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Topics, Trends & Updates
August 2016
New HIV Testing Guideline
On July 13, 2016, the HIV Clinical Guidelines Program (NYSDOH AIDS Institute) published a new guideline, HIV TestingTopics addressed by the HIV Testing guideline include the following:

Hot Topics
Trends: Top 5 Guidelines in July
Update: What We're Reading
Successful Same-Day ART Initiation with a Complex Patient Population
Christopher J. Hoffmann, MD, MPH, Johns Hopkins University

A move to test and initiate treatment on the same day will require changes in traditional approaches to HIV management. Those changes may include restructuring clinic services and identifying individuals who are the best candidates for immediate antiretroviral therapy (ART) initiation. A recent article (Pilcher et al. PMID: 27434707) describing immediate ART initiation by the San Francisco General Hospital outpatient HIV clinic provides insight into both issues.

Beginning in July 2013, the clinic began to offer same-day ART initiation with a protocol called RAPID. During the entire reported period (6/2013 to 12/2014), only patients lacking private insurance were eligible. In the first 6 months, eligibility for RAPID care was also limited to patients with acute or recent HIV infection, but criteria were liberalized after January 2014. Patients were referred from outpatient clinics and HIV testing centers in San Francisco, and taxi vouchers were available for patients to be transported from across the city. 

The RAPID protocol provided same day HIV education, blood draws for laboratory testing, accelerated insurance approval efforts, and a directly observed first ART dose. Patients for whom insurance approval was not obtained were given a 5-day starter-pack. This process took 3 to 4 hours. Within the 7 days after the initial visit, a nurse followed up by phone.

During the 18 month study period, 39 patients who would be considered "complicated" in most treatment settings were initiated on the RAPID protocol (2 patients per month). Patients' CD4 counts ranged from 3 to 1391 cells/mm3, 27% were considered homeless, 42% had a "major" mental health disorder, and 42% reported use of any illicit substance. Despite these challenges, 37 patients (95%) initiated ART within 24 hours of their clinic visit. Approximately 90% had a viral load <200 copies/mL within 6 months after clinic referral. Only 4 (10%) were lost from care (no visit in a 6 month period); 8 (20%) transferred care to another clinic.

Although limited by its very small sample size and low volume of patients during the observation period (2 patients per month), this report is valuable for its description of a same-day ART initiation program that succeeded with complex patients. With the right clinical resources, these results suggest that most people living with HIV can initiate ART rapidly with success. This report also underscores that ART should not be delayed automatically because of mental illness, substance abuse, and/or unstable housing. 
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HIV Clinical Guidelines Program 
New York State Department of Health AIDS Institute
In collaboration with the Division of Infectious Diseases
Johns Hopkins University School of Medicine

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