Linkage and Antiretroviral Therapy Within 72 Hours at a Federally Qualified Health Center in New Orleans

While HIV incidence declines nationally, the Southern United States remains disproportionally affected. New Orleans ranks third in the United States for the rate of new HIV infections. Previous studies in San Francisco, Haiti, and South Africa have shown that immediate initiation of antiretroviral therapy (ART) leads to earlier virologic suppression, increased retention in care, and decreased mortality. Further, the publication of three influential studies showed no linked transmission events in patients when ART results in viral suppression. Scientific advances demonstrate that effective treatment with ART prevents sexual HIV transmission. The Centers for Disease Control and Prevention has endorsed the concept of U = U (undetectable = untransmittable.) The Federally Qualified Health Center (FQHC), CrescentCare, partnered with the New Orleans Office of Health Policy, to start all newly diagnosed patients on ART within 72 h of diagnosis. The CrescentCare Start Initiative (CCSI) enhances navigation, expedites clinic intake, and initiates immediate ART. CCSI started on December 1, 2016, and in October 2017 underwent an analysis comparing the first 8 months to a matched cohort. A Standard Operating Procedure (SOP) was disseminated agency wide, including training sessions for all providers. CCSI optimized provider availability and the navigator scheduled patients into any available slot. The intervention leveraged existing CrecentCare-run HIV testing sites, its sexually transmitted diseases (STD) clinic, and informed the clinic’s referral network. A navigator was available 24 h per day to coordinate linkage of new diagnoses. The intake process for CCSI was streamlined for a focused HIV visit with a treating provider. Initial visit was 30 min. The first dose of ART was directly observed. Providers were encouraged to use tenofovir alafenanide/entricitabine (TAF/FTC) + dolutegravir as the initial regimen. It was chosen for the regimen’s effectiveness, tolerability, and empiric coverage of hepatitis B, and approved use in patients with a creatinine clearance greater than or equal to 30 mL/min. After the visit, baseline HIV labs were drawn, and patients saw case management, behavioral health, and eligibility specialists when indicated. A medical checklist was developed to standardize workflow. All primary-care providers committed to seeing patients for the initial visit. Referral was then made to an HIV specialist for on-going management. Labs were reviewed within 48 h. An HIV specialist regularly reviewed patient encounters. Follow-up appointments were made within 4 weeks and were longer in duration. The patient navigator assisted with all appointments through the second provider visit. The provider or patient could decline therapy through shared decision making. In October, CCSI was compared to a cohort from the previous year. The comparator group tested positive at CrescentCare community testing sites and used the same navigator to minimize confounders. The 29 patients in the cohort saw an HIV specialist for their initial visit and were started on an integrase-based initial regimen (Table 1). Viral suppression was defined as an HIV RNA less than 200 copies/mm. Time to suppression was defined as days from diagnosis to viral suppression. All patient information and data points were complete through October 6, 2017. For patients who transferred care, the last viral load was used for analysis. Continuous characteristics were compared using Wilcoxon’s rank-sum test, given that normality could not be assumed. HIV viral load was log-transformed before analysis. Pearson’s v test was used to compare categorical variables (Fisher’s exact test when sample size assumptions were not met). Time to suppression (median and 95% confidence interval) was estimated using the Kaplan-Meier product-limit method; the logrank test was used to assess differences in time to suppression between the two groups of patients. Analyses were conducted using SAS software v. 9.4 (SAS Institute, Inc., Cary, NC). Seventy-seven patients with a new diagnosis of HIV were referred to CCSI from December 5, 2016, to August 6, 2017. 92% (71/77) were linked, saw a treating provider, and started ART within 72 h of diagnosis. Four of the six patients not linked within 72 h were linked to care within 30 days of diagnosis. 69% (49/71) were seen within 24 h of diagnosis, and the remainder (31%, 22/71) within 72 h. Tenofovir