Rapid ART Start Protocol

The Rapid Antiretroviral Therapy (ART) Start Protocol focuses on helping people with a new HIV diagnosis access ART and comprehensive treatment as soon as possible. Launched in 2016, the Rapid ART Start Protocol has served veterans with a new diagnosis of HIV presenting for care at a Veterans Health Administration (VA) infectious disease clinic in Atlanta, Georgia. The protocol established guidelines for prompt patient notification of a positive HIV test result, a first visit with a multidisciplinary care team to establish HIV care and address social needs, and timely follow-up within four to six weeks to monitor progress and medication adherence. A retrospective cohort study from 2012–2020 showed positive outcomes, including decreases in the time to first appointment, the time to ART initiation, and the time to reach viral suppression. In addition, patients receiving the intervention were more likely to reach viral suppression compared to patients seen pre-intervention at the same clinic.

Atlanta, GA

Implementation Guide
False
Evidence-informed intervention
Evidence-informed intervention
Icon for Intervention Type
Clinical service delivery model
Icon for HIV Care Continuum
Linkage to HIV medical care; Prescription of antiretroviral therapy; Viral suppression
Icon for Focus Population
People with a new diagnosis of HIV
Icon for Priority Funding
Non-RWHAP
Icon for Setting
Hospital or hospital-based clinic
Need Addressed

The Atlanta VA Medical Center Infectious Disease Clinic (IDC), the largest HIV clinic in the VA system, provides care to nearly 2,000 people with HIV each year in northern Georgia and neighboring states.1 In the VA setting, most people seen and diagnosed with HIV continue to receive their HIV care within the VA. Despite this integrated setting, wait times for receiving initial lab results had often delayed initiation of ART for people with new HIV diagnoses. The Rapid ART Start Protocol aimed to streamline this process and offer patients a prompt (ideally same-day or within 72 hours) initial assessment with a multidisciplinary team, including a nurse, scheduler, primary care provider, pharmacist, psychologist, and social worker.

Core Elements
Rapid outreach to patients with new HIV diagnoses

The Rapid ART Start Protocol sought to remove barriers that typically delay care, such as HIV genotyping, and streamline ART initiation for people with a new diagnosis of HIV. It called for initial patient contact within 72 hours and preferably on the same day of diagnosis. The IDC received notification of HIV diagnosis from the lab or directly from clinical providers, and reached out to the person to schedule a comprehensive initial visit with a multidisciplinary team of providers.

Multidisciplinary initial visit including prescription of ART

Several different providers actively participated in the patient's initial visit, including the prescribing clinician, a nurse, a scheduler, a pharmacist, a social worker, and a psychologist. The clinician began each visit with a patient assessment, which included lab work as well as comprehensive opportunistic infection screening, sexually transmitted infection screening, ART prescription, and partner prophylaxis and counseling. The social worker coordinated the partner notification process and connected the person to resources needed to overcome any barriers to accessing care. Finally, the psychologist worked with each person to address any mental health and/or substance use concerns.

Regular and timely follow-up

The Rapid ART Start Protocol called for a follow-up telephone visit with the pharmacist and social worker at day 14 to address any medication side effects and provide counseling. In addition, the patient would get scheduled for an in-person follow-up visit within four to six weeks to further address any medication issues and review follow-up lab work. At this second in-person visit, the patient would be scheduled for another in-person visit six to eight weeks later, resulting in an overall count of three in-person visits and one telephone visit within the first 10-14 weeks of diagnosis.

Outcomes

The VA clinic conducted a pre-post evaluation using a retrospective cohort design to assess the impact of the Rapid ART Start Protocol. The study sample included patients who were referred to care at the clinic following HIV diagnosis between January 1, 2012, and February 1, 2020 (n=116). People attending the clinic prior to the launch of the Rapid ART Start Protocol in 2016 (n=58) served as the historical control group. Most of the patients in the study were male (95%), Black (85%) with a median age of 44; demographically the control group and the Rapid ART group (intervention group) were very similar. The study’s primary measures included time from referral to the first medical visit, time from the first medical visit to ART initiation, and time from diagnosis to viral suppression; all three were lower for the intervention group. 

CategoryInformation
Evaluation dataData from the VA’s Electronic Health Record (EHR) and corporate data warehouse (the VA Informatics and Computing Infrastructure). These included demographics, social characteristics, indicators of clinical care, ART prescribed, and viral outcomes. 
Measures
  • Time from referral to first attended clinic appointment
  • Time from first attended visit to ART initiation
  • Time from HIV diagnosis to viral suppression
  • Viral suppression reached at any time during the study period
Results
  • The median time from referral to first attended clinic appointment decreased from 20 days pre-intervention to one day post-intervention.*
  • The median time from first attended visit to ART initiation decreased from 27.5 days pre-intervention to zero days post-intervention.*
  • The median time from HIV diagnosis to viral suppression decreased from 180.5 days pre-intervention to 62 days post-intervention.*
  • Patients in the intervention group were over 2.5 times as likely to reach viral suppression during the study period compared to pre-intervention patients.*

* statistically significant

Source: O’Shea JG, Gallini JW, Cui X, et al. Rapid antiretroviral therapy Program: Development and evaluation at a Veterans Affairs medical center in the Southern United States. AIDS Patient Care STDs. 2022;36(6):219-225.

Planning & Implementation

Integrated care management. The VA health system offered an integrated care management setting that facilitated efficient uptake of the Rapid ART Start Protocol. Design factors contributing to this success included built-in health care coverage for all patients, the ability to pick up medications the same day as the clinic visit, a centralized EHR system, and the ability to offer patients long-term follow-up care in the familiar VA setting.

Staffing needs. The Rapid ART Start Protocol needed institutional buy-in to ensure staff were available to promptly notify people of a new HIV diagnosis, help patients navigate the rapid ART initiation process, and participate in the multidisciplinary care team activities. Providers also noted that patients often had immediate needs, such as housing or substance use challenges, that needed to be addressed on the same day as ART initiation.

Provider education about rapid ART. Through the Rapid ART Start Protocol, staff were trained on differences in the rapid ART approach compared to the traditional model of care, including the importance of beginning ART before obtaining all relevant lab results. Staff were also educated on medication adherence techniques and supplies such as pillboxes. This training was important to ensure provider comfort with initiating ART during the first clinical visit.

Lessons Learned
  • The population served at the IDC had significant mental health needs. These conditions necessitated involvement of a multidisciplinary care team, including psychologists and social workers, to offer prompt support for mental health needs and connection to social services in addition to prompt ART initiation.
  • Despite the presence of the multidisciplinary team, some providers involved in the Rapid ART Start Protocol felt the effort was understaffed, noting the intensive supports needed to serve this population.
  • Barriers related to insurance and transportation were mitigated within the Rapid ART Start Protocol due to the VA’s care model. Other health systems may benefit from established provider networks that can promptly resolve insurance and social determinants of health barriers affecting rapid ART initiation.

“The findings from this study support the use of this Rapid Start ART Protocol for all VA facilities as a strategy to achieve [Ending the HIV Epidemic in the U.S. initiative] goals.”

Contact
Division of Infectious Diseases, Emory University School of Medicine
Jesse G. O’Shea, MD, MSc

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