At the at the International Conference on HIV Treatment and Prevention Adherence in Miami on June 19, Whitman-Walker Health presented a poster showing their intial evaluation of a same-day-start antiretroviral therapy (ART) program, which led to their adopting the program as a part of their service delivery program.
Whitman-Walker Health, a federally qualified health center in Washington, D.C., piloted a program called Fast Forward, which offered same-day ART start to newly diagnosed patients. The pilot program ran for a year, from November 2017 to October 2018. After spending some time getting buy-in from staff and creating a protocol for people who wanted to start treatment on the same day as their HIV diagnosis, they launched.
"What is already known is that people have decreased morbidity and mortality when they start sooner on medications," said Heather Alt, BSN, RN, ACRN, CPH, deputy director of nursing at Whitman-Walker Health. "But we also knew anecdotally it's something we'd hear from patients. They'd say, 'I want to start meds today. Now what?' And that hadn't been a reality until recently."
Over the evaluation period, 36 people chose to enroll in the Fast Forward program, while 31 people received treatment per the standard-of-care. Both arms were majority people of color, and over 75% of participants in both arms were age 34 and under.
In Whitman-Walker's standard of care, when people are diagnosed with HIV, they meet with their care team the same day and receive a blood draw for resistance testing and other tests to determine the best ARV regimen -- a process that can typically take one to three weeks. In Fast Forward, when people were diagnosed, they would meet with their care team and be asked if they'd like to start treatment the same day. If they decided to start, they were sent home with a supply of medications and a follow-up appointment.
"We're very much putting the patient in the driver's seat," said Alt. "If folks didn't feel ready, we would not push them to start."
The results showed that there was no statistical difference between arms when looking at the time to viral suppression or engagement in care. But the authors note that the similar outcomes in both arms may be due to the fact that Whitman-Walker and Washington, D.C. have implemented a "Red Carpet" program for people with HIV to be able to better keep people who are newly diagnosed in care and on ART.
The Red Carpet care program was established by Whitman-Walker in 2008 to help newly diagnosed people living with HIV get connected to care and any additional services they might need as quickly as possible. This replaced a scenario in which people were diagnosed, sent home, and expected to follow up with phone calls and paperwork to get insured and make a doctor's appointment that could be weeks or months away. And some people would be in denial or fear of their diagnosis and would simply not come back. When D.C. was getting national attention for having the worst HIV epidemic in the United States, it adopted Whitman-Walker's Red Carpet program citywide in 2010 as a way to increase engagement in care and viral suppression. Many people credit it with helping to reduce HIV transmission in the district. In a 2017 interview with Pew Charitable Trusts, Channing Wickham, executive director of the Washington AIDS Partnership, said that the Red Carpet program helped turn D.C.'s HIV epidemic around.
"D.C. was a national embarrassment in terms of our HIV rates, really by almost any measure," he said. "If we can turn things around in 10 years, then any jurisdiction can do it -- if they have the will to do it."
The poster reported that more analysis of the program will be done in the future on issues like time to viral suppression, predictors of engagement in care, and an evaluation of people who started care at Whitman-Walker after the first year of the Fast Forward program, to determine how the implementation of the program impacted their standard of care overall.
"Even though we don't yet have enough data to properly analyze for statistical significance, we are eliminating the time that a patient is sent out the door wondering how they are they are going to get medications, and what starting treatment is going to be like, which is extremely impactful," said Alt.