To achieve the Ending the HIV Epidemic in the US (EHE) initiative goal of reducing new HIV infections in the United States by 90% by 2030, people with HIV (PWH) need to have a diagnosis as early as possible and be treated with antiretroviral therapy (ART) rapidly and effectively to have sustained viral suppression.^1,2 Rapid initiation of ART, ideally on the same day as HIV diagnosis or return to care, offers immediate access to HIV medical care.^3–6 Rapid ART reduces the time to viral suppression and improves morbidity and mortality in PWH.^3–5 Delays in initiating ART are associated with subsequent lower rates of viral suppression and retention in care, and with earlier development of first AIDS event.⁵

The Ryan White HIV/AIDS Program (RWHAP) is a federally funded program providing a comprehensive system of HIV primary medical care, essential support services, and medications for low-income PWH who are uninsured and underserved.⁷ For the past 30 years, the RWHAP has had an important role in the national public health response to HIV—more than half of adults with diagnosed HIV rely on the program.^8,9 However, RWHAP may have specific eligibility requirements and considerations that can affect clinic enrollment and ART initiation processes.

Rapid linkage to HIV care and ART initiation is now the standard of care for treating PWH and is a key strategy of EHE.^1–6 Structural, provider-related, and patient-level barriers may impede rapid clinic enrollment and initiation of ART. Understanding and addressing these barriers is essential to meet the goals of EHE. In this study, we examined the availability of, and barriers to, rapid enrollment and ART initiation among HIV care facilities attended by a representative sample of PWH in the United States, overall and by RWHAP funding status of facilities.

The Medical Monitoring Project (MMP) is a two-stage complex sample survey that produces nationally representative estimates of US adults with diagnosed HIV.¹⁰ We analyzed MMP Facility Survey data collected 07/2021–11/2021 on characteristics of 455 facilities providing care to MMP 2019 cycle respondents (response rate, 45%).¹¹ Participating facility characteristics and survey administration methods have been described elsewhere.¹¹ Data were weighted based on weighting classes informed by a nonresponse analysis to reduce nonresponse bias in facility-level estimates. Facility data on the number of business days needed to offer an appointment to patients who are new to the facility, availability of and barriers to rapid enrollment and ART initiation, and facility characteristics, including RWHAP funding, were collected. Time to enrollment was defined as the number of business days from an initial request by patients who are new to the facility until an appointment with an HIV care provider is routinely offered. Rapid enrollment was defined as ≤1 business day. Rapid ART initiation was defined as routinely being able to provide a 30-day supply of ART at the first HIV care provider visit. The term provider refers to a health care professional with prescribing privileges authorized by the state. See Appendix 1 for relevant survey questions, Supplemental Digital Content, http://links.lww.com/QAI/C508. We generated weighted percentages with 95% confidence intervals (CI) of facility characteristics. We assessed significant (P < 0.05) differences in characteristics of facilities by RWHAP funding status using Rao–Scott χ² tests.

Among HIV care facilities providing care to a nationally representative sample of US PWH, we documented the availability of and barriers to rapid enrollment and ART initiation, which are key strategies of Ending the HIV Epidemic in the United States. Only 1 in 5 facilities could routinely enroll patients with a first appointment in ≤1 day. However, 73% of facilities reported all patients were routinely able to obtain a 30-day supply of ART on the day of their first HIV care provider visit. Structural, provider-related, or patient-level barriers may delay rapid enrollment or ART initiation. HIV care programs can benefit from removing barriers to care, easing requirements for clinical enrollment and ART prescriptions, and improving patient readiness.

Although rapid clinic enrollment is a crucial component of efforts to reduce the time from HIV diagnosis to viral suppression, only 20% of HIV facilities were able to provide rapid enrollment. Insufficient provider capacity was a major barrier to rapid enrollment. Studies have highlighted gaps between the current HIV workforce and the demand for HIV services, along with high dissatisfaction among HIV care providers regarding remuneration and administrative tasks.^11–13 To address this HIV workforce shortage, strategies such as establishing a broad base of clinicians serving fewer patients and recruiting/training non-HIV primary care providers have been proposed.¹⁴ In addition, task shifting and care models that prioritize patients with higher medical needs and newly diagnosed individuals are also potential solutions.^15–17 Likewise, improved care coordination in Federally Qualified Health Centers has shown promise in addressing provider capacity issues.^11,18

Many facilities require certain documents, generally related to establishing benefits in order for services to be covered (such as proof of income or residence), before scheduling or offering an appointment for clinic enrollment. Notably, RWHAP-funded facilities mandate more documents for scheduling the first appointment, which may hinder rapid enrollment and ART initiation. We also found that requiring diagnostic or confirmatory HIV test results could be a barrier to both rapid clinic enrollment and ART initiation. These concerns or policies may stem from past experiences when ART had higher toxicity and testing methods were less precise.^19,20 To expedite care, successful interventions have involved easing document requirements and expanding eligibility (eg, presumptive RWHAP eligibility) for rapid enrollment.¹⁶ Other streamlining efforts include dedicated open scheduling slots specifically for patients starting ART and not mandating baseline laboratory tests before an appointment or ART initiation.^6,21

Our findings show that patient—and, to a lesser extent, provider—concerns about rapid enrollment and ART initiation are prevalent. Patient preference was a frequently reported barrier to both rapid clinic enrollment and ART initiation. Concerns about side effects, mistrust of medications/providers, impact on quality of life, HIV stigma, discrimination, and preference for alternative medicine/self-care are linked to lower ART acceptance in patients already receiving HIV care.^22–24 Patient–provider communication that reinforces respect, trust, and HIV treatment literacy, along with convenient multipurpose HIV care facilities and personalized treatment plans addressing possible diagnosis denial, are essential for optimizing engagement.^25,26

Provider knowledge, attitudes, and beliefs about rapid ART initiation vary. Many providers adhere to “traditional” views of readiness (eg, insufficient time to adjust to an HIV diagnosis), which in turn influences perceived patient willingness to start treatment.^19,27 Furthermore, provider views on readiness differ based on patient characteristics, potentially leading to disparities if certain groups are not considered ready for treatment.¹⁹ Our data reveal that a minority of facilities report providers (12%) or facility administration (4%) not being fully committed to immediate ART initiation. Other surveys also support this by indicating provider apprehension toward rapid ART initiation because of ART resistance and effectiveness concerns.^16,28

To improve perceived readiness among both patients and providers, exploring shared decision-making and providing education for both parties are crucial areas of focus. Patients may not be fully prepared for ART initiation before their first visit date. Since Rapid ART initiation is now the standard of care, clinics, programs, and providers should have personnel available to offer ART promptly while also being attentive to patients’ preferences and needs. Training initiatives, such as those provided by AIDS Education Training Centers and Centers for Disease Control and Prevention’s Capacity Building Assistance programs, have demonstrated some success in increasing the quality of care provided to PWH.^16,29–31 Enhancing and expanding patient-centered initiatives focused on the benefits of rapid ART initiation, along with increasing provider participation in these efforts, may help improve rapid ART knowledge and beliefs.

Some limitations of this analysis include low facility survey response rate, although we minimized potential bias by weighting the data based on information known for all facilities. Because patients did not complete facility surveys, barriers such as patient readiness were measured from the facility perspective, and some terms that were not defined were subject to interpretation from the facility. Patient-level information, including diagnosis date, was unavailable for this study, preventing the calculation of key metrics such as the time from diagnosis to the first appointment and ART initiation. In addition, individual outcomes and sociodemographic factors associated with ART receipt and care were not reported here but have been published by the MMP.³² Facilities adapt varying ancillary services to overcome barriers to care. The survey did not measure the implementation of reported practices, nor was the quality of implemented practices assessed. Facility patients’ perspectives on the availability of services and their quality may differ from those of facility staff.^33,34 Finally, social desirability bias in reporting on facility practices might have affected our estimates.

The barriers reported in this analysis are similar to those in prior studies.^16,19 Future analyses should consider individual-level variables such as housing instability, stigma, and medical mistrust to better understand their impact on rapid enrollment and ART initiation. Structural, provider-related, or patient-level barriers may delay rapid clinic enrollment or ART initiation. To ensure the success of rapid ART programs, health systems must streamline bureaucratic processes, reduce structural barriers, increase the HIV workforce, and improve patient/provider readiness to initiate ART rapidly.

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