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Clinicians Weigh In on the Advantages of Fast Antiretroviral Remedy for HIV in EDs

As a part of a nationwide technique to finish the HIV epidemic in america, emergency departments (EDs) have an vital function in HIV testing and therapy, particularly for sufferers with restricted entry to well being care.1

“The ED is a key venue where persons with an undiagnosed HIV infection can be diagnosed and linked to care; for some, the ED may be the only point of entry into the health care system,” defined Lieutenant Commander Jesse O’Shea, MD, MSc, an epidemiologist on the Facilities for Illness Management and Prevention’s (CDC) Division of HIV prevention. “This presents a unique opportunity to immediately engage with patients who otherwise might be missed,” Dr O’Shea added.

The effectiveness of speedy antiretroviral remedy (ART) for HIV an infection has been demonstrated in varied settings, together with an outpatient Veterans Well being Administration HIV clinic in Atlanta, Georgia; a routine linkage to care program in Chicago, Illinois; and a big community of websites in San Francisco, California. In every of those settings, viral suppression and continued engagement in care had been noticed following the implementation of speedy ART.2-4

Proceed Studying

As well as, outcomes of a retrospective examine printed in July 2023 in Open Discussion board Infectious Illnesses spotlight the vital function EDs may play in speedy ART initiation amongst sufferers who check constructive on routine opt-out HIV screening.5

Proof for the Advantages of Fast ART

Researchers at Alameda Well being System in Oakland, California investigated the effectiveness of a protocol by which 14-day speedy ART starter packs had been administered to eligible sufferers within the ED with a reactive HIV antigen/antibody (Ag/Ab) check end result. The choice to make use of starter packs was devised as a technique to keep away from challenges related to prescribing ART, together with insurance coverage boundaries and after-hours prescribing.

Based mostly on suggestions from HIV physicians within the well being system’s referral community, bictegravir/emtricitabine/tenofovir alafenamide was chosen for speedy ART initiation attributable to its “ease of use (1 pill, once a day), low side effect profile, and low resistance profiles,” the researchers famous.5

Of 106 sufferers who examined HIV Ag/Ab reactive at 2 EDs throughout the 1-year examine interval, 23.6% obtained speedy ART starter packs. Two of those sufferers subsequently examined unfavourable for HIV an infection.

Sufferers with a reactive HIV Ag/Ab check end result had been referred to partnering clinics for expedited appointments. Two full-time ED-based HIV navigators supplied vital help to sufferers (comparable to arranging transportation) till it was confirmed that every affected person had arrived for his or her first appointment on the HIV clinic.

Sufferers who initiated speedy ART within the ED had been considerably extra more likely to attend follow-up visits inside 30 days in contrast with those that didn’t obtain speedy ART (82.6% vs 50.0%, respectively; P =.01).

Of sufferers who examined constructive for HIV an infection and initiated speedy ART, the 6-month incidence of immune reconstitution inflammatory syndrome was 4.3% (95% CI, 0.11-23.0).

“This is an important paper in that it shows that patients who are newly diagnosed with HIV in the ED are amenable to getting ART right away, and those who get immediate ART are more likely to follow-up in outpatient HIV care,” stated Monica Gandhi, MD, MPH; Professor of Medication and Affiliate Chief within the Division of HIV, Infectious Illnesses, and International Medication on the College of California San Francisco (UCSF); Director of the UCSF-Bay Space Heart for AIDS Analysis; and Medical Director of the “Ward 86” HIV Clinic at San Francisco Normal Hospital.

In line with Dr O’Shea, this “foundational work underscores the potential for a paradigm shift in EDs to diagnose and treat HIV that may reverberate to other hospital departments involved in patient care.”

Increasing Fast ART in ED Settings

A variety of measures are wanted to develop the supply of speedy ART companies in EDs, together with common opt-out HIV testing and the “capacity and willingness of ED providers and care teams to champion a protocol,” Dr O’Shea stated.

Different vital measures embody “buy-in from the hospital system hosting the ED since the starter packs for rapid ART need to be purchased for patients even prior to being set up for insurance benefits in some instances,” Dr Gandhi defined. Of observe, grant funding for the aforementioned speedy ART program at Alameda Well being System was supplied by the California Division of Public Well being.5

“There also needs to be referral to an outpatient HIV clinic with calls from that clinic to the newly diagnosed patients to ensure there are no side effects from the medications and that the follow-up appointment is kept,” Dr O’Shea famous.

Dr O’Shea additionally famous the significance of entry to navigators or case managers to help with wants comparable to insurance coverage enrollment, transportation, translation for non-English audio system, and different boundaries to outpatient follow-up care.

A number of matters warrant additional analysis on this space, together with the cost-effectiveness of speedy ART applications throughout totally different settings (eg, rural vs city), and the potential for ED-based speedy ART to instigate engagement in HIV care or the re-engagement of beforehand identified sufferers who had been nonadherent to HIV care after prognosis and therapy initiation, Dr O’Shea steered.

As well as, there’s a “need for implementation research to determine the factors involved in increasing and scaling up rapid ART uptake and initiation in ED settings,” Dr O’Shea acknowledged, including that the “CDC recently advertised a funding opportunity to support research focusing on how to deploy and optimize rapid ART delivery in emergency departments.”6

Dr Gandhi famous the necessity for additional follow-up analysis on whether or not examine sufferers who initiated speedy ART at Alameda Well being system achieved virologic suppression and remained engaged in HIV care, in addition to on the significance of teaching different ED physicians and HIV clinicians relating to this speedy ART initiative. “This pilot program is exciting and should be replicated in other ED settings,” she stated.

In line with Dr O’Shea, “All people with HIV should receive a timely HIV diagnosis, be promptly linked to care, and be rapidly started on ART.” Dr O’Shea means that “by doing so, we can accelerate progress along the HIV care continuum from diagnosis to linkage [in care] and ultimately viral suppression.”


  1. Facilities for Illness Management and Prevention. Making opt-out HIV testing routine in the emergency department. Up to date June 7, 2022. Accessed August 31, 2023.
  2. O’Shea JG, Gallini JW, Cui X, Moanna A, Marconi VC. Rapid antiretroviral therapy program: development and evaluation at a Veterans Affairs Medical Center in the southern United States. AIDS Affected person Care STDS. 2022;36(6):219-225. doi:10.1089/apc.2022.0039
  3. McNulty M, Schmitt J, Friedman E, et al. Implementing rapid initiation of antiretroviral therapy for acute HIV infection within a routine testing and linkage to care program in Chicago. J Int Assoc Provid AIDS Care. 2020;19:2325958220939754. doi:10.1177/2325958220939754
  4. Bacon OML, Coffey SC, Hsu LC, Chin JCS, Havlir DV, Buchbinder SP. Development of a citywide rapid antiretroviral therapy initiative in San Francisco. Am J Prev Med. 2021;61(5 Suppl 1):S47-S54. doi:10.1016/j.amepre.2021.06.001
  5. White DAE, Jewett M, Burns M, et al. Implementing a rapid antiretroviral therapy program using starter packs for emergency department patients diagnosed with HIV infection. Open Discussion board Infect Dis. Revealed on-line June 2, 2023. doi:10.1093/ofid/ofad292
  6. Facilities for Illness Management and Prevention. Notice of funding opportunity PS-23-005: expanding rapid initiation of antiretroviral therapy in non-traditional settings: emergency department. Up to date January 27, 2023. Accessed August 31, 2023.

This text initially appeared on Infectious Disease Advisor

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