Transcript Grant Colfax - Institute of Medicine

Offering ARV Treatment to All
HIV-infected Persons in San Francisco
Grant Colfax, MD
Director of HIV Prevention and Research
San Francisco Department of Public Health
Institute of Medicine HIV Screening and Access to Care Workshop
June 21, 2010
 Offer antiretroviral therapy to all HIV-infected
individuals unless there is a reason not to
 Decision to start ART made by patient in conjunction
with the provider
 Old paradigm: Drugs are toxic so defer therapy as long
as possible
 New paradigm: Although new drugs are not
completely benign, they are less “toxic” than the virus
 Rather than treating only when there was a strong
reason to treat, the default is now to treat unless
there is a strong reason not to treat
 CD4 <500 vs. >500 (n = 9,155)
 Relative risk 1.94 (95% CI 1.37-2.79) of death
 CD4 <350 vs. 350-500 (n = 8,362)
 Relative risk 1.69 (95% CI 1.26-2.26) of death
Risk for death decreased if therapy started
when CD4 > 500
Kitahata, et al., NEJM, 2009
 HIV replication leads to liver, cardiac and renal
disease
 HIV replication is associated with increased risk for
malignancies and declines in neurocognitive function
 ART is associated with reduced risk of these non-AIDS
complications
Viral replication can do more damage than drug side effects
HIV Prevalence, by Region and Subgroup
35
Prevalence (%)
30
25
20
15
10
5
0
Adapted from: El-Sadr, et al., NEJM, 2010
Parameters
2004 (%)
2008 (%)
Among MSM, HIV Test in Last 12 mos.
65
71
HIV-Positive People Unaware of Status
24
15-20
Linkage to Care
88% (2006–2007)
Engaged in Care
71
78
ART Coverage (PWA)
74 (2005)
90
Virologic Suppression
52 (2005)
72
100%
92%
% Receiving ART
88%
87% 87%
90%
80%
93%
92%
88%
88% 86%
89%
84%
84%
93%
92% 92%
87%
90%
85%
86%
89%
80%
90% 88%
87% 87%
80%
70%
60%
50%
40%
30%
20%
10%
0%
High Level Estimate*
Low Level Estimate
*Top value of percentage (including the gray area) indicates the proportion of ART use after excluding persons who were
lost-to-follow-up.
100%
% Receiving ART
90%
80%
70%
60%
50%
40%
70%
30%
74%
71%
60%
65%
61%
73%
69%
60%
66%
59% 62%
20%
10%
0%
*Shaded areas indicate patients who are known to have started ART but the type of ART does not refer to the highly active
antiretroviral therapy (HAART) or such information is not available.
Charlebois, CROI, 2010
Donnell, et al., Lancet, 2010. Abstract #136.
Das, et al., PloSOne, 2010
GROUP
Avg. Expend $ Clients
per Client
% Clients
ADAP Only
$13,572
1,986
44.68%
Medi-Cal
$6,349
67
1.51%
Private Insure $2,784
957
21.53%
Medicare
$3,288
1,435
32.28%
TOTAL
$7,820
4,445
100.00%
Source: California State Office of AIDS
CD4 Count: 350-500
CD4 Count >500
ART
Number (%)
Number (%)
Yes
1,097 (60%)
748 (48%)
No
753 (40%)
825 (52%)
 Over last 12 months
 2,621 patients seen
 2,169 (83%) already on ART


452 not on ART
1,685 (78%) of those on ART have undetectable HIV viral load



Resistance
Non-adherence
Recently started ART – not undetectable yet
 In 2009, there were 501 new patients to PHP
 Average CD4 = 426
 124 (25%) were on ART at first visit (average CD4 = 375)
 302 (75%) not on ART (average CD4 = 442)
Courtesy of Brad Hare
 Use electronic medical record (HERO) to capture
medication prescribing, medication switches and
laboratory response to treatment (CD4 and viral load)
 myHERO – patient portal, new features
 Annual patient satisfaction survey
 Monitor for patients lost to follow up or dropping out
of care

Referred to outreach team for support and engagement
 Active surveillance for resistance
 Collaboration with UCSF virology lab
Courtesy of Brad Hare
 Primary care provider (NP, Int Med, FP, ID/HIV)
 Social workers
 Screening and referral for substance use or mental health
concerns (HIV Specialty Psychiatry/Psychology)
 Housing, disability, benefits (including ADAP enrollment)
 Pharmacist lead ART adherence program
 1:1 assessments of barriers, education, medicine reviews,
ongoing monitoring
 Patient education program and support groups
 Linkage to care team
 Patient information sheet
Courtesy of Brad Hare
100
90
80
75.75
75.68
77.19
70
78.78
80.54
80.03
82.09
83.83
84.32
68.62
60.46
60
54.91
56.39
58.69
60.05
59.14
54.51
% on ART
50
48.15
40
30
20
10
0
Q1-08
Q2-08
Q3-08
Q4-08
Q1-09
Q2-09
Q3-09
Q4-09
Q1-10
% Undetectable
Caveats and Challenges
 Treatment decisions to benefit individual
 We hope for secondary prevention benefits
 Emphasis on changing provider behavior

Clinical guidelines don’t necessarily change practice

Pendulum has swung between early vs. deferred treatment several times

Many providers in SF have lived through eras of single, dual, early treatment

We don’t know the best way to encourage providers to adopt guidelines
 In communities with more limited resources, it may not be possible to treat all

But we need to change our thinking about tolerating “a little bit” of virus

We don’t deny medications for many other chronic diseases where beneficial outcomes are
relatively small or unknown
 Community response

In SF, general support

Some patients will refuse tx; that’s OK, if risks/benefits are made clear

Conspiracy theories must be addressed
Testing and treating alone will not
eliminate the epidemic…
Coates, Lancet, 2008
Acknowledgements and Thanks
 SFDPH
 Moupali Das
 Mitch Katz
 Sharon Pipkin
 Susan Scheer
 Michaela Varisto
 UCSF
 Steve Deeks
 Brad Hare
 Diane Havlir
 Jeff Sheehey