Building Capacity to Implement Rapid Start ART to Improve Care Engagement in Ryan White HIV/AIDS Program Settings

The Building Capacity to Implement Rapid Start to Improve Care Engagement Initiative funded 14 sites across the United States to implement and evaluate “Rapid Start” antiretroviral therapy (ART) services. The Health Resources and Services Administration’s Ryan White HIV/ AIDS Program (RWHAP) Part F–Special Projects of National Significance (SPNS) Program sponsored this initiative to accelerate the initiation of ART and entry into HIV medical care for people with HIV who are newly diagnosed, new to care, or out of care. Each of the implementation sites had the capacity and infrastructure to support Rapid Start ART, had initiated pilot projects, or were ready to expand Rapid Start ART services, with the goal of replicating and expanding successful Rapid Start ART models. Implementation sites included RWHAP-funded clinics, Federally Qualified Health Centers, academic medical centers, and community-based organizations. Funding from the Department of Health and Human Services (HHS) Minority HIV/AIDS Fund (MHAF) also supported this initiative.

Project Goals

The University of California, San Francisco (UCSF) was the initiative’s Evaluation and Technical Assistance Provider (ETAP). UCSF offered technical assistance to the implementation sites, evaluated the implementation of Rapid Start ART services, assessed HIV care continuum outcomes, and produced resources for future replication and scale-up of Rapid Start ART in other RWHAP provider organizations.

Key Characteristics of Rapid Start ART Services

• Provision of client-centered services
• On-site testing or strong partnerships with testing programs
• Warm hand-offs and accessible linkage coordinators
• Accessible education on beginning ART
• Accelerated access to a medical visit with an HIV provider
• Early and sustained access to ART. Pre-approved ART regimens and starter pack of medications
• Patient-Centered
• Expedited Patient Flow
• Benefits & Supportive Needs
• Accelerated insurance/payor approval and clinic enrollment Team
• Follow-up with continued education, patient navigation, and supportive services

Learning Collaborative

All sites participated in the initiative-wide Learning Collaborative1 that provided the structure for technical assistance. The Learning Collaborative also provided a common set of strategies for adoption, uptake, and integration of Rapid Start ART services. Sites participated in regular initiative-wide learning sessions and received individualized coaching to support local quality improvement projects to benefit implementation outcomes. The Learning Collaborative:

• Facilitated capacity building by providing training, offering TA, and facilitating peer-to-peer learning to share best practices and lessons learned
• Collaborated on the development of quality measures that were used by all sites to assess progress in short cycles associated with quality improvement and longer-term trends
• Provided opportunities for engagement with subject matter experts to guide the development and implementation of Rapid Start ART

Multi-site Evaluation focusing on Implementation, Effectiveness, and Cost

Based on the Proctor Implementation Science Framework2 and the Dynamic Capabilities Model,3 UCSF used an Effectiveness-Implementation Hybrid Type 24 Design to assess the key implementation strategies for uptake of Rapid Start ART services and assessed HIV care continuum outcomes for the patients served by these 14 implementation sites. Using a mix of qualitative and quantitative data collection approaches (Embedded Experimental Model Design5), the ETAP multi-site evaluation included:

• Conducting a process evaluation to characterize adaptation, implementation, and barriers and facilitators associated with Rapid Start ART service implementation
• Evaluating clinical care delivery, including time to entry into care and initiation of ART, as well as rates of engagement and retention in care after rapid ART initiation
• Assessing the impact of adoption and implementation of Rapid Start ART services on increased viral suppression (VS), shorter time to VS, and/or durable and sustained VS
• Collecting cost data to determine the labor, programmatic, and structural costs associated with adapting and implementing the models of Rapid Start ART service provision at the implementation sites

Dissemination and Replication

Implementation materials are being developed through the course of the initiative, building to the capstone Rapid Start ART Replication & Implementation Manual. Other products include:

• Materials that focus on overcoming specific challenges (e.g., marketing, integration with housing programs, and integrating technology)
• Webinars and conference presentations about Rapid Start ART implementation
• Examples of clinic/agency protocols and workflow maps
• Journal articles describing evaluation findings
• Partners: Impact Marketing + Communications and TargetHIV

Principal Investigator

Janet Myers, PhD, MPH 

Project Director

Beth Bourdeau, PhD