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Feasible to prescribe ART to emergency department patients with suspected acute HIV infection
Michael Carter, 2016-07-08 08:00:00
antiretroviral therapy (ART) for individuals presenting to emergency
departments with suspected acute HIV infection (AHI) is highly feasible,
investigators report in the July 1st edition of the Journal of Acquired Immune Deficiency
Syndromes. A year long pilot study in Los Angeles identified eleven
eligible people, ten of whom started ART and eight completed at least one
project shows that empiric treatment in the ED [emergency department] is
feasible and well received by patients,” comment the authors. “It offers a
novel entry point into the HIV care continuum and an opportunity to immediately
engage patients in this care continuum after diagnosis, while beginning to
reduce their viral load and limiting the size of their reservoirs.”
suggest this treatment strategy is consistent with recommendations to offer
immediate ART to all people with HIV.
Therapy during the
acute stage of infection could have long-term health benefits including a
higher CD4 count, decreased inflammation and a lower viral set point. Viral
load is extremely high during acute HIV infection meaning people are highly
infectious. Therefore, treatment during the acute phase would reduce viral
load, thereby significantly reducing infectiousness.
Los Angeles wanted to see if it was possible to provide empiric ART to people
with suspected acute HIV infection attending emergency departments.
designed a 12-month pilot study. Acute HIV infection was defined as a
positive HIV antigen antibody Ag/Ab) result pending antibody and viral load
confirmation. People with a positive Ag/Ab result were considered for ART if
they met a set of criteria, including:
- Symptoms consistent with acute
- Possible recent exposure to
- No health conditions that might
outweigh the benefits of ART.
- Underwent testing to confirm
- Patient agreed to adhere to
therapy and follow-up and to provide reliable contact information so they could
be notified of confirmed results.
therapy consisted of tenofovir/emtricitabine with darunavir/ritonavir and
During the 12-month study period, 21,221 people were screened for HIV, 457
HIV-positive people were identified, 91 were newly diagnosed and 16 had
confirmed acute infection.
met the criteria for empiric ART and ten initiated this treatment. The other patient left the emergency department against medical advice before receiving
his ART prescription. Of the ten people who started empiric therapy, eight
completed one or more follow-up appointments.
Nine people were confirmed as having acute HIV infection. The other two
individuals had chronic infection. “Those two chronically infected patients
were still linked to health care, and they continued their ART prescribed by
the ED,” note the authors.
In addition, six
people with acute HIV infection who did not meet the criteria for empiric
treatment were also identified. The main reason for excluding these individuals
was due to the inability to obtain reliable contact information in the event of
a false result; other reasons included denial of risk activity or no symptoms
consistent with acute infection.
testing in the ED offers a unique opportunity to identify and intervene early
for those with AHI,” write the investigators. “The best available data support
the potential benefits of immediate ART intervention for AHI, which include
limiting the viral reservoirs and preventing further HIV transmission.”
They conclude, “if
empiric ART is scaled up to EDs around the country, where marginalized and
disenfranchised individuals often seek care, it could potentially reach into
the heart of the HIV epidemic and have a major public health impact on
decreasing HIV transmissions and facilitating the end of the epidemic.”