Need for Speed: Rapid Antiretroviral Initiation in the Emergency Department

Antiretroviral therapy (ART) is recommended for all individuals with HIV. The US Department of Health & Human Services recommends treatment initiation “immediately (or as soon as possible) after HIV diagnosis.”¹ Rapid therapy initiation on the day of diagnosis has demonstrated improvements in 10- to 12-month outcomes including viral suppression, linkage to care, and retention in care^2-4 in South Africa and Haiti.

Emergency departments (EDs) are an important entry point into the health care system and have been identified as a location with opportunity for increased HIV diagnosis and management.^5,6 In this paper, White et al describe the implementation and outcomes of a protocol for rapid ART initiation in 2 EDs in California.

All adult patients undergoing blood testing in the ED underwent opt-out HIV screening, which was a preexisting protocol in the 2 centers. Patients attaining an HIV antigen/antibody reactive result underwent evaluation by ED physicians for rapid ART initiation eligibility, which required being treatment-naïve being discharged from the ED, and a signal-to-cutoff ratio of at least 1.58, suggesting a low posttest probability of false-positive screening result. Exclusion criteria for rapid ART initiation included evidence of an opportunistic infection, pregnancy, kidney or liver dysfunction, planned hospital admission, or physician discretion. A checklist and medical record documentation template were developed to facilitate eligibility assessment.

Eligible adults were offered a 14-day starter pack of bictegravir/emtricitabine/tenofovir alafenamide for HIV management, which was provided free of charge to the patient. Starter packs were supplied by manufacturer donation and allowed for use by the Pharmacy and Therapeutics Committee as an exemption to hospital policy. Ineligible patients were initiated on therapy after evaluation by an inpatient infectious disease specialist or an outpatient clinic provider. Linkage to care was facilitated by 2 ED-based HIV navigators for all patients, regardless of rapid ART eligibility and acceptance, and partnering clinics agreed to expedite HIV appointments. Education sessions were provided to ED physicians. The program was supported by a grant from the California Department of Public Health.

Outcomes of effectiveness and safety were assessed retrospectively for the first 12 months of the program. Collected data included the number of patients receiving rapid ART initiation from the ED, the time to first clinic visit, and the 6-month incidence of immune reconstitution inflammatory syndrome (IRIS).

From July 2021 to June 2022, 15,980 patients were eligible for HIV screening in the ED, 10,606 patients underwent screening, and 165 patients had a reactive HIV antigen/antibody test.

Of the 106 patients who were considered for rapid ART initiation, the majority were male (75.5%), were Black (52.8%) or Hispanic/Latinx (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 the starter kit, with 25 patients accepting. Reasons for ineligibility are summarized in the TABLE. A total of 13 patients had a false-positive HIV antigen/antibody result. Of these, 2 patients received the ART starter kit from the ED; one discontinued therapy after 10 days, and the other was lost to follow-up.

Patients receiving rapid ART initiation had decreased time to ART initiation, with a median duration of 0 days IQR, 0-1) vs 6 days (IQR, 3-11; P < .001), and decreased time to first clinic visit, with a median duration of 8 days (IQR, 3-11) vs 13 days (IQR, 8-43); P < .01). Four patients were lost to follow-up after receiving a starter kit. IRIS occurred in 1 patient who received rapid ART initiation after receiving a diagnosis of cryptococcal meningitis and cytomegalovirus retinitis during a subsequent hospitalization. These opportunistic infections were determined to be clinically occult during the initial ED visit.

This paper describes an ED program to initiate ART on the day of HIV diagnosis for select patients and provide linkage to care after ED discharge. Patient eligibility criteria and the medication agent and quantity in the starter kit were selected judiciously to prioritize the safety of rapid ART initiation. Authors observed that the immediate availability of ART allowed patients to “gain a sense of control, feel supported, and understand that HIV is managed by taking a daily medication.” Because only 6 months of follow-up data were collected, future research is needed on the longitudinal impact of this intervention. Additionally, the protocol excluded patients with opportunistic infections and those who were pregnant. National guidelines emphasize the importance of early ART initiation in these scenarios¹; targeted interventions to promote safe yet expedited ART initiation may reduce the consequences of delayed treatment in these populations. Notably, public funding, manufacturer-donated starter kits, and collaboration with outpatient clinics contributed to the implementation and maintenance of this program. This framework may be adopted in other EDs, within local regulations and with dedicated health care resources, to advance the comprehensive care of individuals with HIV.

Highlighted Study

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 Forum Infect Dis. 2023;10(7):ofad292. doi:10.1093/ofid/ofad292

References

1. Guidelines for the use of antiretroviral agents in adults and adolescents with HIV. Clinical Info HIV.gov. Accessed July 17, 2023. https://clinicalinfo.hiv.gov/en/guidelines/adult-and-adolescent-arv
2. Rosen S, Maskew M, Fox MP, et al. Initiating antiretroviral therapy for HIV at a patient’s first clinic visit: the RapIT randomized controlled trial. PLoS Med. 2016;13(5):e1002015. doi:10.1371/journal.pmed.1002015
3. Koenig SP, Dorvil N, Dévieux JG, et al. Same-day HIV testing with initiation of antiretroviral therapy versus standard care for persons living with HIV: a randomized unblinded trial. PLoS Med. 2017;14(7):e1002357. doi:10.1371/journal.pmed.1002357
4. Labhardt ND, Ringera I, Lejone TI, et al. Effect of offering same-day ART vs usual health facility referral during home-based HIV testing on linkage to care and viral suppression among adults with HIV in Lesotho: the CASCADE randomized clinical trial. JAMA. 2018;319(11):1103-1112. doi:10.1001/jama.2018.1818
5. DeRose J, Zucker J, Cennimo D, Swaminathan S. Missed testing opportunities for HIV screening and early diagnosis in anurban tertiary care center. AIDS Res Treat. 2017;2017:5708620. doi:10.1155/2017/5708620
6. Olatosi B, Siddiqi KA, Conserve DF. Towards ending the human immunodeficiency virus epidemic in the US: state of human immunodeficiency virus screening during physician and emergency department visits, 2009 to 2014. Medicine (Baltimore). 2020;99(2):e18525. doi:10.1097/MD.0000000000018525