Accelerating the
HIV Care Continuum in the
Emergency Room
Kathleen Jacobson MD
Sanjay Arora MD
Mike Menchine MD MPH
Background
• Recent Article
– Engaged in care & virally suppressed
– Estimated to be 94.0% less likely to transmit HIV
– Than undiagnosed HIV-infected people
Skarbinski, et al, JAMA IM 2015
• Even if they are not virally suppressed
– HIV-infected patients prescribed ART
– Estimated to be 30.3% less likely to transmit HIV
– Than those retained in care but not prescribed
ART
• Note: Analysis did not account for all transmission
risk factors including acute HIV
Skarbinski, et al, JAMA IM 2015
Risk of Transmission
• Findings are consistent with..
• HPTN 052 study
– Showed 96% reduction in sero-discordant partners if the
HIV positive partner was on ART and had an undetectable
viral load
– (Cohen et al. NEJM Aug 2011)
• Rakai study
– Showed for each 1 log rise in viral load there was a
correlated increase risk factor of 2.45 for HIV
transmission.
– (Quinn et al. NEJM 2000)
Primary/Acute HIV Infection
http://www.cdc.gov/hiv/pdfHIVtestingAlgorithmRecommendation-Final.pdf
Primary/Acute HIV Infection
• Typically has very high viral loads
• Stacey et al. J Virol 2009
• HIV transmission risk likely very high
• Supported by
– Primary HIV infection accounted for half of all
forward transmitted infections.
– Brenner et al. JID 2007
HIV Reservoirs in Primary HIV
Infection
• Earlier intervention in acute HIV
– Decreases the size of latent HIV reservoirs
– Delayed viral rebound
– May have long term health implications
(Payne et al. #35, Uprety et al. #374, Ghosn et al, #373, Etemad et al. #110 LB)
ED Testing Recommendations
• 2006 CDC Testing Guidelines
• Routine screening for HIV infection in all
healthcare facilities…
• Including Emergency Departments
• HIV patients who go to an ED are less likely to
be aware of their diagnosis of HIV
(Hall et al. JAMA IM, 2013)
First HIV Care Continuum in the ED
• Most recently, the First HIV Care Continuum
for Emergency Rooms
• (Hsieh et al. Annals of EM, July 2015)
– Recognized the potential role that emergency
rooms might play downstream in the care
continuum
– Called for feasibility studies
4th Generation Testing
• Identify acute HIV infections between 10-21
days post exposure
• Patients are likely to be symptomatic
• Possibly seek medical care for the non-specific
acute viral illness
(Branson et al. CDC June 27,2014)
• Opportunity to intervene earlier in acute HIV
• Potentially decreasing the size of HIV reservoirs
• Possibly interrupt further HIV transmission
Feasibility of Empiric Treatment
• We describe a small pilot demonstration
project looking at…
– Feasibility and acceptance
– Empiric treatment
– Suspected acutely infected individuals
– While still in the emergency department
• Note:
• Project to be discussed -Los Angeles CountyModel for
-Ventura County HIV Testing Program• funded by the State Office of AIDs
Los Angeles County
Los Angeles County 2013
HIV Infections per 100,000
Los Angeles County + University of Southern
California
• Largest ED in the western United States
• 170,000 annual visits
• 65% Hispanic
• 80% household income <$20,000
Los Angeles County + University of Southern
California Emergency Department
• March 2011 -non-targeted POC screening
• June 2013 - 4th generation testing
• December 2014-mounting evidence
supporting early ART in acute HIV infection
– Effort to simplify the HIV Care Continuum
– Began empiric antiretroviral therapy
– Suspected acute HIV
Rationale
• HIV specialty team considered the risks and benefits of
empiric treatment including:
– Safety of PEP in HIV negative patients
• (Bock et al. Advancing Science Improving Care Conference, Oct 2014)
– ART is generally well tolerated
– Minimal side effects-can be monitored
– Unlikely to develop resistance
• (Guidelines for Use of Antiretroviral Agents in HIV Infected Adults
and Adolescence http://aidsinfo.nih.gov/guidelines accessed
5/26/2015)
– Improved access to care
– Could be called to stop ART for negative confirmatory results
– Potential benefit of decreasing further HIV transmission
• (Cohen et al. NEJM, 2011, Strabinski et al. JAMA IM, 2015
Eligibility Criteria
• Clinical history c/w acute HIV infection
• Negative HIV test < 6-12 months
• No co morbid conditions that have risks that
outweigh the benefits
• 4th gen positive test
• Pending Multi-spot and HIV VL by PCR
• Stable baseline CBC and chemistry panel
• Genotype, VL, CD4 able to be ordered in ED
Eligibility Criteria
• Patient understands/agrees:
–
–
–
–
–
–
Confirmatory tests pending
They are willing to take the medicine
To commit to abstinence
To condom use if not abstinent
To partner notification
The importance of adhering to a follow up
appointment.
– They have phone, text or email available for contact.
• If the patient’s history was compelling for acute
HIV infection not all criterion needed to be met
LACUSC ED Testing Program
•
•
•
•
•
Screened > 72, 707 patients
Tested > 61,914
Identified 967 HIV positive
285 newly diagnosed HIV positive patients
32 acutely infected individuals
• Between Dec 10, 2014 to Dec 1, 2015
16 Acutely Infected Individuals
Empiric Treatment
• Began December 10, 2014
– 16 total confirmed acutely infected patients
– 11 patients met our acute HIV/empiric ART criteria
– All agreed to empirically start ART
– One left AMA prior to beginning ART
– 10 began ART empirically in the ED
4 Drug Empiric ART Regimen
• 2NRTIs +
Protease Inhibtor +
Integrase Inhibitor
• Decision based on known local resistance to…
– NRTIs
– PIs
Results of Empirically Treated
• 10/11 confirmed – acute HIV infected
• 1/11 - chronically HIV infected
Since Dec 10,2014
• 6 additional confirmed acute HIV infected patients
• Did not consider / did not meet our criteria
• *All patients confirmed acutely infected -urgently
reported to PHD to be prioritized for PHI referral.
Lessons Learned/Future Directions
• Identification of acute HIV infected patients is
– Limited by provider inability to always predict which
patients are acutely infected.
– (Braun et al. CID, May 27 , 2015)
• Future goals to capture more of the acute patients
while still in the emergency room by either using
– Signal to cut off ratio of the 4th generation lab based test
• Can better predict who is in the earlier stages of infection (Ramos
et al. J of Clin Virology, Dec 2013)
– Rapid bedside POC 4th generation HIV Ag/Ab test
• Separate out those w/ positive p24 antigen (Masciotra et al. J of
Clin Virology, Dec 2013),
Conclusions
• Emergency Department 4th generation testing allows
a unique opportunity to
– Identify acute HIV Infection
– Intervene early in acute HIV infections.
• Potential benefit of urgent ART in acute HIV infections
to decrease viral reservoirs.
• We identified rationale and criteria to support
empiric ART for suspected cases of acute HIV infection
in the ED.
Conclusions
• Early experience shows empiric treatment in
the emergency department is…
– Feasible and
– Well received by patients.
• Accelerated the HIV Care Continuum
Accelerated the HIV Care Continuum
Conclusions
•
•
•
•
In line with current recommendations to
Move from diagnosis to…
Immediate prescription of ART
In an effort to reduce HIV transmission
(Skarbinski et al. JAMA IM 2015 and START)
http://www.niaid.nih.gov/news/QA/Pages/STARTqa.aspx
• https://plus.google.com/+HanifNurAssyifa#+HanifNurAssyifa/posts
Next Steps
• Treatment of acutely infected individuals in the
emergency room is only the beginning.
• Already expanded to include treatment of
– Newly diagnosed chronically infected
– Return to care patients
• Critical Role Emergency Rooms Testing Programs
play in the HIV Care Continuum
Acknowledgements
• Funding Support
– Focus
– PAETC
– LAC DHSP
• HIV Fellows
– 2015/2016
• Meredith Lora MD
• Stephen Merjavy MD
– 2014/2015
• Kristin Walshe MD
• Kenneth Leong MD
• Staff
– Jonathon Lam
– Adrianne Berumen