Empiric 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 follow-up visit.
“Our demonstration 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.”
The researchers 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.
Investigators in Los Angeles wanted to see if it was possible to provide empiric ART to people with suspected acute HIV infection attending emergency departments.
They therefore 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 infection.
- Possible recent exposure to HIV.
- No health conditions that might outweigh the benefits of ART.
- Underwent testing to confirm suspected infection.
- Patient agreed to adhere to therapy and follow-up and to provide reliable contact information so they could be notified of confirmed results.
Empiric HIV therapy consisted of tenofovir/emtricitabine with darunavir/ritonavir and raltegravir.
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.
Eleven people 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.
“Ag/Ab assay 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.”
Jacobson KR et al. High feasibility of empiric HIV treatment for patients with suspected acute HIV in an emergency department. J Acquir Immune Defic, 72: 242-45, 2016.