care at a site that accepted uninsured or Medicaid patients. The researchers believe this finding "highlights the importance of Medicaid expansion to the improvement in ART initiation in San Francisco."

Time from diagnosis to a viral load below 200 copies fell significantly for all groups analyzed, regardless of sex, age, race/ethnicity, or housing status. Among racial/ethnic group, Asians/Pacific Islanders had the shortest time to viral suppression, followed by Hispanics, then whites and blacks.

The researchers concluded that "time from HIV diagnosis to first virologic suppression can be shortened on a citywide basis, using a collaborative multisector approach." They stressed that robust improvements in time to ART and virologic response applied to vulnerable populations such as racial and ethnic minorities and the homeless.
Still, 15% of people diagnosed with HIV in 2016 had not begun ART within 1 year of diagnosis.

1. Bacon O, Chin JC, Hsu L, et al. The rapid ART program initiative for HIV diagnosis (RAPID) in San Francisco. 25th Conference on Retroviruses and Opportunistic Infections (CROI). March 4-7, 2018. Boston. Abstract 93.