Knowledge, structural barriers and attitudes to HIV Rapid Start among New Jersey providers

BackgroundRapid Start results in persons with HIV (PWH) initiating antiretroviral therapy (ART) in less than seven days. Benefits associated with Rapid Start include linkage to medical care and starting ART on the same day as diagnosis. These PWH were better retained in medical care and likely to achieve virologic suppression, in a shorter time, than those who did not have access to Rapid Start. Despite recommendations to initiate ART less than seven days after diagnosis, slow uptake of Rapid Start, in New Jersey were noted. ObjectiveIdentify knowledge, structural barriers and attitudes to Rapid Start, among New Jersey providers. MethodsAn electronic survey using Qualtrics consisting of 33 questions with the following domains: provider and practice characteristics (11), knowledge (1), structural barriers (9) and attitudes to diverse patient types was administered to New Jersey providers. The results were analyzed using descriptive statistics due to small numbers over strata. Approval to conduct this survey was obtained from the William Paterson University Institutional Review Board. ResultsThe respondents were less than 55 years old (36/56, 64%), female (44/60, 73%), heterosexual (50/59, 85%), and nurse practitioners or physician assistants (41/59, 69%). Those who identified as internal medicine (9, 47%) or infectious disease (6, 60%) providers or worked in Ryan White (3, 30%) and non-Ryan White (6, 55%) practices correctly identified that integrase inhibitors had the lowest prevalence of transmitted resistance, when compared to those in private and other clinical settings. Newly diagnosed patients were referred for medical care in 37 (65%) of the medical sites. However, only providers from Ryan White (federally funded clinics for HIV patients) (64%) and non-Ryan White (73%) public sites reported co-located HIV testing sites. Seventy percent of medical sites reported that they offered same-day medical appointments. However, a lower proportion of private (62%), public Ryan White (55%), and other medical sites (36%) offered same-day appointments compared to public non-Ryan White sites (82%). Despite having staff available 40 hours per week (91%), only 55% of Ryan White sites offered extended office hours in the early morning, evenings, or on Saturdays. When compared to providers in public Ryan White sites, a higher proportions of providers in non-Ryan White sites were comfortable doing Rapid Start either on the day of or within one week of diagnosis, 72% and 82%, respectively, or starting ART before genotype results were available, 46% and 55%, respectively. Providers in public non-Ryan White sites were comfortable with Rapid Start for the following diverse groups of patients: with untreated mental illness (64%), engaging in unprotected sex (73%), with multiple partners (91%), actively using illicit drugs (91%), without health insurance (91%), homeless (100%), and with acute infection (82%). ConclusionsPolicy and administrative decisions are needed to eliminate structural barriers at the clinic level. Education on guideline recommendations and with diverse groups of patients will increase comfort with Rapid Start.