Implementing an HIV Test and Treat Rapid Response Anti Retroviral Initiation Program in a Southern City with High HIV Incidence

Abstract Background Early initiation of antiretroviral (ART) after HIV diagnosis (Test and Treat Rapid Response, TTRR) is safe and acceptable, shortens the time to virologic suppression, reduces HIV associated morbidity and mortality, and can potentially decrease HIV transmission. Miami Dade County is first in the US for HIV incidence. As with other cities in the South, barriers to routine HIV care result in delays in engagement in care. The average time from HIV diagnosis at the Florida Department of Health (FDOH) STD clinic in Miami to ART initiation is 60 days. The University of Miami, in collaboration with the FDOH, implemented a pilot HIV TTRR program in 2016 whose aim is to speed up the process from initial HIV diagnosis to initiation of ART. This study describes enrolled patients’ demographics and the time to ART initiation in the first year of implementation (March 2016–February 2017). Methods When an individual is diagnosed with HIV at the FDOH STD clinic, a TTRR team consisting of a Disease Intervention Specialist, Patient Navigator, Case Manager, and HIV Provider, is activated. This team ensures that: 1) a visit with an HIV provider occurs within 48 hours; 2) ART is prescribed as soon as possible (1–7 days from diagnosis); and 3) provision of ART and appropriate follow up occurs at the initial visit. Demographics, laboratory results, and time to ART were recorded and summarized Results In one year, 45 patients were enrolled (73% male, 27% female); 70% of male were MSM. A majority were foreign born (32% Cuba, 24% Haiti, 18% other Hispanic countries), and from ethnic minorities (53 % Hispanic, 30% African American). An HIV Provider evaluated 48% of the patients the same day of HIV diagnosis; 88% within 48 hours. The mean time to ART initiation was 6 days (37% same day, 69% <7 days). FTC/TAF/EVG/c was most frequently prescribed (91%). The mean viral load at initial presentation was 4.32 log10 (SD=1.1). The mean CD4 count was 463 cells/mm3 (SD=263); 20% had less than 200 cells/mm3. All but one patient came to the next consecutive appointment. Conclusion Implementation of a TTRR program is feasible in cities with recognized barriers to HIV care. TTRR programs should be essential components of HIV prevention efforts to control the spread of the HIV epidemic in the South. Funding from P30A1073961 and H97HA27433. Disclosures All authors: No reported disclosures

Multilevel Determinants of Rapid Antiretroviral Treatment Implementation and Demand in Miami-Dade County

Rapidly linking newly diagnosed HIV patients to antiretroviral treatment (ART) is the best practice for achieving optimal treatment outcomes, including viral suppression. However, rapid ART implementation varies throughout the United States, highlighting the importance of identifying rapid ART implementation determinants in US HIV epicenters, such as Miami-Dade County (MDC). Clinic focus groups (N = 4 clinics) and patient interviews (N = 31 recently diagnosed patients) systematically and qualitatively assessed rapid ART implementation determinants in MDC. Independent coders analyzed focus groups and interviews using a directed content analysis approach guided by the Consolidated Framework for Implementation Research. For clinic stakeholders, key rapid ART implementation determinants included the following: complexity and adaptability (innovation characteristics); networks between clinics and patient needs rooted in structural inequities (outer setting); leadership and available resources (inner setting); staff/provider flexibility (characteristics of individuals); and appointing patient navigators and champions (process). For patients, key determinants included complexity and relative advantage of rapid treatment (innovation characteristics); patient needs and clinic networks (outer setting); provider knowledge and skills (inner setting); provider warmth and affirmation (characteristics of individuals); and need for improved outreach (process). Multilevel factors impact clinic implementation and patient demand for rapid ART in MDC. Informed by these factors, we identified potential implementation strategies to enhance rapid ART implementation throughout MDC. These implementation strategies can be tested in an implementation trial, enhancing the toolkit of strategies to ensure that evidence-based tools, particularly rapid ART, are readily available to the most impacted communities

Implementation of an Immediate HIV Treatment Initiation Program in a Public/Academic Medical Center in the U.S. South: The Miami Test and Treat Rapid Response Program

Test and Rapid Response Treatment (TRRT) linkage programs have demonstrated improved HIV suppression rates. This paper describes the design and implementation of the Miami TRRT initiative and its clinical impact. Assisted by a dedicated care navigator, patients receiving a reactive HIV rapid test at the Florida Department of Health STD Clinic were offered same-day HIV care at the University of Miami/Jackson Memorial Medical Center Adult HIV Outpatient Clinic. Patient retention and labs were tracked for 12 months. Of the 2337 individuals tested, 46 had a reactive HIV test; 41 (89%) consented to participate. For the 36 patients in continued care for a year, 33 (91.7%) achieved virological suppression (< 200 copies/mL) within 70 days of their reactive HIV rapid test; at 12 months, 35 (97.2%) remained suppressed, and mean CD4 T cell counts increased from 452 ± 266 to 597 ± 322 cells/mm . The Miami TRRT initiative demonstrated that immediate linkage to care is feasible and improves retention and suppression in a public/academic medical center in the U.S. South

HIV medical providers\u27 perceptions of the use of antiretroviral therapy as nonoccupational postexposure prophylaxis in 2 major metropolitan area

INTRO: In 2005, the Centers for Disease Control and Prevention expanded its recommendation of post exposure prophylaxis (PEP) use in the workplace to include non-occupational exposures (nPEP). The availability and extensive use of nPEP has not achieved widespread acceptance among health care providers of high-risk populations, and public health and primary care agencies have been sparse in their implementation of nPEP promotion, protocols, and practices. METHODS: We conducted a survey of HIV providers (n=142, response rate = 61%) in Miami-Dade County (Florida) and the District of Columbia (DC) that focused on their knowledge, attitudes, beliefs and practices related to the delivery of nPEP. We then analyzed differences in survey responses by site and by history of prescribing nPEP using bivariate and multivariate logistic regression. RESULTS: More DC providers (59.7%) reported ever prescribing nPEP than in Miami (39.5%%, p < 0.048). The majority of practices in both cities did not have a written nPEP protocol and rarely or never had patients request nPEP. Multivariable analysis for history of prescribing nPEP was dominated by having patients request nPEP (OR = 21.53) and the belief that nPEP would lead to antiretroviral resistance (OR = 0.14), as well as having an nPEP written protocol (OR = 7.49). DISCUSSION: Our findings are consistent with earlier studies showing the underuse of nPEP as a prevention strategy. The significance of having an nPEP written protocol and of patient requests for nPEP speaks to the importance of using targeted strategies to promote widespread awareness of the use of HIV antiretroviral medications as a prevention intervention