RAPID INITIATION OF HIV TREATMENT: ONE PHYSICIAN’S PERSPECTIVE

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.

Learn more about Dr. Alozie and read a press release from Health News Today.

El Paso: Strong Means Healing

August 3 marks the one-year anniversary of the mass shooting that occurred at an El Paso Walmart. During this tragic event, 23 people lost their lives and 23 others were injured. The shooting has been described as the deadliest attack on Latinos in modern American history.

In response to the tragedy, El Paso Strong continues to connect community members to services to help them heal. The multi-media campaign encourages victims, families, first responders and the community at-large to seek support when coping with the psychological and emotional effects associated with the shooting.

Specially produced videos, such as the one below, feature local residents encouraging members of the community to reach out and seek help when they need it.

El Paso Strong – Strength Means Seeking Help from EHN on Vimeo.

Image source

The events held in El Paso to commemorate the anniversary of the shooting are expected to focus on healing and kindness. Groundbreaking for the Healing Garden, a reflective memorial honoring the victims, took place on August 2. For “Act of Kindness Day” on August 3, people are invited to help overcome hate by doing a good deed for someone else. Participants are asked to wear white and use the social media hashtag #loveforelpaso and tag @elpasounitedfrc.

Image source

Achieving Together is dedicated to social justice. In our quest to end the HIV epidemic in Texas, there is no room for the hateful and xenophobic rhetoric that motivated this tragic event. Horrific acts of violence such as this are likely “to incite fear in anyone, but especially in Hispanic communities on the border, who are facing additional forms of structural violence.” 

We want to recognize those who lost their lives or were impacted by the shooting and also honor the healing that has occurred during the past year. If we work together, we can dismantle oppressive systems and provide opportunities and freedoms so that people from all communities – including Black, Latino, and LGBTQ communities – can thrive and achieve optimal health and wellness. Will you join us?

Reflections on the Achieving Together Long-Term Survivors Webinar

On June 5, 2020, in celebration of Long-Term HIV Survivors Day, Texas HIV Syndicate member Barry Waller led a panel discussion with three long-term survivors here in Texas. Participants came from across the state and had a combined experience of 88 years of living with HIV: Gary Cooper, Austin; Glenda Small, San Antonio; and Steven Vargas, Houston.

When I tested positive for 1985, there were no services or treatments for HIV – only fear, government indifference, and the threat of being rounded up and quarantined. Friends were dying all around me, friends far more accomplished in life than I had been.

-Gary Cooper

Long-Term HIV Survivors Day, started by Tez Anderson of Let’s Kick ASS (AIDS Survivor Syndrome), in 2014 recognizes the resilience and strength of long-term survivors of HIV. Tez chose June 5 because it is the anniversary of the first reporting of cases by the CDC of what would later be known as AIDS.

Long-term HIV survivors are defined as those who have been living with HIV for more than 20 years. Currently, there are almost 19,500 Texans who have been living with HIV for more than 20 years.  These long-term survivors represent two out of every ten Texans living with HIV.

Hopefully we can get together and do this thing right and become as one and realize that everyone is a human being, and everybody deserves to live, and everybody deserves to have a chance.

-Glenda Small

We want to celebrate the long-term survivors currently living in Texas.  Long-term HIV survivors bring so many strengths with them to the fight to end HIV.  Many also face a number of unique challenges, including medical care, medication, housing, social isolation, and more. 

I had to do my part. I had to step up and use what I learned to help other people. And so I did.

-Steven Vargas

You can watch the webinar here and listen as these three individuals share their unique stories, perspectives, and wisdom:  

Embracing Telemedicine: One Doctor’s Experience

For Dr. Gene Voskuhl, Medical Director at Resource Center’s LGBTQ Health facility in Dallas, Texas, telemedicine started as a means to help rural patients with the added benefit of shortening his own exhausting commute. He now believes that telemedicine serves a broader purpose. When asked how telemedicine is linked to ending the HIV epidemic in Texas, he responded, “Without a doubt, I am convinced that telemedicine is an option for people who have barriers to medical care. Sometimes it is as simple as transportation, time, sometimes it’s kids or family. I am convinced this will increase retention to care and the number of people in treatment.”

Dr. Voskuhl began exploring telemedicine in 2018 when he was working with the Callie Clinic in Sherman, Texas. He lived in Dallas and commuted to Sherman three days a week while also working part time with the Resource Center as they worked to open a new primary care medical program. He loved the people and the patients at the Callie Clinic and wanted to find a way to continue to work with them even after the new Resource Center LGBTQ Health facility was up and running.

In 2019, Dr. Voskuhl attended a two-day training at Texas Tech that provided IT training for telemedicine. That summer, he created a home-built system, which he now refers to as a bit of a “Frankenstein system,” while the CFO/IT staff at the Callie Clinic pulled the in-house telemedicine equipment together. They used a Zoom platform which had patient health information (PHI) encrypted. Patients at the Callie Clinic would go to the clinic and Dr. Voskuhl was able to see them online from his home. That was the beginning! When the Center’s LGBTQ Health opened, Dr. Voskuhl was able and willing to continue to serve his patients at the Callie Clinic using the telemedicine platform.

Once the coronavirus arrived, things began to change. With more barriers in place for patients to physically attend clinic appointments, it became an easy decision to add telemedicine at Resource Center. They had already been exploring the use of telemedicine for PrEP, so this just put the plan into high gear. Additionally, the Texas Medical Board (TMB) temporarily relaxed some of their previous telemedicine restrictions. Providers are now allowed to conduct video or phone appointments whereas in the past appointments had to be live video (synchronous) calls. Dr. Voskuhl is able to connect to patients at the Callie Clinic through the clinic’s EMR system. Instead of dialing in to the Zoom platform, he can dial into the Callie Clinic directly on his phone and patients have the option of telemedicine via video or telephone. At LGBTQ Health, he starts with a telemedicine visit to do an initial screening and can then have patients come in if he needs to see them in person. When asked if he hopes the TMB will continue to allow phone appointments he said, “Absolutely! Partly because Texas is so big and diverse that coronavirus hot spots will continue to pop up – so allowing me or other physicians to deal with those locally makes the most sense. There is no other way to think about this other than that the flexibility allowed has saved lives.”

Dr. Voskuhl has learned a few lessons, both about himself and about telemedicine.

  • Personally, he still requires some face-to-face time with clients and co-workers.
  • He has found that it is good for him to be on a schedule while working from home and it is important to go out at times.
  • Listening is the most helpful aspect of his telemedicine calls.
  • Asking people about their experience with telemedicine and what he can do differently is important. Some people love the telemedicine option and some absolutely hate it – they just don’t feel connected. He believes you can’t force telemedicine on people: “You can support it, but you have to be flexible.”

Dr. Voskuhl goes to the Callie Clinic once a month to see patients who prefer in-person visits, although he is not traveling right now due to the coronavirus.

From a technical perspective, lighting and especially audio are very important. You have to project a little bit more on the camera and be more animated on screen. There are a lot of little lessons to be learned – “like you have to move the mouse around every now and then or the screen goes dark!”

Dr. Voskuhl’s advice for others is, “Don’t be afraid – it seems daunting, but it is really not.” He said, “Hey, we did it, anybody can do it. There are online resources out there, online (TexLatrc.org for example), in-person and on the telephone. Don’t be afraid, because if you don’t know the answers there are people with the answers who can help you figure it out.”

Initially, he believed telemedicine was a way to link rural patients to care. Now, he sees that urban folks have many of the same barriers to accessing medical care. Telemedicine is a good way for many different patients to connect to medical care. When asked if he recommends telemedicine for others, Dr. Voskuhl said, “Absolutely, this is a tool for Texans, for our HIV folks and PrEP, to connect with medical care. One, it is important and two, it’s not that hard!”


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.

HIV Long-Term Survivors Awareness Day

Tez Anderson, the founder of Let’s Kick ASS (AIDS Survivor Syndrome), started HIV Long-Term Survivors Awareness Day to celebrate the strength, determination, and lives of people who have lived with HIV for 20, 30, or more years.  Many long-term survivors were part of the early days of activism and have roots in the development of the systems that work to prevent and treat HIV today. 

The first HIV Long-Term Survivors Awareness Day was June 5, 2014.  The date of June 5th was chosen because it is the anniversary of the first reporting of cases by the CDC of what would later be known as AIDS.

Long-term HIV survivors bring so many strengths with them to the fight to end HIV.  Many also face a number of unique challenges, including: medical care, medication, housing, and social isolation, and more. You can read more about aging with HIV in Barry Waller’s wonderfully-written previous post HIV and Aging.

This Friday June 5th, Achieving Together is honored to host, listen, and learn from a panel of long-term survivors here in Texas moderated by Barry Waller. Please see the information below on the webinar and read the panelists and host’s bios.

Friday June 5th, 2020

11am-12:30pm CST

Log in at: Achieving Together Conversation Series: HIV Long Term Survivors Awareness Day

You do not need to download any additional software as the platform (GoToMeeting) will run in your web browser.

Or by phone at: (872) 240-3311     Access Code: 160-952-933

Host:

Barry Waller, Austin, Texas

For over 36 years, Barry Waller has worked in the mental health, intellectual disabilities, physical disabilities, and aging fields at both the community and state agency levels in various administrative and management positions. He has a Master’s Degree in Social Work. As the Texas Legislature combined various state agencies, Barry went to work at the Department of Aging and Disability Services (DADS) as Assistant Commissioner over Provider Services. In this position, he managed directly administered services and various contracts with several thousand providers of disability and/or aging services throughout Texas.

Now retired, Barry spends his time working with different community and volunteer organizations. He served for nine years on the Board of Directors at AIDS Services of Austin, where he still remains as a volunteer. He has also served twice on the Board of Directors for OutYouth Austin and currently serves on the HIV Planning Council, a workgroup at the City of Austin on the City’s Age-Friendly Plan, and the Steering Committee of the LGBT Coalition on Aging.

Panelists:

Gary Cooper, Austin

I had just arrived back in Texas and started life with a new partner in 1985 when I tested positive and learned that my t-cells were already depleted; my new partner tested negative, and opted to stay together (we still are.) As the crisis worsened—most of our friends died—I struggled to continue professional employment, hiding my status and coping with several relocations as my partner’s career progressed. Although I’d never been involved in community volunteer work, I threw myself into helping to create the response to AIDS in Little Rock and later St. Louis, continuing my involvement in Austin as a board member of AIDS Services of Austin in the early 2000’s. Once I had gone on disability in 1993 after hospitalization with complications, I no longer tried to conceal my status and continue to make myself available to local media as a long-term survivor (most recently in a Statesman/USA Today article on lessons learned from the AIDS epidemic that apply to our current pandemic).

Glenda Small, San Antonio

I am 63 years old, originally from New Orleans, Louisiana. I relocated to San Antonio because of Hurricane Katrina in 2005, and I decided to make San Antonio my home because I didn’t want to go back & start all over again. I have been HIV+ for 28 years, I have been on the Executive Board of Director’s for B.E.A.T. Coalition Trust for over 10 years; I have been on the Executive Board of P.E.E.R.S. for women (a support group for Women infected & affected by HIV/AIDS) for about 9 years; I’ve served 2 terms on the Ryan White planning Council here in San Antonio; I am on the End Stigma End HIV/AIDS Alliance known as ESEHA; I am a member of the peer mentoring advocacy group here in San Antonio; I was inducted in to Sister Love the Leading Women Society, also the Black Women’s Initiative for San Antonio, and two years ago I received an award from the Top Ladies of Distinction for Hidden Heroes!

Steven Vargas, Houston

Steven began helping people living with HIV in 1989, has been living with HIV since 1995, and was recognized as one of Poz Magazine’s “100 Long Term Survivors” in its annual “Top 100” December 2015 issue. Steven is a board member of Houston’s OH Project which preserves the experiences of Houstonians impacted by HIV, and is serving a four-year term as a Community Member representative to the U.S. Department of Health and Human Services Panel on Antiretroviral Guidelines for Adults and Adolescents. He also serves as a Trainer for NMAC’s Building Leaders of Color program and as a consultant with Project CHATT (Comprehensive HIV/AIDS Training and Technical Assistance), which provides technical assistance to Ryan White planning bodies in reaching their legislative requirements. He is also the Community Co-Chair of Houston’s HIV Prevention Community Planning Group (2020-2021), and serves on the local Ryan White Planning Council as the Co-Chair of the Comprehensive HIV Planning Committee.