A qualitative assessment of readiness to sustain Rapid Start ART in 14 publicly funded HIV clinics in the United States

TL;DR

This study assesses the readiness of 14 U.S. HIV clinics to sustain Rapid Start ART, finding that funding and staffing are key to long-term success.

Contribution

The study identifies three distinct stages of sustainability readiness for Rapid Start ART in U.S. clinics.

Findings

Three stages of readiness were identified: 'Well-oiled machine', 'On track', and 'To be determined'.

Funding and staffing were the most critical factors affecting sustainability of RS-ART.

Feasibility and acceptability of RS-ART were high, but long-term sustainability remains uncertain without proper resources.

Abstract

Current standards advise starting HIV antiretroviral therapy (ART) as soon as possible with the goal of achieving viral suppression. Applying the domains of a sustainability framework as a roadmap, we examine factors and strategies impacting readiness to sustain Rapid Start ART (RS-ART) across 14 sites participating in a national initiative that successfully implemented this intervention to link people with HIV to initiate ART treatment within seven days after linkage or re-engagement in care. While sustainability entails the ongoing delivery of a previously implemented intervention, factors and strategies for sustaining RS-ART have not been well-defined or studied.

We conducted one-on-one semi-structured interviews with a purposeful sample of key informants from each of the 14 sites. Data were organized using Dedoose and analyzed using thematic analysis.

We conducted a total of 27 interviews with decision-makers and key staff implementing RS-ART. We identified a continuum across the sites, reflecting three different stages of readiness to sustain RS-ART. “Well-oiled machine” sites had comprehensive sustainability plans in place with RS-ART established as their current standard practice, supported by secured funding and organizational capacity. “On track” sites demonstrated a clear vision toward sustaining RS-ART, with progress contingent on securing funding and finalizing staffing plans. “To be determined” sites faced challenges, expressing uncertainty about obtaining necessary funding and determining sufficient human resources to sustain RS-ART. While feasibility and acceptability of RS-ART, driven by improved service and patient outcomes, were high across all sites, available funding and the necessary human resources were the two critical, interrelated factors impacting readiness to sustain RS-ART.

Sites positioned to sustain RS-ART were able to secure funding for the necessary staff positions to effectively integrate it as standard of care. Future funding of HIV care programs must provide sufficient resources for all individuals to be offered RS-ART services to improve life expectancy, manage HIV as a chronic disease and prevent transmission to others. Given the dynamic nature of sustainability, future longitudinal studies are needed to evaluate RS-ART sustainability outcomes and its long-term effectiveness after it has been sustained.

The online version contains supplementary material available at 10.1186/s43058-026-00863-9.