Essential elements of and challenges to rapid ART implementation: a qualitative study of three programs in the United States

Abstract

Background Antiretroviral therapy (ART) initiation on the day of an HIV diagnosis or as soon as possible after diagnosis, known as rapid ART (henceforth “RAPID”), is considered to be a safe and effective intervention to quickly reduce viral load and potentially improve engagement in care over time. However, implementation of RAPID programming is not yet widespread. To facilitate broader dissemination of RAPID, we sought to understand health care worker experiences with RAPID implementation and to identify essential programmatic elements. Methods We conducted 27 key informant interviews with medical providers and staff involved in RAPID service delivery in three distinct clinical settings: an HIV clinic, a Federally Qualified Health Center and a sexual health and wellness clinic. Interviews were structured around domains associated with the Consolidated Framework for Implementation Research and were audio-recorded, transcribed, and thematically analyzed. Findings We identified seven (7) essential elements across settings associated with successful RAPID program implementation. These high-impact elements represent essential components without which a RAPID program could not function. There was no one requisite formation. Instead, we observed a constellation of essential elements that could be operationalized in various formations and by various people in various roles. The essential elements included: (1) presence of an implementation champion; (2) comfort and competence prescribing RAPID ART; (3) expedited access to ART medications; (4) expertise in benefits, linkage, and care navigation; (5) RAPID team member flexibility and organizations’ adaptive capacity; (6) patient-centered approach; and (7) strong communication methods and culture. Conclusions The RAPID model can be applied to a diverse range of clinical contexts. The operational structure of RAPID programs is shaped by the clinical setting in which they function, and therefore the essential elements identified may not apply equally to all programs. Based on the seven essential elements described above we recommend future implementers identify where these elements currently exist within a practice; leverage them when possible; strengthen them when necessary or develop them if they do not yet exist; and look to these elements when challenges arise for potential solutions.

Experiences of initiating rapid antiretroviral therapy among people newly diagnosed with HIV in East London: a qualitative study

“…Other qualitative studies have shown more time to process the diagnosis, and denial are barriers to starting immediately 17–19. Additional barriers cited in other qualitative studies, but not ours, include feeling too healthy to need medication,17 fear of side-effects,17 20 the stigmatising nature of attending clinic,20 not understanding the benefits of rapid ART17 and logistical issues 18 19…”

“…Literature looking at rapid ART has found high uptake rates, in a variety of settings 8–10 12 13. Qualitative studies in the USA, Eastern Africa and South Africa show various barriers to and facilitators of uptake among people living with HIV and their healthcare professionals 14–23. Barriers include time to adjust to the new HIV diagnosis, shock, denial, fear of domestic violence, anticipated side-effects and logistical issues.…”

“…Barriers include time to adjust to the new HIV diagnosis, shock, denial, fear of domestic violence, anticipated side-effects and logistical issues. Facilitators such as wanting to improve health, a sense of agency, the benefits of viral suppression and provider knowledge and attitudes have been reported 14–23…”

Lessons learned from U.S. rapid antiretroviral therapy initiation programs

“…Applying an implementation research framework such as can help distill the key factors affecting implementation of a new HIV treatment program, [19][20][21] and the Consolidated Framework for Implementation Research (CFIR) has been used previously to evaluate R-ART implementation in the US. 22,23 The objective of this analysis was to use the CFIR to understand factors affecting implementation of R-ART in the US through qualitative analysis of interviews with medical leadership who have implemented R-ART in different locations and care settings.…”

Rapid start antiretroviral therapies for improved engagement in HIV care: implementation science evaluation protocol

“…Institutional inertia, access to same-day insurance, personnel [ 46 ], clinic capacity issues, inefficient referral networks, and lack of culturally-appropriate care [ 47 ] are likely to affect access to rapid ART start services. Strains on the HIV care workforce raise questions about the long-term sustainability; provider shortages and increased demand on linkage to care or navigation services are also challenges [ 48 ]. Costs for initiation of rapid ART start services and processes, patient load, and the variety of third-party payers can all affect rapid ART start implementation [ 49 ].…”