A study published in the journal AIDS in May adds to the body of evidence concluding that starting antiretroviral therapy (ART) early—ideally, upon HIV diagnosis—significantly reduces the time to viral suppression. JumpstART, a program in New York City’s public Sexual Health Clinics designed to expedite HIV treatment initiation, provides newly diagnosed patients with a 30-day supply of ART on the day of diagnosis, plus linkage to HIV care.
The retrospective cohort study looked at newly diagnosed Sexual Health Clinic patients between November 2016 and September 2019 and compared 230 JumpstART and 73 non-JumpstART patients to assess how many had achieved viral suppression. Three months post-diagnosis, 83% of JumpstART patients achieved viral suppression, versus 45% of non-JumpstART patients. Among the virally suppressed in both groups, the median time to viral suppression was 31 days (JumpstART) and 95 days (non-JumpstART).
Researchers noted that clinic staff make efforts to provide benefits navigation, counseling, and active linkage to HIV providers in the community for ongoing HIV care so that patients can have uninterrupted access to daily medication after finishing their Sexual Health Clinic–provided 30-day supply. But even those JumpstART patients who were not linked to care within one month of diagnosis also showed a shorter time to viral suppression, according to researchers.
The study did not include follow-up of patients, but there are plans to assess durable viral suppression among a cohort of patients enrolled in same-day ART initiation using citywide HIV surveillance data, said study co-author Preeti Pathela, Dr.P.H., M.P.H., director of Research and Evaluation at the New York City Department of Health and Mental Hygiene’s Bureau of Sexually Transmitted Disease Control.
It’s not the first study to conclude that immediate initiation of ART can pay dividends for those newly diagnosed with HIV. The results of the START study in 2015 revealed that immediately starting ART improved measures of health and reduced the risks of infections and cancer. Similarly, a study from San Francisco’s Ward 86 in 2019 showed that rapid ART initiation resulted in viral suppression for more than 90% of patients after one year.
Other studies have found that within several months of initiating ART, the amount of HIV found in the blood is so low it can’t be detected through routine lab tests. Being “undetectable” is currently the gold standard for HIV care, because it ensures better health and the inability to pass HIV to a sexual partner. The Centers for Disease Control and Prevention (CDC) also recommends rapid initiation of ART for those newly diagnosed with HIV.
Clinics May Face Obstacles to Rapid ART Initiation
Pathela and colleagues noted in their May paper that shortening the time to viral suppression is the “shared responsibility of HIV testing sites, health departments, Ryan White program administrators, HIV clinics, and case management organizations.” According to Pathela, having on-site medication and efficient coordination between staff (i.e., navigators, clinicians dispensing ART) is key to streamlining what can be a bureaucratic and time-consuming process in getting patients on ART right away. “It is possible for other clinics to do this as well, if they have appropriate numbers of trained staff, an established network of community providers to accept referred patients, and resources for the purchase of medication,” said Pathela.
“Increased co-location and integration of services, improved screening in diverse settings, and enhanced referrals to services through established partnerships such as the Health Department’s PlaySure Network and Ryan White Part A program are key to facilitating access to health care and improving health outcomes among people affected by HIV,” she said.
But not every clinic has the resources to streamline the process of getting patients started on ART right away, said Tavell Kindall, Ph.D., D.N.P., APRN, FNP, a family nurse practitioner and director of HIV Prevention and Treatment at St. Thomas Community Health Center in New Orleans. According to Kindall, the JumpstART research is inspirational for clinicians who can initiate immediate ART, but he warned that some clinics, especially those without good AIDS Drug Assistance Program services or expanded Medicaid under the Affordable Care Act, may not have the resources to support someone newly diagnosed.
“We’re fortunate, in this clinic,” said Kindall. “Many patients have Medicaid, and Louisiana Medicaid covers ART and HIV care, but we’re surrounded by Southern states that don’t. And I have primary care providers screening everyone for HIV who comes through the door, unless they opt out. If they’re positive, they will refer the patient to me. I can walk downstairs and get them started [on ART] right away.”
Kindall noted that St. Thomas has case managers, HIV linkage coordinators, and Ryan White coordinators all on the same team at the same location.
Beyond effective coordination at sexual health and HIV clinics, people who get positive diagnoses from primary care doctors need clear information on where to go next, and that doesn’t always happen, said Kindall. In fact, it’s unlikely that a primary care doctor will even recommend HIV testing unless a patient asks for it. According to the most recent data, although the CDC has recommended opt-out HIV testing for primary care doctors, the number of doctors actually doing that is extremely low.
The best case scenario: A primary care doctor will ask patients if they want an HIV test. Then, if they test positive, the doctor will know exactly where to send them, because there is already a relationship with staff at an HIV or sexual health clinic. “What I hear is, doctors are afraid to tell patients that they’re [HIV] positive, and they’re not even comfortable talking about sexual health,” said Kindall. “They don’t even know when patients are at risk.”
More information about the New York City Ending the Epidemic Plan, including select initiatives, is available on the city’s website.