A Nurse-Driven Model to Facilitating Same-Day ART Initiation

Segment Description: Heather Alt, BSN, RN, ACRN, CPH, deputy director of nursing at Whitman-Walker Health, discusses research presented at ANAC 2019 on a nurse-led model for same-day initiation of antiretroviral therapy for people newly diagnosed with HIV.

Interview transcript: (modified slightly for readability):

Contagion®: In general, can you discuss some of the pros of early, even same-day, initiation of ART for people newly diagnosed with HIV?

Alt: We know through a couple of clinical trials that there's a lot of benefits for patients to start on meds as soon as possible, and that's both a benefit for the community [to] get people's viral loads under control. And then also on an individual basis, but more than the quantitative benefits, I think that it could be a really stigma-reducing effort to help people get on meds as soon as possible so that they're leaving their health center the same day as they might receive their diagnosis with a plan and already on treatment.

Contagion®: Why are nurses uniquely positioned to facilitate same-day ART initiation?

Alt: I always say that nurses are the most compassionate control freaks and if you want something done and done well and done kindly, to give it to a nurse. Often, the nurse is doing a lot of the relationship building and might speak with the patient in between appointments and know their lifestyle and how to fit medication in and that can help inform the whole clinical team and what treatment might be right for the patient, of course we want to involve the patient as well.

Contagion®: Can you discuss the key takeaways from this program?

Alt: When we developed it, we were making it for patients who either recently tested HIV positive, whether that was on-site at our federally qualified health center, or maybe they tested positive through their external primary care office or an ER or a home test…So either they had just tested positive, or maybe they had tested positive some time ago, but had never entered HIV medical care and for whatever reason, today was the day that they were ready to take those steps so we're going to do everything we can to get them started on their treatment. And also, when we developed the program, we wanted to make sure that we had options for anybody and everybody to access meds, whether or not they had coverage. And so we have a really robust system in place to make sure that people are able to start meds.

We have a wonderful department at Whitman-Walker Health called the Public Benefits and Insurance Navigation team that’re able to figure out what coverage options might be available for patients. And the sort of the final thing that makes our program strong and unique is we also offer directly observed therapy of the first dose, so not only have you had this very emotionally laden, complicated day, but someone's able to start treatment with them by their side, and I think that's a really powerful moment. So the nurses will offer to the patient that they'd like to start their meds with us.

Contagion®: Is this a model that can be easily implemented in other community health centers?

Alt: I think it's very flexible and dynamic and can be tailored to fit all sorts of practices. We already had a great system in place to get people same-day medical care as when they tested positive so we just kind of stuffed starting treatment into that, but I think, once it was set up, it did not take a lot of resources after that to maintain it. It was first just identifying what the resources are for patients who might not have coverage that day in order to access meds but, after that—the nurse is often seen as a nucleus of the health center—I think it's very easy to replicate and give to 1 role or a person to champion at their agency.

I think this is a situation where you don't need to wait for the data to show whether it's the right thing to do or not. I think it is the right thing to do and certainly around reducing stigma. [In] our existing model…patients would start meds maybe 3 weeks after they entered medical care, which is still a relatively short period of time, but even reducing that weight by 3 weeks so the patient's not marinating in, “What's treatment going to be like? How am I going to access meds? Someone told me this is a really serious health condition, but I'm not doing anything about it.” Since we're able to take some of that away, I think we're offering people a lot of hope and action.

The study, Fast Forward to Viral Suppression: A Nurse-driven Model for Facilitating Same Day Start of ARVs Following Reactive HIV+ Result or First-time Engagement in HIV Care, was presented Friday, November 8, 2019, at ANAC 2019, in Portland, Oregon.