High Feasibility of Empiric HIV Treatment for Patients With Suspected Acute HIV in an Emergency Department

Abstract

Earlier intervention in acute HIV infection limits HIV reservoirs and may decrease HIV transmission. We developed criteria for empiric antiretroviral therapy (ART) in an emergency department (ED) routine HIV screening program. We assessed the feasibility and willingness of patients with suspected acute HIV infection in the ED to begin ART. A suspected acute HIV infection was defined as a positive HIV antigen antibody combination immunoassay with pending HIV-antibody differentiation test results and HIV RNA viral load. During the study period, there were 16 confirmed cases of acute HIV infection: 11 met our criteria for empiric ART and agreed to treatment, 10 were prescribed ART, and 1 left the ED against medical advice without a prescription for ART. Eight patients completed at least one follow-up visit. Empiric HIV treatment in an ED is feasible, well received by patients, and offers a unique entry point into the HIV care continuum.

Expanding Hospital Human Immunodeficiency Virus Testing in the Bronx, New York and Washington, District of Columbia: Results From the HPTN 065 Study

“…Hospitals were encouraged to use routine laboratory-based HIV tests for screening because they facilitate testing larger numbers of patients and were better at identifying acute infections that would be missed by point-of-care antibody tests. [10, 11, 28–30] At the two hospitals in the Bronx and the two in DC that successfully adopted centralized laboratory HIV testing during the study, the annual number of tests conducted during ED visits more than doubled. However, in most participating hospitals, point-of-care rapid HIV tests constituted the majority of tests performed during the study period.…”

HIV Prevention and Treatment: The Evolving Role of the Emergency Department

“…Acute HIV infection is a medical and public health emergency that is now often recognized in the ED and merits immediate treatment with antiretroviral therapy. 43 Previously, given the nonspecific nature of acute HIV infection and older first-line HIV testing that would not routinely detect HIV infection at very early points, emergency physicians would rarely knowingly encounter acute HIV infection, and, even if it was encountered, treatment was considered to be supportive. Now, with recent scaling up of efforts for routine HIV testing in EDs, and the development of the HIV-1 and -2 antigen/ antibody immunoassay tests that detect acute and chronic infections, increasing numbers of patients with acute infections are identified in the ED.…”

“…Immediate treatment of acute HIV identified in the ED under the supervision of an HIV or infectious disease specialist is safe and feasible, as demonstrated by recent data from our study conducted in a large urban ED, as well as that of the Rapid ART Program Initiative for HIV Diagnoses (RAPID) program in San Francisco. 43,59 Antiretroviral therapy in acute infection is identical to that used in chronic infection, which consists of a 3-drug regimen with a nucleoside reverse transcriptase inhibitor backbone plus either a protease inhibitor or integrase inhibitor (see Figure E1, available online at http://www. annemergmed.com).…”

Implementing Rapid Initiation of Antiretroviral Therapy for Acute HIV Infection Within a Routine Testing and Linkage to Care Program in Chicago

“…25 , 26 However, the rapid initiation protocols from US-based studies have so far involved significant utilization of health care resources in the form of dedicated staff/personnel to assist with patient navigation, linkage, prescribing ART, and sometimes case management services. 11 , 13 , 15 , 22 The purpose of the current study is to evaluate outcomes of individuals diagnosed with AHI in the setting of a routine linkage to care program in Chicago, the Expanded Testing and Linkage to Care (X-TLC) program. We report on the feasibility of implementing rapid initiation of ART for AHI across diverse health care organizations within an ongoing HIV testing and linkage to care program, primarily utilizing existing staff and resources.…”

“…19 As more data are reported, there is increasing evidence that rapid initiation of ART should be recognized as a practice that improves clinical outcomes and may possibly decrease forward transmission events. [10][11][12][13][14][15][16][17][18][19][20][21][22][23][24] The World Health Organization and International AIDS Society have guidelines in support of rapid initiation of ART when clinically appropriate. 25,26 However, the rapid initiation protocols from US-based studies have so far involved significant utilization of health care resources in the form of dedicated staff/personnel to assist with patient navigation, linkage, prescribing ART, and sometimes case management services.…”