Hiroyu Hatano describes herself as a regular doctor who takes care of HIV and AIDS patients. Yet as an infectious disease specialist with expertise in HIV cure research, she has played an important role in ensuring that individuals recently infected with HIV receive the best clinical care not only to ensure healthy lives, but also to prepare them for treatment in a future where a cure for HIV exists.
While working at Ward 86, the HIV clinic at San Francisco General Hospital, Hatano developed and implemented a clinical program called the Rapid Antiretroviral Program Initiative for new Diagnoses—or RAPID, for short. Since its recent inception in July 2013, RAPID has ensured that dozens of individuals newly diagnosed with HIV have been immediately linked to HIV treatment and care.
Specifically, RAPID makes it possible for individuals diagnosed at San Francisco General Hospital or community testing sites such as Magnet or City Clinic, to be seen at Ward 86 on the day of diagnosis. Once referred to Ward 86, individuals meet with Hatano or one of the other HIV attending specialists with expertise in acute HIV. Hatano explains that she takes the time to go over why treatment is important to start immediately, and if the individual agrees to start treatment, he or she is provided with a “starter pack” treatment regimen on-site and takes the first dose of antiretroviral therapy (ART) at the clinic.
This early treatment is critical to ensure the best possible outcomes for CD4 cell count recovery and immune system health. In addition, early ART start, as close to the infection as possible, also benefits the community. Early viral load control with ART helps to decrease the likelihood that individuals will transmit HIV to others during a time when they are highly infectious, says Diane Jones, RN, a nurse at the University of California, San Francisco (UCSF) Positive Health Program at San Francisco General Hospital.
In addition to health benefits conferred by early treatment, this early linkage to care may make it more likely that individuals are engaged and retained in care—an important piece of ART treatment adherence.
“It used to be that if you tested positive, one person would disclose your test results to you, another person would meet you for your initial clinic visit, and then you would meet the doctor that would become your regular doctor,” explained Hatano. The problem is that individuals can be lost from care between each step of the existing process. RAPID emphasizes linkage to care and continuity of care. The goal is for the first provider that individuals see to become their regular long-term provider.
But, perhaps the most exciting benefit of RAPID is its implications for treatment at a time in the future when HIV has a cure. Hatano based RAPID’s development in part on research related to eradicating HIV from the body by focusing on decreasing HIV “reservoirs,” areas where HIV persists in the body even during ART treatment. A number of recent studies have demonstrated the importance of timely ART treatment in preventing the growth of HIV reservoirs, which, once established, are difficult to reduce in size by existing treatments.
And by timely, Hatano means that even a few days can make a big difference.
“Recent research has shown that if you’re treated within a week, versus two weeks, versus three weeks, that changes how big your reservoir is, how much your total body burden is of HIV. And that’s quite new. We had a sense that earlier treatment was better, but we didn’t have a sense that days really mattered.”
Hatano predicts that using early treatment to stunt the growth of HIV reservoirs will be one part of the multifaceted strategy that will be used to cure HIV. Early treatment increases the likelihood that future treatments will be able to rid reservoirs from the body altogether.
“We’ve come to understand that curing anybody is going to require a multi-pronged approach—it’s not going to be one magic pill,” explained Hatano “I think any approach is going to require very early treatment. If we’re aiming for cure strategies down the line, then obviously we want to set people up for the best opportunity to potentially do that in the future.”
Dr. Diane Havlir, chief of the HIV/AIDS Division at San Francisco General Hospital, notes that, “On an individual level, there’s some data that suggest lower reservoir [leads to] fewer long-term complications” and raises the possibility that “people might be more ready for cure interventions.”
Hatano is quick to credit the context in which she was able to develop and implement RAPID, including the support of her dedicated colleagues in HIV treatment and research, the existing treatment strategies at Ward 86, and the community of San Francisco.
“In some ways, this has been possible because we’re in San Francisco. I think a critical piece is that the community is behind us. There has been a long-standing relationship between the community and Ward 86. There’s a lot of trust that’s been built up. We already had a program called PHAST [Positive Health Access to Services and Treatment], which was staffed by nurses, nurse practitioners, and social workers to help people transition from testing positive to getting into care. So there were so many pieces that already existed which really allowed, I think, this to happen here so quickly.”
Hatano has observed a surprising, yet encouraging response to RAPID from patients themselves. She and other clinicians initially worried that patients might not be ready for such an overwhelming experience on the same day of their diagnosis. Yet she notes that because the clinicians are able to tailor each conversation based on the individual needs of each patient and what they’re ready for, “the response has been overwhelmingly positive from a patient perspective. Patients have said to us, ‘at least I’m doing something about it now.’ We didn’t anticipate that response, but it’s always rewarding when we hear that.”
While there are likely individual providers or medical groups already starting individuals on ART as early as possible, barriers do exist that may prevent RAPID from becoming an official clinic initiative in many areas.
“There are a lot of pieces that need to be in place for this to happen. You have to have the right test out there to diagnose people with acute HIV. You have to have patients be willing to start medicines, you have to have doctors willing to carry pagers so that they’re always available when there’s a new diagnosis. You have to have doctors that buy into the research that’s coming out and believe in the importance of this.”
Yet, looking forward, Hatano is hopeful that RAPID program, or initiatives like it, will increasingly be implemented in new cities as awareness builds about the importance of early treatment. She notes that as she has spoken about RAPID locally or at conferences, “there’s certainly been interest in doing this elsewhere.”
Have you seen how the RAPID program is making a difference in our community? Share your thoughts in the comments below!
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