Why I Am Excited About Rapid ART Initiation

Jason Halperin, MD, MPH

Assistant Professor of Medicine
Department of Infectious Diseases
Tulane University
Infectious Disease Physician
New Orleans, Louisiana

Jason Halperin, MD, MPH, has no relevant conflicts of interest to report.

View ClinicalThoughts from this Author

Released: September 9, 2019

Rapid start is an intervention to immediately link patients to care and to initiate ART, ideally on the same day of HIV diagnosis, even before lab results are obtained. It is a paradigm shift in how we practice. Providing immediate access to ART is possible in part because of the safety, tolerability, high barrier to resistance, and effectiveness of our first-line ART regimens. But it also requires provider flexibility and intentional clinicwide planning. 

My clinic, CrescentCare, a federally qualified health center and the largest provider of HIV services in New Orleans, launched a rapid start program in December 2016. Our program replicated the success of the University of California, San Francisco’s Ward 86 rapid start program—the first in the United States.

Both the New Orleans and San Francisco programs have demonstrated that starting HIV treatment on the day of diagnosis is safe, is well tolerated, and has high uptake. It is also effective, with almost 100% of patients in both cohorts achieving viral suppression within approximately 4 weeks and sustained, with more than 90% maintaining viral suppression 12 months after diagnosis.

Costs and Benefits of Rapid ART Programs
The IAS-USA guidelines encourage rapid ART whereas the DHHS guidelines label the practice investigational, recognizing that rapid start programming is resource intensive. It is true that this intervention requires appropriate planning. The key facilitators for my program include the following:

  1. Ensuring sustained access to ART
  2. Same-day provider appointments
  3. Flexible provider scheduling (on-call backup)
  4. ART regimen preapproved prior to genotyping or lab testing
  5. Availability of ART starter packs
  6. Accelerated process for health insurance initiation
  7. Observation of first ART dose in clinic

However, rapid start is a red-carpet linkage intervention that is patient centered and demonstrates our commitment to treatment access. Moreover, our data suggest that the benefits of this model extend beyond increased rates of ART uptake and earlier viral suppression; it also fosters improved retention in care and higher rates of sustained viral suppression. 

I believe the reason for its success is the profound relationship that develops between the provider and the patient when the patient is seen on the day of HIV diagnosis, started on ART, and counseled on improved health outcomes and the Undetectable=Untransmittable (U=U) message. Of course, rapid start still needs to be coupled with best practices in retention programming that prioritizes medication access and viral suppression.

Promoting Equity of Care
Rapid start is also an innovation that supports equity. For example, black men have had delays in linkage to care and ART initiation compared with white men. Furthermore, black men are less likely to be prescribed a preferred first-line ART regimen. Rapid start is a quality improvement intervention that purposefully upholds equity, ensuring that all people living with HIV can be welcomed into care and started on ART at the time of diagnosis.

In summary, we can see patients on the day of HIV diagnosis and start the process of achieving viral suppression, compressing our HIV continuum from linkage to viral suppression into just 4 weeks. This model of care is successful and achievable.

More Discussion
To hear more about the examples from New Orleans and San Francisco and how we overcame some of the barriers to implementing rapid ART initiation, please see our online video program. To add your thoughts and experiences with rapid ART, answer the polling question and join the discussion by posting a comment. 

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