Antiretroviral treatment (ART) is recommended for all HIV-infected people. The U.S. Department of Health and Human Services recommends starting treatment “immediately (or as soon as possible) after an HIV diagnosis.”1 Initiating rapid treatment on the day of diagnosis has demonstrated improved outcomes at 10 to 12 months, including viral suppression, linkage to care, and retention in care2-4 in South Africa and Haiti.
The emergency department (ED) is an important entry point into the health care system and is considered a site with opportunities to enhance HIV diagnosis and management.5.6 In this article, White et al describe the implementation and outcomes of a rapid-start ART program in 2 emergency departments in California.
All adult patients who presented for blood testing in the emergency department received opt-out HIV screening, a preexisting protocol at both centers. Patients with HIV antigen/antibody response results were evaluated by ED physicians for eligibility for rapid ART initiation, which requires treatment naïve upon discharge from the ED and a signal-to-cutoff ratio of at least 1.58, indicating a low probability of false-positive screening after testing result. Exclusion criteria for rapid initiation of ART included evidence of opportunistic infection, pregnancy, renal or hepatic dysfunction, planned admission, or physician judgment. Checklists and medical record documentation templates were developed to facilitate eligibility assessment.
Eligible adults received a 14-day starter pack of bictegravir/emtricitabine/tenofovir alafenamide for HIV management, which was provided free of charge to patients. Starter packs are provided by donation from the manufacturer and are permitted for use by the Pharmacy and Therapeutics Committee as a waiver of hospital policy. Ineligible patients begin treatment after evaluation by an inpatient infectious disease specialist or outpatient clinic provider. Regardless of rapid ART eligibility and acceptance, 2 emergency department-based HIV navigators provided linkage to care for all patients, and partner clinics agreed to expedite HIV appointments. Educational sessions are provided for emergency physicians. This program is supported by a grant from the California Department of Public Health.
Efficacy and safety results during the first 12 months of the program were retrospectively assessed. Data collected included the number of patients who received rapid ART initiation from the emergency department, time to first visit, and the 6-month incidence of immune reconstitution inflammatory syndrome (IRIS).
From July 2021 to June 2022, 15,980 patients in the emergency department were eligible for HIV screening, 10,606 patients were screened, and 165 patients underwent reactive HIV antigen/antibody testing.
Of the 106 patients considered for initiation of rapid ART, the majority were male (75.5%), black (52.8%), or Hispanic/Latino (22.6%), and had Medicaid coverage (72.6%). A total of 31 patients met all eligibility criteria for rapid ART initiation, and 26 patients were offered a starter kit, of which 25 accepted it.The reasons for failure are summarized in table. A total of 13 patients had false-positive HIV antigen/antibody results. Of these, 2 patients received ART starter kits from the emergency department; one patient discontinued treatment after 10 days and the other patient was lost to follow-up.
Patients who received rapid ART initiation had shorter time to ART initiation, with a median duration of 0 days (IQR, 0-1) versus a median duration of 6 days (IQR, 3-11; IQR, 3-11). ask < .001), the time to first visit was shortened, with a median duration of 8 days (IQR, 3-11) versus 13 days (IQR, 8-43); ask < .01). Four patients were lost to follow-up after receiving the starter kit. One patient was diagnosed with cryptococcal meningitis and cytomegalovirus retinitis during subsequent hospitalization and received rapid ART and subsequently developed IRIS. These opportunistic infections were identified as clinically occult infections at the time of the initial ED visit.
This article describes an emergency room program that initiates antiretroviral therapy on the day of HIV diagnosis in selected patients and provides linkage to care after emergency room discharge. Patient eligibility criteria as well as the drugs and quantities in the starter kit were judiciously selected to prioritize safety for rapid ART initiation. The authors observed that the immediate availability of antiretroviral therapy allowed patients to “gain a sense of control, feel supported, and understand that HIV is controlled by taking daily medication.” Since only 6 months of follow-up data were collected , therefore future research on the longitudinal effects of this intervention is needed. In addition, patients with opportunistic infections and pregnant patients were excluded from this protocol.National guidelines emphasize the importance of early initiation of ART in these settings1;Targeted interventions that promote safe and rapid initiation of antiretroviral therapy may reduce the consequences of delayed treatment in these populations. Notably, public funding, donations of starter kits from manufacturers, and partnerships with outpatient clinics all contribute to the implementation and maintenance of the program. Other emergency departments can adopt this framework, within the confines of local regulations and utilizing specialized health care resources, to promote comprehensive care for people living with HIV.
refer to
- Guidelines for the use of antiretroviral drugs in adults and adolescents living with HIV. Clinical Information HIV.gov. Access date: July 17, 2023. https://clinicalinfo.hiv.gov/en/guidelines/adult-and-adolescent-arv
- Rosen S, Maschue M, Fox MP, et al. Initiating HIV antiretroviral therapy at the patient’s first visit: the RapIT randomized controlled trial. PLOS Medicine. 2016;13(5):e1002015. doi:10.1371/journal.pmed.1002015
- Koenig SP, Dorvil N, Dévieux JG, et al. Same-day HIV testing and initiation of antiretroviral therapy versus standard care in people living with HIV: a randomized, unblinded trial. PLOS Medicine. 2017;14(7):e1002357. doi:10.1371/journal.pmed.1002357
- Labhardt ND, Ringera I, Lejone TI, et al. Impact on care and viral suppression of same-day antiretroviral therapy offered during home HIV testing compared with routine health facility referral among adults living with HIV in Lesotho: the CASCADE randomized clinical trial. Journal of the American Medical Association. 2018;319(11):1103-1112. doi:10.1001/jama.2018.1818
- DeRose J, Zucker J, Cennimo D, Swaminathan S. Missed testing opportunities for HIV screening and early diagnosis in urban tertiary care centers. AIDS treatment. 2017;2017:5708620. Number: 10.1155/2017/5708620
- Oratosi B, Siddiqi KA, Conservative DF. Ending the human immunodeficiency virus epidemic in the United States: Status of human immunodeficiency virus screening during physician and emergency department visits, 2009 to 2014. Medicine (Baltimore). 2020;99(2):e18525. Number: 10.1097/MD.0000000000018525