Prescribing antiretroviral therapy (ART) soon after an HIV diagnosis is referred to as rapid initiation, or rapid start. Research indicates that rapid ART initiation can improve program outcomes, especially by reducing loss to care in the period before ART. Achieving Together sat down with Dr. Gene Voskuhl, Medical Director at the Resource Center’s LGBTQ Health Clinic in Dallas, Texas, to learn more about his experience with rapid start.
“Rapid start is a critical component of ending the HIV epidemic,” says Dr.Voskuhl, who has created and implemented several rapid start initiatives and believes it is an important aspect of HIV medical practice. “I had to be slapped in the face with this one, I’m afraid.” He admits that he initially needed to be convinced that this was the right direction to be moving. “Rapid start is a good idea for two reasons 1) to make the health of individual better and 2) to decrease viral load in community and to decrease transmissions.”
“I came from a time where we did it systematically and in pieces. Unless people were sick and in the hospital, it was usually months before people with HIV were prescribed medications. We lost a fair number of people to follow-up,” Dr. Voskuhl says. “We had a structural system that wanted to educate first, that wanted to explain what a CD4 is, what a viral load is, so we intentionally developed an education process before people started medication. We also had a system that demanded that the provider see lab results before initiating medications. Rapid start does not need either of those. We still educate and we still assess readiness, we just do it a lot faster. Just not fully at the start. You don’t have to be fully educated before you start a medication, you just have to be eventually educated so you can protect yourself.”
Get Everyone on Board
When asked what it takes to start a rapid start program, he said, “Talking, listening, working on attitudes and being ready.” This is true for organizations, prescribers and clients. Within an organization, it is critical to make sure that all staff – nurses to case managers to frontline staff – understand what rapid start is and what it isn’t. Dr. Voskuhl says communicating the basic ideas to everyone in the clinic of why rapid start is important and why we do certain things as soon as someone calls with a diagnosis is particularly important. “We have become pretty aggressive within our practice. Once we become notified that someone is living with HIV, we have 48 hours to connect them to care.” Dr. Voskuhl notes that there is not a consensus on the specific timing of rapid start. Some say a within a week of the diagnosis, some say 48 hours, and some say the same day. “It depends on your system as to how you can set this up. If someone is in a different county you may not be able to get them started the same day but if they are in the same building, we will work with them on that day.”
Prescribers need to understand the science behind rapid start to be comfortable moving forward. One person can make a big difference. If the physician is uncomfortable starting therapy without seeing the lab results, they might not do it. “For me, I have learned that most of the labs are fairly normal, so I feel comfortable starting someone on a regimen, getting the labs a few days later and making adjustments, if needed. With today’s medications you generally don’t even have to make adjustments once you are able to see the labs, the single tablet regimes are highly effective. It is important to pay attention and get your lab results back pretty quickly,” he says. He adds that while he can prescribe medication based on a confirmatory test, the labs must be at least drawn before someone is put on medication. This is an overall safety issue as well. He also notes that some lab results don’t come back in a timely manner, based on the analysis needed, so rapid start might not be the best for that individual that day.
Patient Responses
While it took some time for Dr. Voskuhl to adopt a new procedure, patients responded positively. “People want the medication that will make them healthier …people want to talk about their options. If you have diabetes you want to get treatment, if you have an infection you want to get it treated, you don’t want to wait two weeks to get started on treatment in those circumstances.”
Dr. Voskuhl can now prescribe a medication for a patient in the clinic at the time he is interviewing them so that the patient can leave the clinic with a medication in hand. He said that this has been a pretty powerful moment for both himself and the patient. “Not everyone does this, but I show them the medication if they are ready and we dose them in the clinic and people can suddenly be in charge of their health care. It’s a subtle shift sometimes but a powerful one.” He reports that people who have started their medication in the clinic come back and he has not seen any dropouts from this. None.
Some people want to wait before they get started, they want to think about it, they want to read a little more or bring someone in with them and he says this is fine. He goes with the patient decision. “Most people are ready to act early on and since the medications are so well tolerated, they take them and go, and they tell me, ‘I didn’t have any side effects so I just keep taking them’.”
Challenges
Dr. Voskuhl acknowledges that there can be challenges to implementing rapid start programs. Some organizations might need detailed protocols or guidance from the state before getting started. He says it’s important to look at how your patients will be accessing their medications – do they have insurance, are they unfunded or will they be on Ryan White? Different authorizations and paperwork can be involved. Another issue is being prepared for having to adjust for health insurance. “If you rush things, sometimes you don’t know what the insurance formulary is and we may give them a sample medication that their insurance is not going to pay for. Then you may have to change the medication down the road which can be problematic.” He is hopeful that moving forward, insurance companies will come on board and that most of the medications will be on their formularies. “There is no reason that we should not be able to access medications quickly for a population that really needs it.”
The Science is Strong
There is strong science behind rapid start, and it is available for those who want to learn more about it. “If you want to serve your patients well, you need to have rapid start as an option. No doubt.” He says there is science that shows that viral load goes down fast with rapid start and there is science that shows retention in care is better with rapid start – all the science is there. “People get to undetectable faster and they’re retained in care better if rapid start is part of your process.”
Dr. Voskuhl ends with, “This is important. If we are talking about ending the epidemic, we have to talk about rapid start as well. You gotta try it. It’s not that complicated and it’s not that hard and it’s definitely for the health of your patients and the health of our community. I just hope people will try.”
Resources
Dr. Voskuhl’s suggests these resources and guidelines for more information on implementing rapid start:
IAS-USA: https://www.iasusa.org/guidelines
DHHS: http://aidsinfo.nih.gov/guidelines
WHO: http://www.who.int/hiv/pub/guidelines/advanced-HIV-Disease/en
For more perspectives on rapid initiation, see these previous Achieving Together posts: Rapid Initiation of HIV Treatment: One Physician’s Perspective and How One Organization Uses Rapid Initiation to Link People from HIV Testing to Care.
Dr. Gene Voskuhl graduated from the University of Oklahoma, where he specialized in infectious diseases and eventually helped launch the University’s HIV Clinic. He later worked at Gilead (the manufacturer of PrEP medication Truvada) as a medical scientist, instructing fellow physicians on how to safely treat LGBTQ patients and prescribe appropriate pharmaceuticals. Volunteering for Resource Center gave him an even deeper insight into the needs of the LGBTQ and HIV populations in North Texas, and further fanned the flames of his passion towards equity in healthcare. He is currently the Medical Director at the Center’s LGBTQ Health facility, which provides affirming and compassionate care in a stigma-free environment.