In 2020, the Virginia Department of Health (VDH) launched the Virginia Rapid Start Collaborative (Virginia Rapid Start) with HIV care providers across the state with the goals to initiate antiretroviral therapy (ART) for clients within 14 days of initial HIV diagnosis and to improve access to, and retention in, high-quality HIV care and support services. After issuing a preliminary agency readiness assessment survey, VDH launched the pilot Rapid Start program with five providers, which eventually grew into a larger collaborative of 16 providers. Through Virginia Rapid Start, providers initiated ART medications within an average of four days of HIV diagnosis, as compared with the overall statewide average of 28 days. In the first two years, Virginia Rapid Start clients had higher rates of viral suppression compared to both the RWHAP Part B overall and Virginia overall. The success of the Virginia Rapid Start led VDH to expand the program to the entire Virginia RWHAP Part B starting in fiscal year 2023.
Rapid Start, an evidence-based intervention, is the provision of ART within a short period (usually defined as same day or within seven days) from when a person receives a diagnosis of HIV or reengages in care after disconnecting from HIV care.1 By reducing the time between diagnosis and treatment, Rapid Start lessens the time to reach viral suppression and also improves other HIV care continuum outcomes, including linkage to and retention in care.2,3 When the VDH prevention unit first attempted to launch Virginia Rapid Start in 2016, the program lacked provider buy-in. In 2020, VDH administered a readiness assessment survey with HIV care providers across the state, finding that 91% of the respondents thought their organization should offer Rapid Start.4 In July 2020, VDH launched the Virginia Rapid Start Collaborative with five pilot provider sites.
Rapid Start programs receive referrals for clients with a new HIV diagnosis from various sources. Virginia has a strong home testing program where clients who test positive at home can be linked to services via VDH Disease Intervention Specialists (DIS). Most providers who offer Rapid Start have onsite HIV testing available but may also receive referrals from community-based organizations (CBOs). In Virginia Rapid Start the provider site’s patient navigation staff then work with clients with a new diagnosis of HIV to set up an initial clinical appointment and provide them with a list of documentation needed for RWHAP eligibility. Additionally, providers may reengage clients previously diagnosed with HIV who have a CD4 count less than 200 cells/mm.
Within 14 days, but most often within the same day to 72 hours, Virginia Rapid Start provider staff (usually a medical case manager) complete a client intake, conduct a health screening, and provide ART education. The clinician meets with the client to conduct lab tests, prescribe ART, and may also observe the client’s first dose. Clinicians may provide ART starter packs during the initial appointment. Clients fill long-term prescriptions onsite or at a partner pharmacy once their health care coverage is confirmed. VDH established relationships with pharmaceutical companies to aid ART provision prior to the client’s ADAP application approval. In the first year, VDH covered medication purchases for Virginia Rapid Start; in subsequent years, agencies worked with pharmaceutical companies to obtain medication samples to have on hand to distribute as needed.
Providers connect clients to needed support services during the initial appointment or as identified during follow-up. Virginia Rapid Start funds help cover the cost of select support services, including transportation, medical and non-medical case management, client education materials, and linguistic services.
The Virginia Rapid Start protocol emphasizes the importance of providers following up with clients for at least six months. Provider staff (usually the medical case manager) call the client the day after the initial appointment to follow up on the medication prescribed to inquire about any side effects and the client’s general wellbeing. Provider staff use various approaches to follow-up, including calls, texts, emails, outreach via PositiveLinks (an app that facilitates communication for HIV care) and in-person visits. Follow up visits are held with the client 10 days, 30 days, and 45 days after the initial appointment. The medical case manager coordinates longer-term follow-up, with in-person or virtual visits 90 days and 180 days after the initial appointment.
VDH ensures that clients have immediate access to the RWHAP AIDS Drug Assistance Program (ADAP), known statewide as the Virginia Medication Assistance Program (VA MAP). VA MAP covers ongoing ART prescription costs directly, or purchases health care coverage for clients. When Virginia Rapid Start first began, VDH set up a process to approve VA MAP applications within 48 hours. With the recent implementation of the Virginia RWHAP Unified Eligibility in 2022, all persons seeking RWHAP Part B and/or VA MAP services must apply through a subrecipient provider. Providers create, update, and upload supporting documentation into the VDH client-level data system, Provide Enterprise®, for immediate VA MAP enrollment.
The Virginia Rapid Start Collaborative participants include RWHAP Part B partners, testing centers, and DIS, all working and learning together to provide expedited access to integrated HIV care services. Representation of people with HIV is also essential to ensure effective implementation of integrated services and program success. Monthly collaborative learning sessions were held over the course of the Virginia Rapid Start pilot period to address selected action steps, provide any needed training, and discuss best practices. Each meeting provided an opportunity for team members to share experiences, learn quality improvement techniques, and plan future actions; local evidence-based practices were adopted and shared across the collaborative.
“Because we have such a diverse set of agencies, having another group of people that mirror what your program might look like, and being able to ask certain questions is helpful. [VDH] doesn’t necessarily have to have all the answers and doesn’t have to step in. It creates more partnerships across the state.”
Through Virginia Rapid Start, clients received ART medications within an average of four days of HIV diagnosis, as compared with the overall statewide average of 28 days. In the first two years, more Virginia Rapid Start clients reached viral suppression (87%) compared to both the RWHAP Part B program overall (79%) and Virginia overall (62%).
Source: National Ryan White Conference on HIV Care & Treatment (NRWC) 2022. Rapid Start Collaborative Initiative: Enhancing Access to Care for People with HIV in Virginia.
Early involvement of HIV care providers. From May to June 2020, VDH sent a readiness assessment survey to all HIV care providers associated with the VA Division of Disease Prevention (DDP), collecting response data via REDCap. Hearing from 38 organizations, VDH found that almost all organizations were interested in Rapid Start, but many did not have plans for implementation and required guidance. From this survey, VDH identified five initial providers to pilot Rapid Start across Virginia’s five health regions.
Model process from neighbor jurisdiction. VDH used the Washington, DC Department of Health’s rapid ART protocol and procedures as models for the Virginia Rapid Start program. VDH adapted the DC protocol and gave it to participating Virginia providers, with an invitation to customize the standard protocol to best fit their clinic.
Plan, Do, Study, Act (PSDA) cycle. VDH used the Plan-Do-Study-Act (PDSA) model to iteratively test and refine the Virginia Rapid Start implementation, carrying out multiple PDSA cycles in the 16 pilot facilities. PDSA findings helped the sites to facilitate quicker access to ART medications and linkage with peer coaches, make smoother referrals, and also informed the client process map from HIV diagnosis through intensive case management follow-up. Virginia Rapid Start continues to use the PDSA approach to test ideas and close other gaps in the HIV care continuum, such as retention in care.
Data collection. When implementing Virginia Rapid Start, VDH trained providers on tracking their processes and outcomes in REDCap. Through this method, VDH ensured that providers used comparable data, although some providers used both REDCap and an internal database approach (e.g., CAREWare).
Through Virginia Rapid Start, VDH is growing Rapid Start as a standard of HIV care across the state. The first year of Virginia Rapid Start included five pilot providers; by the end of the second year, there were 16 participating providers. State funds covered Rapid Start in the first year (2020–2021) with the pilot providers. In the second year (2021–2022), Rapid Start services were funded through a hybrid of state funding and RWHAP Part B pharmaceutical rebates. In the final pilot year (2022–2023), all services were funded by RWHAP Part B pharmaceutical rebates. VDH is expanding the RWHAP Part B to include Rapid Start in all provider contracts, beginning in fiscal year 2023.
“…We're committed to funding. The program is really committed to infrastructure building, structural improvements, and process improvements.”
- Defining Rapid Start: Before the Virginia Rapid Start Collaborative began in 2020, VDH attempted to strictly define Rapid Start as same-day initiation of ART. However, because HIV care providers serve different populations and vary in size, VDH found that a flexible approach was necessary to implement Rapid Start statewide.
- Learning collaborative model: Working with peers helped providers implement Virginia Rapid Start. VDH gave providers a starting point, through the standard procedure and protocol, allowing providers to adapt the plan to best fit their site. Through implementation of a standard data collection and analysis approach, providers received training to submit data via REDCap. Finally, through regularly scheduled meetings, providers shared best practices and troubleshot challenges. Meetings also provided a place for VDH to speak on overall data trends, the use of the PDSA improvement model, and the collaborative learning model to determine the impact of changes.
- Interdisciplinary collaboration: It was critical to engage staff at implementing sites through an interdisciplinary team, including medical case managers, clinicians, and eligibility determination staff, to best address the needs of clients as the Rapid Start approach was new to many sites. Staff education and buy-in ensured continuity of established policies and procedures, in addition to sustained program success.
- Funding: Although initially starting with five RWHAP Part B providers, VDH found that securing funding allowed more resources and infrastructure for providers to easily implement Virginia Rapid Start and to scale up the program across various providers. As part of funding, it is vital to build relationships with pharmaceutical companies to provide ART prior to client VA MAP approval.
- Data collection: It was important to decide early on the type of data to collect and analyze. Staff prioritized just a few data elements, e.g., dates of linkage to care, viral suppression. This limited dataset minimized data reporting burden, while still ensuring VDH could monitor program quality and outcomes.
- Flexibility: Time for emergent appointments must be built into staff schedules for quick access to HIV providers, labs, and ART.
“What's really worked is letting the agencies tailor the program to how it works at their agency, rather than giving them a prescribed procedure or method …really allowing [the] agency to look at their internal processes and determine how it can work at their agency.”
- NIH. Initiation of Antiretroviral Therapy. 2019.
- Ford N, Migone C, Farzan A, et al. Benefits and risks of rapid initiation of antiretroviral therapy. AIDS. 2018;32(1):17-32. doi:10.1097/QAD.0000000000001671
- Bacon OML, Coffey SC, Hsu LC, Chin JCS, Havlir DV, Buchbinder SP. Development of a citywide rapid antiretroviral therapy initiative in San Francisco. Am J Prev Med. 2021;61(5 Suppl 1):S47-S54. doi:10.1016/j.amepre.2021.06.001