Better medications and new strategies help make it possible to achieve our goal of ending the HIV epidemic in Texas. For a person with HIV, antiretroviral therapy (ART) dramatically reduces HIV-related morbidity and mortality. Immediate linkage to care and treatment is essential for someone diagnosed with HIV. Sometimes called “rapid start” or “test and treat,” rapid initiation is a process that connects newly diagnosed people to treatment and medication within a very short time period, ideally one day.
Achieving Together interviewed Dr. Ogechika Alozie, Medical Director of Sunset ID Care in El Paso, Texas, about his experience implementing rapid initiation.
Please tell us about the use of rapid initiation at Sunset ID Care. When and how did it begin?
For us, the conversation around rapid start was something we began entertaining around 2016 or 2017. This was around the time when UCSF made their initial data presentation about their work with rapid initiation. We began to realize that the faster we got someone onto medication, the better. We also had a host of medications that could be given early without any higher risk of resistance. In 2018, we at Sunset ID Care started really thinking about it and got some money from the state and the feds to create our HIV Navigator position. I often talk about PPT: People, Process, Technology. This is what made implementing rapid start possible. We had the person, the Navigator. This role was really important in terms of creating a liaison between the testing location and getting people into care. We worked out the process, which was how we were going to operationalize things. We also had a range of technology available, including an EMR and text message service. So, we decided to try it out. At first, we thought: Should it be a week? Or 72 hours? Then we decided, no, let’s go for (starting medication) the same day. So that’s how we designed the program. The more we tried it, the more our partners, including the health department and county hospital, started seeing the efficiency of being able to diagnose somebody and get them on a pill the same day.
What challenges have you faced in doing this? How have you addressed them?
Initially, the biggest challenge was getting people to believe we could do it. It took a long time to get funding for the Navigator position and other things we wanted to do. The next step was operationalizing it and working out the process. I often tell people that everything doesn’t have to be perfect on day one, but you have to have a direction and you have to have a goal. As you’re going along, every two weeks or month, look at what’s working and what’s not working and tweak things. We would continually adjust until the process was smooth. With our processes in place, fast-forward to COVID times, and we were able to transition quickly to telemedicine.
Establishing relationships was critical to our success. We don’t do testing internally. We’ve never been set up like that – we deliberately set ourselves up as the referral site. We focused on what we thought we could do really well. We wanted to make sure that our partners, especially the health department, understood that we were the go-to for HIV treatment.
Sunset ID Care is a standalone clinic but we partner with Project CHAMPS and we’re all in the same building, so we have the case management side and clinical side co-located. It’s helped us create a really good cohesiveness and work flow to allow us to provide the best possible care for patients.
In terms of patient linkage to care, what have you seen since starting rapid initiation?
The biggest thing is the reality that if you give patients the option and opportunity to engage with healthcare quickly, they will do it. We’ve had this misconception in the past that people need time to be mentally ready for care. And there may be people who are like that. But what we’ve seen time and time again is that people want their care. If you give them a system that works, they will come into that system.
Once upon a time, we in HIV wanted the clinical staff or the case management staff to do the role of the HIV Navigator. It’s possible to take case managers and have them adapt to that role, but anyone who has do that as their part-time job isn’t going to do it as well, because the value of an HIV navigator isn’t just navigating the patient into the system, but it’s creating relationships with outside partners. Historically, we in HIV have failed at partnering with each other. We think one organization wants to eat the whole funding pot. If you focus on what you do well, you can partner with people who do other things on the spectrum. Our organization has specifically and deliberately decided not to grow outside of what we do really well. We bring in partners to extend the services our patients receive. I think that attitude, of wanting to build partnerships and bridges has helped us.
It’s hard to say what the direct contribution of rapid start is to our community viral load. I understand from our data that our community of El Paso, as a whole, is doing well in terms of the spectrum of care and viral suppression. I don’t think it’s a simple cause and effect – I believe in bundles of care. One intervention isn’t the sole intervention that causes anything to change, but when you stack interventions on top of each other, you get a bundle effect that provides improved care, improved cohesion, and hopefully improved patient satisfaction.
What tips or recommendations do you have for other organizations who are interested in implementing rapid start?
It’s a journey. Each organization comes from a different stage in that journey. If you’re starting from scratch, the biggest thing that people need to understand is that inertia paralysis is the biggest problem. People get so freaked out by the process that they never do anything. They put a committee together, they give one or two people a task, and two years later they still haven’t done anything. I tell people all the time that you have to try. You can’t score unless you shoot. Be willing to fail fast. That’s the key. Failure is not the problem. But, if you’ve failed for three years, you’ve stunted the growth of your organization. Be able to fail over 90 days and then pivot. Be willing to look at what happened, what went wrong, and how can it be fixed.
For my physician colleagues, I’d say: Stop trying to be the quarterback. This is more like soccer. We’re all on the playing field, we all have a role. When we start thinking we’re the boss, we become less willing to delegate tasks. You have to allow the clinical pharmacist, the nurse practitioner, the RNs to take on some of the challenges and some of the clinical pieces.
What resources/information do you suggest would be useful for an organization just starting out with implementing rapid start?
Texas DSHS is a great resource. AETCs across the state also provide a wealth of knowledge. They’re able to bring together people from across the state and outside the state as well.
Thank you, Dr. Alozie, for sharing your insights with us! Be sure to check out our previous interview with Abounding Prosperity about their use of rapid initiation.
Dr. Alozie is an infectious disease specialist serving patients in El Paso, Texas. Dr. Alozie is board-certified in infectious disease by the American Board of Internal Medicine (ABIM). He is also board-certified in clinical informatics by the American Board of Preventive Medicine (ABPM), making him one of less than 100 such certified physicians in the state of Texas.
He is a Fellow of the American College of Physicians (ACP). Since 1975, over 35,000 physicians have earned ACP Fellowship, a mark of distinction representing the pinnacle of integrity, professionalism, and scholarship for those who aspire to pursue careers in Internal Medicine
Dr. Alozie received his medical degree from the University of Benin – Faculty of Medicine in Benin, Nigeria. He completed his residency and internship in internal medicine at Hennepin County Medical Center, followed by his fellowship training in infectious disease at the University of Minnesota.
He was recognized as the 2016 “Best Physician in the City” by City Magazine, El Paso. He was also awarded the “Pharmacy Award for Innovative Practice” by the El Paso Pharmacy Association in February of 2018. As an infectious disease specialist Dr. Alozie believes patient care is the most important part of medical care.