Rapid Start InitiationStarting HIV Treatment As Soon As Possible
Rapid Start initiation is an HIV treatment strategy that is supported and recommended by many organizations, including the US Department of Health and Human Services (DHHS).1-4 Rapid Start can provide health benefits for people with HIV, such as an increase in the uptake of ART and linkage to care, decrease in the time to viral suppression, and improvement in viral suppression rates, when HIV treatment is taken as prescribed.1
What is Rapid Start?
Rapid Start is the initiation of antiretroviral treatment (ART) as soon as possible after an HIV diagnosis.1 While Rapid Start is supported and recommended by DHHS, the World Health Organization (WHO), the AIDS Education Training Center (AETC), and the New York State Department of Health (NYSDOH), the definitions of Rapid Start and the length of time between diagnosis and treatment initiation vary.1-4 When initiating ART, it is important to educate patients about the goals and benefits of ART and to identify and address barriers to care engagement and treatment adherence.
Initiating ART immediately (or as soon as possible) after an HIV diagnosis1
DHHS
Rapid initiation is defined as within 7 days from the day of HIV diagnosis2
WHO
Starting HIV treatment as soon as possible after the diagnosis of HIV infection, preferably on the first clinic visit (and even on the same day the HIV diagnosis is made)3
AETC
Rapid initiation of ART preferably on the same day of diagnosis or within 72 hours—should be offered to all individuals who are candidates for rapid ART initiation4
NYSDOH
Based on the recommendations from DHHS, WHO, and NYSDOH, Gilead recommends Rapid Start be considered on the same day of diagnosis, within 3 days, or within 7 days.1,2,4 Gilead's suggested 1-3-7 framework for Rapid Start may help organizations and clinics implement a Rapid Start protocol and help move patients through the HIV care continuum quickly.
Gilead's suggested 1-3-7 framework for Rapid Start
Potential benefits of Rapid start
According to DHHS guidelines, beginning HIV treatment as soon as possible after a diagnosis may provide important health benefits, including helping:
- Increase the uptake of ART and viral suppression rates when HIV treatment is taken as prescribed1
- Decrease the time to viral suppression1
- Reduce transmission to HIV-negative sexual partners if an undetectable viral load (HIV-1 RNA <200 c/mL) is maintained for at least 6 months1
- Improve retention in care1
Why Rapid Start Matters:
- Getting to and keeping an undetectable viral load may help reduce internalized stigma5
- Data from 2013 to 2014 (N=86) showed that the median time to viral suppression was 2.5 months sooner among Rapid Start patients (n=39) compared with those in a non–Rapid Start intervention (P=0.0001)6
- Data from 2016 to 2017 (N=274) showed that more people were virally suppressed (<100 copies/mL) after 1 year when they initiated same-day Rapid Start vs standard ART care (50.4% vs 34.3%; P=0.007)7
- According to DHHS, achieving and maintaining an undetectable viral load by taking and adhering to ART as prescribed for at least 6 months prevents transmission of HIV to sexual partners1
A Rapid Start Case Study: Valley AIDS Council
In 2022, the Valley AIDS Council (VAC)—primary provider of HIV services, education, and testing services in the Harlingen, Texas area and Gilead grant recipient—implemented RAPIDO: Rapid ART Program for Individuals to reach unDetectable Outcomes.8,9,10 This Rapid ART initiation program focused on making HIV healthcare, education, and resources more accessible to the Hispanic/Latino communities served by VAC.
Many factors contribute to low rates of engagement in HIV care by the Hispanic/Latino community. These include, but are not limited to, stigma, language barriers, lack of education about HIV, and limited access to care and culturally appropriate services.11
In patients 13 and older:
- In 2021, the Hispanic/Latino community represented 18% of the US population, but represented 25% of people reportedly living with HIV12
- In 2022, only 73% of HIV-positive Hispanic/Latino people with diagnosed HIV in the US received HIV care13
- No more than 64% of Hispanic/Latino people with diagnosed HIV in the US were virally suppressed13
In just one year, the program was successful in building trustworthiness in their South Texas community, thanks in good part to their ‘red carpet’ approach concerning patient navigation, which included10:
- Providing HIV education (like U=U and the importance of treatment) within 2 hours of a preliminary positive HIV test
- Scheduling a same-day appointment with a clinician (virtual or in-person) who provides a 2–week ART starter pack
- Coordinating with a case manager who provides 8 weeks of focused services, including follow-up testing
Results of RAPIDO program after 1 year14
Through RAPIDO, VAC showed that a holistic, patient-centric strategy, combined with appropriate treatment and equity, could help in the reduction of barriers to HIV healthcare and lead to better outcomes for people living with HIV.10
Rapid Start and Health Equity
For people living with HIV who face barriers to care, such as income inequality, medical mistrust, or stigma, it can be difficult to seek and receive the care they need.11,15-17
Rapid Start looks to address bias by standardizing protocols for every patient, no matter their financial situation.18,19,§ It may also help individuals get linked to care in the same visit, alleviating the burden of coordinating additional visits or taking additional time to return for subsequent appointments.5,20
“The Rapid Start program really helps with bias and equity because it is the same protocol [for everyone], and it is not dependent on somebody’s housing status or funding.”18
Linking patients to treatment immediately following a positive HIV diagnosis may lead to better engagement in care and, therefore, better health outcomes in the long term.15,16
- US Department of Health and Human Services (DHHS). Panel on Antiretroviral Guidelines for Adults and Adolescents. Guidelines for the Use of Antiretroviral Agents in Adults and Adolescents with HIV. Published February 27, 2024. Accessed June 20, 2024. https://clinicalinfo.hiv.gov/en/guidelines/adult-and-adolescent-arv
- World Health Organization. Consolidated Guidelines on HIV Prevention, Testing, Treatment, Service Delivery and Monitoring: Recommendations for a Public Health Approach. Published July 16, 2021. Accessed June 20, 2024. https://www.who.int/publications/i/item/9789240031593
- Coffey S, Bacchetti P, Sachdev D, et al. RAPID antiretroviral therapy: high virologic suppression rates with immediate antiretroviral therapy initiation in a vulnerable urban clinic population. AIDS. 2019;33(5):825-832. doi:10.1097/QAD.0000000000002124
- Radix AE, Fine SM, Vail RM, et al. Rapid ART Initiation. Published January 27, 2020. Updated February 9, 2023. Accessed June 21, 2024. https://www.hivguidelines.org/wp-content/uploads/2023/01/NYSDOH-AI-Rapid-ART-Initiation_10-5-2023_HG.pdf
- Eisinger RW, Dieffenbach CW, Fauci AS. HIV viral load and transmissibility of HIV infection: undetectable equals untransmittable. JAMA. 2019;321(5):451-452. doi:10.1001/jama.2018.21167
- Pilcher CD, Ospina-Norvell C, Dasgupta A, et al. The effect of same-day observed initiation of antiretroviral therapy on HIV viral load and treatment outcomes in a US public health setting. J Acquir Immune Defic Syndr. 2017;74(1):44-51. doi: 10.1097/QAI.0000000000001134
- Labhardt ND, Ringera I, Lejone TI, et al. Effect of offering same-day ART vs usual health facility referral during home-based HIV testing on linkage to care and viral suppression among adults with HIV in Lesotho: the CASCADE randomized clinical trial. JAMA. 2018;319(11):1103-1112. doi:10.1001/jama.2018.1818
- Valley Aids Council. Mission & History. Accessed June 21, 2024. https://www.valleyaids.org/mission-history
- TargetHIV. Building Capacity to Implement Rapid ART Start for Improved Care Engagement in the Ryan White HIV/AIDS Program – Evaluation and Technical Assistance Provider. Accessed July 15, 2024. https://www.hrsa.gov/grants/find-funding/HRSA-20-114
- Coronado Jr. Data on File (RAPIDO Flowchart).
- Guilamo-Ramos V, Thimm-Kaiser M, Benzekri A, et al. The invisible US Hispanic/Latino HIV crisis: addressing gaps in the national response. Am J Public Health. 2020;110(1):27-31. doi:10.2105/AJPH.2019.305309
- HIV.org. Impact on racial and ethnic minorities. Updated December 18, 2023. Accessed June 20, 2024. https://www.hiv.gov/hiv-basics/overview/data-and-trends/impact-on-racial-and-ethnic-minorities
- Centers for Disease Control and Prevention. Monitoring selected national HIV prevention and care objectives by using HIV surveillance data—United States and 6 territories and freely associated states, 2022. HIV Surveillance Supplemental Report. 2024;29(No. 2). Published May 2024. Accessed July 15, 2024. https://www.cdc.gov/hiv-data/nhss/national-hiv-prevention-and-care-outcomes.html
- Coronado Jr. Data on File (RAPIDO Outcomes).
- Bourdeau B, Shade SB, Koester KA, et al. Rapid start antiretroviral therapies for improved engagement in HIV care: implementation science evaluation protocol. BMC Health Services Research. 2023;17;23(1):503. doi.org/10.1186/s12913-023-09500-w
- Chow JY, Gao A, Ahn C, et al. Rapid start of antiretroviral therapy in a large urban clinic in the US south: Impact on HIV care continuum outcomes and medication adherence. J Int Assoc Provid AIDS Care. 2024;23:23259582241228164. doi.org/10.1177/23259582241228164
- Sweeney SM, Vanable PA. The association of HIV-related stigma to HIV medication adherence: a systematic review and synthesis of the literature. AIDS and Behavior. 2016;20:29-50. doi:10.1007/s10461-015-1164-1
- U.S. Department of Health and Human Services (DHHS). Harnessing the Power of Community Engagement and Innovation to End the HIV Epidemic: 2023 Ryan White HIV/AIDS Program Highlights. Published September 2023. Accessed June 21, 2024. https://ryanwhite.hrsa.gov/sites/default/files/ryanwhite/data/hrsa-biennial-report-2023.pdf
- Halperin J, Conner K, Butler I, et al. A care continuum of immediate ART for newly diagnosed patients and patients presenting later to care at a federally qualified health center in New Orleans. Open Forum Infectious Diseases. 2019;6(4):ofz161. doi: 10.1093/ofid/ofz161
- Koenig SP, Dorvil N, Dévieux JG, et al. Same-day HIV testing with initiation of antiretroviral therapy versus standard care for people living with HIV: A randomized unblinded trial. PLoS Med. 2017;14(7):e1002357. doi:10.1371/journal.pmed.1002357