Historically, the role of the emergency physician in HIV care has been constrained to treating sick patients with opportunistic infections and postexposure prophylaxis for occupational exposures. However, advances in HIV care have led to medications that have substantially fewer issues with toxicity and resistance, opening up an exciting new opportunity for emergency physicians to participate in treating the HIV virus itself. With this new role, it is crucial that emergency physicians be familiar with the advances in testing and medications for HIV prevention and treatment. To our knowledge, to date there has not yet been an article addressing this expansion of practice. We have compiled a summary of what the emergency physician needs to know, including misconceptions associated with antiretroviral therapy, medication complexity, toxicity, resistance, and usability. Additionally, we review potential indications for prescribing these drugs in the emergency department, including the role of the emergency physician in postexposure prophylaxis, preexposure prophylaxis, and treatment of acute HIV, as well as how emergency physicians can engage with chronic HIV infection.

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Study Objectives: The acute phase of HIV infection is a highly transmissible phase and responsible for a disproportionate amount of new HIV infections. During this phase, individuals have non-specific viral symptoms, high viral loads, and the HIV virus itself is more virulent, which is more conducive to virus transmission than in chronic HIV infection. A key to controlling the spread of HIV is identifying acute HIV infection early and getting newly infected individuals to alter their behavior and start antiretroviral therapy (ART) immediately. The objective of this study is to determine the feasibility and willingness of patients with suspected acute HIV infection to begin empiric antiretroviral therapy in the emergency department. Methods: Since 2011, over 68,000 patients have been tested for HIV in our nontargeted screening program in a large urban emergency department (ED). In this screening program, 852 HIV positive patients have been identified, of which 274 patients were newly diagnosed as HIV positive in the ED. An HIV specialist evaluates all patients who are newly diagnosed with HIV in real time in the emergency department. In December 2014, in conjunction with HIV specialists, we began offering ART to individuals with likely acute infection if they had: 1) a clinical history consistent with acute HIV infection 2) Negative HIV test in the last 6-12 months 3) No co-morbid conditions with risks that outweigh the benefits of treatment 4) 4 th generation positive HIV test with pending HIV 1/2 antibody test and HIV viral load by PCR 5) Stable baseline CBC and chemistry panel in the ED 6) Genotype and CD4 can be ordered in ED and 7) Patient understands and/or agrees to: a) confirmatory tests b) take medication c) commit to abstinence or 100% condom use d) notify partners e) a follow-up appointment and f) provide reliable personal contact information (phone number/email address). Results: From December 1, 2014 to October 1, 2015, there have been 14 confirmed cases of acute HIV infection in our ED screening program. Of these, nine of the cases were identified in the ED in real time as likely acute HIV using the aforementioned criteria. All nine were offered and agreed to empiric ART in the ED after evaluation by an HIV specialist. One patient withdrew prior to starting ART. The other eight patients were prescribed ART in the ED. Eight of the nine patients suspected to be acutely infected were ultimately confirmed to be acutely infected with HIV and one patient was chronically infected. There were no false positive tests. Conclusion: Prescribing empiric ART in the ED for acute HIV infection is feasible and well received by patients. This novel approach using 4 th generation immunoassays and empiric ART facilitates urgent HIV intervention, which can lead to an expanded ED role in the HIV care continuum.