It’s estimated that 13% of people in the U.S. who are living with HIV don’t know it, which can set them up for serious health consequences. Expanded and accessible HIV testing is a pillar of the Ending the HIV Epidemic (EHE) initiative, and it comes with flexible funding for areas that are significantly impacted by HIV. In 2021, Clark County, Nevada had one of the highest HIV rates in the nation with 153 out of every 100,000 residents living with HIV.
The county, home to Las Vegas, launched an initiative, Rapid stART, to find people who had not been tested, but were living with HIV and had been missed. Rapid stART is the result of a three-year-plus journey to bring healthcare workers, medical centers and community stakeholders together to agree on a standard protocol for rapid testing and rapid hand-off to care, making sure no time is lost getting people onto antiretroviral therapy (ART).
The genesis was the realization by one managing nurse of a major hospital that people with AIDS-defining illnesses were showing up in emergency rooms.
“A patient would be discharged from a hospital and sent back to their primary care doctor who didn’t treat HIV, who would then refer the patient to us,” said Jan Richardson, who was then a managing nurse at the University Medical Center of Southern Nevada (UMC). “A lot of these people were sick when we saw them and they had probably been [HIV-] positive for a long time.”
Many had been treated for health problems, not all related to HIV, but no one had inquired about their sexual health histories or tested them. “If this person had only been tested somewhere else and diagnosed early, we could have prevented a hospitalization, and maybe could have prevented progression to late-stage HIV illness,” Richardson said.
In 2019, Richardson, who’s now a consultant with the Clark County Social Service Office of HIV, encouraged doctors in UMC’s emergency department to provide opt-out testing, where people are tested for HIV unless they decline. They agreed, and within two weeks they had their first person who tested positive for HIV. Two nurse navigators were added to regularly visit the ER to ensure that anyone who tests positive gets into care as soon as they leave. “We wanted to make sure [people] didn’t get lost in the system,” Richardson said.
But Richardson knew the county wouldn’t find everyone who needed care unless a critical mass of urgent care facilities and emergency departments provided opt-out testing and linkage to care. “My vision was if we could just start making doctors think about HIV and test for it, then we could reduce some of these hospitalizations.”
To get all stakeholders on board, a county-wide plan with buy-in from healthcare facilities, and funding, was needed.
Rapid stART learning collaborative
In 2020, a learning collaborative was formed, led by the Clark County Social Service Office of HIV, the Pacific AIDS Education and Training Center, and the University of California-San Francisco (UCSF), along with nine community health organizations. Heather Shoop, assistant manager and grant administrator of the Clark County Social Service Office of HIV, was hired in early 2020, just before the COVID pandemic led to the shutdown of in-person meetings and services. Shoop, who helped organize the collaborative, said leadership group meetings, bi-weekly data performance meetings and the creation of more than two dozen webinars, all done via Zoom, gained agreement on best practices and metrics for Rapid stART.
“We built a coordinated program all online during the pandemic, and we expanded Rapid stART through a coordinated community-wide effort where all of the agencies are in touch with us,” Shoop said.
A bill passed in the Nevada legislature, SB 211, which allows primary care and emergency departments to begin opt-out testing for people over the age of 15, was the final piece of the puzzle.
The collaborative agreed on several goals:
- Dramatically expand the number of sites doing Rapid stART testing
- Begin a Rapid stART rideshare program
- Convene a Rapid stART Response team
- Produce a Rapid stART module and manual
The learning collaborative set into motion a process that’s producing results. Between 2020 and 2023, Clark County expanded the number of sites doing opt-out HIV testing from 4 to 27, and the number of agencies linking people to care from 2 to 27. A key part of that linkage to care was a navigation system in which a participating clinic immediately sends a staffer to an ER when they get a call about a person testing positive.
While some facilities provide testing but not services, now they are at least aware of where to refer someone. “You’d think agencies would know where to send clients, but in Clark County there were a lot of agencies providing the same services, with no centralized referral system,” said Octavio Posada, a consultant who coordinated the learning collaborative.
“We connected agencies that wouldn’t know about other services,” he added. “If a patient needs a ride, the facilities can send an Uber or Lyft.”
The vast majority who get tested turn out not to have HIV, but people who test positive can get into care quickly.
The priority is getting a person into medical care on the day of diagnosis or within a seven-day window afterwards
“[Opt-out testing] is rolling out and started with UMC Wellness Center primary and quick cares, and after two years they just hit the 10,000-test mark,” Shoop said. “It is all unfolding as it needs to, and over time we will see more and more clinics, [emergency departments] and primary care centers doing this type of testing.”
Shoop and Richardson emphasized that any county in the U.S. could achieve similar results, and they pointed to a downloadable Rapid stART manual that came out of the collaborative.
HRSA’s Special Projects of National Significance (SPNS), which the county obtained through a joint grant with UCSF, helped fund the Rapid stART learning collaborative.
“The county uses a blend of different funding streams, including Ryan White and EHE funds, but it was EHE that helped the county put the rapid in Rapid stART, specifically by eliminating bureaucratic hurdles,” Shoop said. “The eligibility criteria across Nevada for Ryan White-funded services are multi-pronged: an HIV diagnosis, being a resident of the grant area and having an income less than 400% of the federal poverty level. The more requirements you have, the more time it takes to start people in services, if they’re eligible. With EHE funds the only eligibility requirement is an HIV diagnosis. The priority is getting a person into medical care on the day of diagnosis or within a seven-day window afterwards, and there’s no other barrier around eligibility.”
DOWNLOAD the Rapid stART manual: bit.ly/rapid-start-manual.
Larry Buhl is a multimedia journalist based in Los Angeles. He has covered HIV/AIDS and other infectious diseases for more than two decades. In addition to POSITIVELY AWARE, he is a regular contributor to TheBody.com, Everyday Health and capitalandmain.com. His work has appeared in USA Today, Salon, Undark, KQED, the New York Times and others.