Rapid Start: A Critical Component of Ending the HIV Epidemic

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.

Covering Texans’ Condom Needs: Texas Wears Condoms and The Condom Distribution Network

When used correctly and consistently, condoms are an effective way to prevent the transmission of HIV, as well as other sexually transmitted infections (STIs). The Achieving Together team interviewed two organizations in Texas that distribute free mail order condoms online: Texas Wears Condoms and the Condom Distribution Network. The aim of both programs is to reduce the transmission of HIV and other STIs by making condoms more accessible. By creating access to free condoms available online, Texans are able to obtain condoms regardless of their geographical location. Both programs also work to educate communities and de-stigmatize sexual health.

Texas Wears Condoms

“So far, the program has partnered and collaborated with over 150 community organizations/businesses across the state and distributed 1,913,377 condoms (2019).”

Tell us about Texas Wears Condoms.

This project originally began in 2013 at the University of Texas Health Science Center in San Antonio, now known as UT Health. The grant was originally funded only for services in San Antonio, but in 2017 the program received funds from the Texas Department of State Health Services (TX DSHS) to expand its services to all Texas residents.

What are your goals?

The project has three objectives to meet every year, as set by TX DSHS:

  1. Distribute 2,000,000 condoms
  2. Collaborate with 100 community partners (i.e. retail, civic, faith-based, etc.) to include 50 local (in San Antonio) and 50 statewide.
  3. Have 80 distribution sites including non-conventional businesses, clinics/CBOs/ASOs, and community events. 

Aside from the goals listed above, the purpose of the program is to educate the community and help reduce the spread of HIV and STIs in Texas by expanding free condoms access, improving condom knowledge and destigmatizing condoms/condom use. The program focuses heavily on destigmatizing and normalizing conversations around sex.

What will success look like?

Individuals will have access to sexual health supplies, regardless of their location and income.

Condoms and other sexual health supplies will be destigmatized and not associated with any specific risk behaviors (i.e. you use condoms, so you must sleep around).

We want to serve individuals from every zip code and county in Texas, reduce the numbers of STIs and HIV in Texas, and improve condom variety, brand awareness and delivery time for packages.

We also want to further the conversation about PrEP and PEP.

How does the Achieving Together plan/movement relate to this work?

Several of the guiding principles of the Achieving Together Plan are focus areas of the program: social justice, equity, empowerment, advocacy, and community. The program leverages technology, partnerships and community action to deliver a multi-layered prevention framework to address deficiencies in prevention, care, and treatment. Re-purposing an e-commerce website to provide condoms and sexual health supplies to order and mail directly to consumers has minimized the barriers to access and provided communities with an equitable platform. The program has also empowered individuals living in marginalized, under-served, and geographically isolated areas by making condoms accessible and available with unrestricted access.

What have you learned?

Through client surveys, we have identified barriers to condom use, such as cost, embarrassment, or not knowing what kind to purchase.We’ve also learned that individuals want to learn more about sexual health and how they can protect themselves from STIs/HIV, without the sanctimonious aspect. Individuals want to use safe sex supplies (condoms, lubricants, dental dams), they just don’t always know where to access them, or how to bring up the conversation with their partners.

Social media is a great avenue to connect with your audience and disseminate factual, sex positive information. It can help grow your program’s following organically and with little to no cost.

Finally, we’ve learned that not a lot of people know about PrEP and its benefits.

Condom Distribution Network

“We have decided to focus our efforts in 2020 toward getting younger MSM of color to access our CDNStore this year. This year, our goal is to send at least 65% of our condom orders to 12-35 year-old MSM of color.”

Tell us about the Condom Distribution Network.

The Condom Distribution Network was started in 2014 by AIDS Services of Austin (now Vivent Health) as a way to reach more people through condom distribution. The online store (CDNStore.org) opened around 2016. AIDS Services of Austin (ASA) realized that with so many people of color moving out of central Austin, we needed a way to make it easier for people to get free condoms from ASA without having to come to our locations. We ship free condoms to people in Travis, Williamson, Bastrop, Caldwell, and Hays counties.

We changed our ordering process to make it easier for people to order from us as well as made changes to the way our website looks to give our store a new look. We will be adding videos in both English and Spanish so that people can learn how to put on a condom.

What are your goals?

Our goal is to help more people get access to condoms by removing access as a barrier. We have decided to focus our efforts in 2020 toward getting younger MSM of color to access our CDNStore this year. This year, our goal is to send at least 65% of our condom orders to 12-35 year-old MSM of color.

How does the Achieving Together plan/movement relate to this work?

By normalizing condom use, we believe we can address the stigma around sexual health and testing.

What have you learned?

At ASA, we know that our data can be a great ally to understand what people need. In July, we rolled out our new survey, which captures sexual health information. Within the first month we found that 64% of people who ordered condoms in July had never been tested for syphilis. In response, ASA created a quick one-page infographic with syphilis information, testing recommendations, and locations that were sent out with every condoms order. We were able to see that percentage drop within three months.

ASA has learned that there is still very much a need for condoms in the community and that most people, if given information about this resource, will use it. What we have to do now is make sure this program is getting into the communities that need it and would benefit the most from this program. 

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.

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.