Rapid Start: The Good, the Bad, and the Ugly

Jonathan Colasanti, MD, MSPH

Assistant Professor of Medicine
Department of Infectious Diseases
Emory University
Atlanta, Georgia

Jonathan A. Colasanti, MD, MPH, has no relevant conflicts of interest to report.

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Released: October 9, 2019

When you step back and think about it, it is strange that we are having conversations about why we should immediately provide access to lifesaving medications to all who need them. It seems like common sense, but due in part to the evolution of ART as well as a bureaucratic and inequitable health system, that task is often easier said than done.

Our Atlanta clinic—the Grady Health System Infectious Disease Program—launched a pilot rapid entry program in 2016 that was quickly overwhelmed due to demand. Results from our pilot program demonstrated that, like other rapid start programs, our program had fast and sustained results. We saw improved time to viral suppression, and at 6 months, our retention and viral suppression rates were comparable to historical controls.

In 2018, the pilot program was relaunched as a full program, supported by Part A Ryan White funding. To create a landscape where rapid entry is possible—a program that can include key program facilitators—we had to make policy-level and administrative-level changes, in addition to changing clinic operations and clinician practice. The table highlights some of those changes.

Table. Institutional Changes to Support Rapid Entry

It takes a champion, multilevel buy-in and systematic changes, but it is feasible, safe, and effective (with guidance on regimen choice in both the IAS-USA and DHHS guidelines). The federal Health Resources and Services Administration and local Ryan White offices have shown willingness to make accessing care easier by building in “grace periods” for patients to begin care while still finalizing enrollment paperwork. And most successful programs assign the patient a peer or navigator to assist with obtaining the necessary eligibility documentation while the care process, including ART, is initiated.

The Importance of Medicaid
Because many US states have elected not to expand Medicaid—in particular in the Southeast—we continue to create system work-arounds to gain access to same-day medications. These work-arounds are often cumbersome and time consuming, creating more inefficiencies in the healthcare system.

Medicaid expansion, especially with systems of expeditated enrollment, would be a game-changer for rapid entry, helping patients access medications quickly. When a patient with Medicaid enters the system, enrollment in Ryan White/AIDS Drug Assistance Programs or Pharmaceutical Patient Assistance Program is no longer needed, saving us hours of paperwork and human resource time. This staff time alone would be enough to allow us to expand wrap-around support services to assist with the tougher stage of the care continuum: retention and adherence.

Leveling the Field
The reason I am most excited about rapid entry is that it helps to level the playing field. It is about equity. We have lifesaving therapy that doubles as a public health benefit to decrease transmission, given that “undetectable equals untransmittable” (U=U). Rapid entry also means that, regardless of ability to pay or insurance status, we shift the typical power dynamics in a small but powerful way: By swallowing that pill on Day 1, the patients feel secure that they can take control of their disease rather than being at the mercy of a system.

Although rapid entry is an important start, it is no substitute for retention and adherence programs and resources. But it is a crucial first step for persons living with HIV to seamlessly and successfully navigate the care continuum from diagnosis to viral suppression, allowing them to fully live the benefits of U=U.

More Discussion
To learn more about rapid entry, including examples from other programs in New Orleans and San Francisco, watch this CME/CE-certified online video program featuring an expert panel discussion. 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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