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.

A Quick Look at Strategies Helping Us End the Epidemic

Can you explain how we’re going to end the HIV epidemic in 4 minutes? In this short (roughly 4 minute) video Philip A. Chan explores the preventive strategies helping us tackle HIV and the possibility of ending the epidemic. 

(Click here to see video if it doesn’t appear in your browser.)

Antiviral medications work in a couple different ways. Some keep HIV out of immune cells, and others work to stop the virus itself from replicating. When HIV is effectively treated with antiretrovirals, many people living with HIV can lead healthy lives. Another advantage of antiretroviral treatment is that people’s viral levels become undetectable and they do not transmit HIV to others. In people living with HIV, antiretroviral medications can dramatically reduce HIV transmission. This is called “Treatment as Prevention.” Pre-exposure prophylaxis, or PrEP, also uses antiretroviral medication preventatively in people who don’t have HIV.

One of Achieving Together’s focus areas is to promote the continuum of HIV prevention, care, and treatment. Medical advances, such as pre-exposure prophylaxis (PrEP) and other antiretroviral medications, change the way we think about HIV prevention and treatment. The continuum of prevention, care, and treatment starts with awareness and continues with testing and systems of care that are in place to promote these interventions. We aspire to integrate the prevention and care continuum through a status neutral lens, meaning care should happen regardless of status.

Think Globally. Act Locally: How Austin is Achieving Together Through Their Fast Track City Plan

By Brandon Wollerson & Laura Still

In many ways, Achieving Together: A Community Plan to End the HIV Epidemic in Texas was the catalyst for advancing conversations about ending the HIV epidemic in Austin. As the Texas HIV Syndicate, the integrated prevention and care planning body for Texas, began the process of developing a statewide ending the HIV epidemic plan, those of us working in Austin started having specific conversations about what we were doing to end the HIV epidemic here. We learned about Fast Track Cities, the global movement to end the HIV epidemic, and how San Antonio was the only Fast Track City in Texas at the time; we felt we needed to add Austin to that list!

The process started organically with conversations among key stakeholders at the end of 2017 and early 2018. These conversations led to many meetings and an alignment of the goals and objectives in Austin with those of the Fast Track Cities global initiative. Austin officially became a participating Fast Track City when Mayor Adler and Travis County Judge Sarah Echardt signed the Paris Declaration on June 20, 2018.

Once Austin officially became a Fast Track City, the planning group assembled working groups under four pillars:

  • Prevention
  • Testing and rapid linkage
  • Viral suppression and retention
  • Ending stigma

The working groups are made up of community stakeholders, including organizations, health departments, and people who are personally impacted by HIV. They are tasked with identifying ongoing needs and barriers to ending the HIV epidemic in Austin and addressing them. Some of Austin’s unique challenges are the racial disparities related to people in care, out of care, and virally suppressed. We also need to work harder to reach the most vulnerable people in our communities. 

Aligning Multiple Plans

Austin’s Fast Track City plan is our local vehicle to address ending the HIV epidemic. Achieving Together set the foundation for our local work by giving us the initial tools and language. From there, we looked at our community specifically to identify Austin’s unique challenges, opportunities, and strengths. Austin’s Fast Track City plan maintains elements of Achieving Together. We customized the plan to our unique community.

Achieving Together and the Fast Track Cities movements also remind us that ending the HIV epidemic is bigger than just our local community, that we are connected to the statewide and global cause and commitment to end the HIV epidemic. It’s a “Think globally. Act locally” mindset.

Taking Action Through Rapid Linkage

Achieving Together recognizes that we all need to rely on each other to support the work and the movement of ending the HIV epidemic in Texas. This is not about just one organization, but more about how we work together as an entire community to reflect the values and aspirations of the plan. One concrete way we can work collaboratively in Austin to eliminate barriers to care is through the creation of a Rapid Linkage to Care program throughout the city. We envision a system of care in Austin that rapidly links persons newly diagnosed with HIV into care and treatment within 72 hours.

We have started by identifying organizations that currently offer rapid linkage programming. Next we will work to improve coordination across organizations that provide opportunities for Rapid Linkage at other points of entry, such as emergency departments and non-traditional testing sites. Eventually we hope to create a status neutral system of care as we build a network and process to rapidly link people to HIV care, we can mirror that for people who need rapid access to PrEP or PEP.

While there are many challenges to ending the HIV epidemic in Austin, we hope that by equipping people and organizations with the tools to realize that the more we do to rapidly link people to care and treatment, the better the outcomes will be for them and for our community. We want to reinforce that everyone has something to contribute toward ending the HIV epidemic in Austin and that when we work together collaboratively and efficiently, we can meet our goals and build community at the same time.

Brandon Wollerson, Director of Clinical Operation, KIND Clinic

Brandon Wollerson is Texas Health Action’s first Director of Clinical Operations. In this role, Brandon oversees the clinical operations of all Kind Clinic locations. Brandon holds a Master of Science in Social Work degree from The University of Texas at Austin and has worked in the HIV field in Austin for over 14 years. He is deeply committed to addressing HIV and other LGBTQ+ health equity issues through his leadership with Austin’s Fast-Track Cities, the Texas HIV Syndicate, and Austin’s LGBTQ Quality of Life Advisory Commission. Brandon lives in Austin with his husband, Scott, and their four-year-old daughter, Addie.

Laura Still, Public Health Program Supervisor, Austin Public Health

At Austin Public Health, Laura has served as Planner for the Austin HIV Planning Council and has recently taken on the new role of HIV Outreach and Mobile Testing Supervisor. Her favorite animal is the unicorn.