The Kern County Health Officer’s Clinic (HOC) is a comprehensive sexual health and family planning clinic that provides services to a rural and primarily agricultural county. Kern County HOC services include immunizations, testing for HIV and other sexually transmitted infections (STIs), rapid start services, and assistance with pre-exposure prophylaxis (PrEP) and post-exposure prophylaxis (PEP). With funding and technical support from the California Department of Public Health, Office of AIDS, the HOC began providing Kern County Rapid ART services in 2019, linking people with a new diagnosis of HIV to antiretroviral therapy (ART). The Kern County HOC identifies people with a new diagnosis of HIV through onsite testing, surveillance data, and referrals from local hospital emergency departments. Kern County Rapid ART provides support services and refers clients to other community clinics for ongoing care. A study conducted by the Kern County HOC of clients with a new diagnosis of HIV in 2021 found that on average, Kern County Rapid ART clients were linked to care and provided ART within two days of diagnosis.
Rapid ART is the early administration of ART, usually same day or within seven days from when a person receives a new diagnosis of HIV or is reengaged in care.1 Rapid ART can improve health outcomes among people with HIV by reducing the time to viral suppression.2 Kern County Rapid ART meets this need by providing clients with same-day treatment, additional support services, and follow-up care.
The Kern County HOC relies on a staffing model of Disease Intervention Specialists (DIS) in partnership with nurse practitioners to link people to Kern County Rapid ART. DIS, also known as communicable disease investigators, oversee case management and referral processes and provide benefit enrollment support for the Ryan White HIV/AIDS Program (RWHAP), the AIDS Drug Assistance Program (ADAP), and Medi-Cal (California’s Medicaid program).
In addition to providing onsite walk-in HIV testing, the Kern County HOC participates in the FOCUS program, an initiative that provides opt-out HIV testing within two emergency departments and links clients to care. Clients who have not been prescribed ART in the hospital emergency department are connected to care in the Kern County HOC before being referred to a community provider. The Kern County HOC has memoranda of understanding with the hospitals to exchange health information. Once a client tests positive for HIV at the emergency department, a DIS is alerted via phone or electronic health record (EHR). The DIS also identifies people with a new diagnosis of HIV through surveillance data shared by the state, and by reviewing a list that the hospitals generate daily.
The DIS then links clients to care after a positive HIV test. If a client tests positive from walk-in HIV testing at the Kern County HOC, the DIS is alerted by the EHR and meets with the client immediately. If the client is diagnosed in the emergency department, the DIS contacts the clinician who requested the lab for additional information and identifies any other risk factors that may impact the client’s care. The DIS then reaches out to the client to relay test results, inform them of their treatment options, and schedule a clinical exam in the Kern County HOC, ideally on the same day as the diagnosis. The DIS reviews lab results that the California Department of Public Health submits daily into a surveillance database, and then contacts clients with a new diagnosis of HIV to connect them to care.
At the clinic, the DIS helps the client enroll into ADAP and/or starts the process of Medi-Cal enrollment. RWHAP enrollment is typically managed by the community provider once the client has been referred for ongoing HIV primary care.
The DIS then escorts the client to a nurse practitioner for a physical exam, lab tests, and ART prescriptions. Clients are typically given two seven-day ART starter packs in addition to a three-month prescription for ART (onsite pharmacy is available). The nurse practitioner reviews HIV information with the client and provides education on the diagnosis and treatment.
The DIS enrolls clients into the Kern County HOC’s case management program, which provides support services such as housing, transportation, food vouchers, and substance use disorder treatment. Additionally, the DIS may work with community partners to place unhoused clients in a hotel room for 30 days while case managers assist with permanent housing. Finally, the Kern County HOC provides $10 food gift cards, hygiene kits, and transportation to appointments through a County-owned vehicle or bus service, and may provide a fee waiver to obtain a California identification.
“They’ve always told me that if I need a ride, they would help me. They’ve told me of all the supports they provide, so I keep going to the doctor and taking my medication.” —Kern County HOC clinic client
After the initial visit, the DIS connects clients to a community provider for ongoing HIV primary care. Five days after the Kern County Rapid ART visit, the DIS checks in with the client and assesses medication tolerance and side effects. If the client has not been established in ongoing HIV primary care, the client returns to the Kern County HOC in two weeks to review lab results with the DIS and nurse practitioner. The DIS continues to follow up with all clients until they attend their first follow-up visit with an HIV primary care provider in the community. If unable to see a community provider right away, the Kern County HOC can provide clients with medication refills.
The Kern County HOC conducted a study of 75 clients who either had a new diagnosis of HIV or were reengaged in care from January to December 2021, and measured the time to prescription of ART.
|For the study, Kern County HOC used an Excel spreadsheet that tracked referral source, date of diagnosis, ART prescription, and date of follow-up medical appointment.
Source: Kern County HOC Rapid ART Site Profile developed under the Rapid ART Dissemination Assistance Provider project
“It was taking an extensive amount of time to link somebody who is positive to HIV care… upwards of a month or even possibly longer than that. So, we thought if there was a way for us to introduce this as another piece to our clinic, that we could get people on treatment sooner and avoid these long delays of getting them to a provider.”
Staffing and training. Kern County Rapid ART services are provided by a small team of Kern County HOC staff. The DIS are responsible for linkage coordination, support services, and benefits enrollment, while nurse practitioners conduct clinical services and provide HIV education. Additionally, a consulting physician helps train nurse practitioners on HIV disease progression and rapid ART administration.
Securing starter packs. Kern County HOC receives ART starter pack donations from a partner drug manufacturer, allowing the clinic to provide same-day treatment regardless of a client’s health care coverage status. Typically, clients receive two sets of seven-day packs, but may receive more if they do not have health care coverage and need time to enroll in coverage.
Key partnerships. The California Department of Public Health funded development of the Kern County Rapid ART protocol at the Kern County HOC and provided ongoing clinical consultation. Other partners included local emergency departments that supported HIV testing and Kern County HOC’s streamlined process of linking people to care. Additionally, pharmaceutical manufacturers provide clients with free ART starter packs.
Designing a rapid ART approach. In 2019, the Kern County HOC extended its HIV and STI prevention efforts through PrEP and PEP programs. Staff consider Kern County Rapid ART to be a natural extension of these efforts to connect clients to medication immediately.
In 2019, the California Department of Public Health, Office of AIDS, awarded funding to four providers to implement Kern County Rapid ART. Through the grant, the Kern County HOC had access to a consulting physician who supported protocol development and client treatment. The grant allowed staff to develop the Kern County Rapid ART protocol, design and print materials to share with clients and partners, and to create hygiene kits. It also covered nurse practitioner staff time, food cards, and temporary housing for clients. Additionally, California is a Medicaid expansion state with three managed care plans available to Kern County residents. The state has ample health care coverage options to cover ongoing treatment for people with HIV; it also has expedited enrollment for RWHAP ADAP. Medicaid, RWHAP, and ADAP serve as important funding sources for the clinical aspects of Kern County Rapid ART, ongoing care at partner clinics, and ongoing prescriptions.
- A DIS-led model in partnership with nurse practitioners makes for a small but effective team that links people to rapid ART services, ongoing HIV primary care, and support services.
- Partnerships with local emergency departments that provide opt-out testing offer more opportunities to link clients to care and address gaps in HIV care continuum outcomes.
- The California Department of Public Health was critical in developing the protocol as well as in providing ongoing clinical support crucial to establishing and maintaining Kern County Rapid ART.
- Bourdeau B, Shade SB, Koester KA, et al. Rapid ART antiretroviral therapies for improved engagement in HIV care: implementation science evaluation protocol. BMC Health Serv Res. 2023;23(1):503. doi:10.1186/s12913-023-09500-w
- Geng EH, Havlir DV. The science of Rapid ART—From the when to the how of antiretroviral initiation. PLOS Med. 2017;14(7):e1002358. doi:10.1371/journal.pmed.1002358