Immediate Antiretroviral Therapy: The Need for a Health Equity Approach

Abstract

Immediate antiretroviral therapy (iART), defined as same-day initiation of ART or as soon as possible after diagnosis, has recently been recommended by global and national clinical care guidelines for patients newly diagnosed with human immunodeficiency virus (HIV). Based on San Francisco’s Rapid ART Program Initiative for HIV Diagnoses (RAPID) model, most iART programs in the US condense ART initiation, insurance acquisition, housing assessment, and mental health and substance use evaluation into an initial visit. However, the RAPID model does not explicitly address structural racism and homophobia, HIV-related stigma, medical mistrust, and other important factors at the time of diagnosis experienced more poignantly by African American, Latinx, men who have sex with men (MSM), and transgender patient populations. These factors negatively impact initial and subsequent HIV care engagement and exacerbate significant health disparities along the HIV care continuum. While iART has improved time to viral suppression and linkage to care rates, its association with retention in care and viral suppression, particularly in vulnerable populations, remains controversial. Considering that in the US the HIV epidemic is sharply defined by healthcare disparities, we argue that incorporating an explicit health equity approach into the RAPID model is vital to ensure those who disproportionately bear the burden of HIV are not left behind.

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

“…Researchers have called for studies assessing how RAPID (as a collection of immediate linkage and medication initiation services) is operationalized in different U.S. healthcare settings [ 20 , 21 ]. Understanding how distinct clinical settings operationalize the component parts of RAPID—i.e., immediate access to medical and psychosocial assessment, assistance with establishing insurance benefits, intensive HIV counseling and education, ordering of baseline laboratory tests, provision of ART medications and linkage to HIV primary care services—could be critical to the widespread scale-up of programs [ 18 , 19 , 22 ]. Providing an assessment of the types of implementation strategies that accelerate access to ART and retention in care will also move the field forward.…”

A Qualitative Study of the Experience of Immediate Antiretroviral Therapy Among Urban Persons With Newly Diagnosed Human Immunodeficiency Virus

“…Some HIV experts have wondered whether immediate ART facilitates patient empowerment or whether forgoing models of ART initiation based on “readiness” [ 20 , 21 ] does patients a disservice [ 22 ]. Others have questioned whether the benefits of immediate ART are experienced similarly across gender, sexual, and racial/ethnic identities [ 23 ]. However, literature to date is limited.…”

Test, treat, and maintain: rapid initiation of antiretroviral therapy

“…These findings suggest a need for delivery of the message to start treatment tailored to the individual patient and ensuring providers are skilled in mutual decision-making. Social determinants of health and levels of trust in the medical system will also impact patient decision-making related to rapid treatment initiation, and those who are newly diagnosed with HIV must be treated with empathy and respect to achieve optimal health outcomes [20].…”