Treatment and resources for patients with non-occupational HIV exposure presenting to the emergency department

Correspondence / American Journal of Emergency Medicine 36 (2018) 14971520 1519

Treatment and resources for patients with non-occupational HIV exposure presenting to the emergency department

In the U.S., males account for 76% of the prevalence of all people living with HIV (PLWH), with 69% identifying as gay, bisexual, and other men who have sex with men (MSM) [1-2]. Males likewise comprise 80% of new infections and there is an almost 7 fold increased risk of new infec- tions in black males and two times the rate in Hispanic males compared to white males [2]. Individuals within this demographic utilize Emergen- cy Departments (ED) for the majority of their care [3-4]. Given the in- creased prevalence in this setting, EDs are becoming targeted areas for First-line treatment and prevention for STI and HIV intervention [5-6].

Over the last few months, three males in their 20s presented to our

ED after same-sex interactions with other males living with HIV. Each patient met their respective partners for casual ‘hook-ups’ on smart phone, same-sex dating ‘apps’. High-risk sexual behaviors were noted in each encounter with patients reporting either engaging in condomless anal-receptive intercourse or oral sex. The story was similar for the three patients: the new partner either did not disclose HIV status or falsely-reported HIV-negative status until after the sexual encounter, only then to disclose HIV-positive status. These cases represent a grow- ing area of concern for reservoirs of HIV infection. All ED providers, whether university- or community-based, should have immediate ac- cess to information where free or low-cost post-exposure prophylaxis can be obtained for the patient.

In an attempt to slow the HIV epidemic, numerous states have enacted laws requiring disclosure of HIV status to prospective partners. These laws exist (and vary) at the state-level regarding disclosing HIV status to part- ners [7]. Individuals who do not disclose HIV status and engage in sexual contact can be criminalized with penalty up to 8 years in prison [7]. Despite numerous critiques of these laws, ED providers should know HIV disclosure laws in their respective states to inform patients presenting to the ED after a non-disclosure encounter of their right to pursue formal investigation (for a short review on each states’ laws, see [7]).

The patients who presented to our ED did not want to utilize the services of the sexual assault Nurse Examiner (SANE). We ordered 4th generation HIV antigen/Antibody testing, Syphilis IgG, Nucleic Acid Ampli- fication Testing for Gonorrhea, Chlamydia, and Trichomonas. Since the patients were within 72 hours of exposure, each was prescribed PEP for 28 days, as well as broad-spectrum STI coverage and follow-up with at the HIV clinic at our institution. Patients were informed of the influenza-like side effects of PEP and instructed to not discontinue or interrupt therapy. The Case Manager in our ED provided patients with information and resources to help pay for PEP, which costs between

$600 to $1,000. Finally, these situations afforded us the opportunity to dis- cuss with these patients the benefits of Pre-exposure prophylaxis (PrEP) during periods of high-risk Sexual activity in their lives to both prevent HIV transmission and fear associated with false-disclosure encounters.

The example from our patients demonstrate the need for non-occupa- tional exposure PEP (nPEP) resources in the ED. Patients who are eligible for PEP include those with a substantial risk for HIV exposure within the last 72 h [8], when the source is known to be HIV-infected. If the source’s HIV status is unknown, determination of PEP is made on a case-by-case basis. The recommended PEP regimen for those with adequate creatinine clearance is a 3-drug combination of tenofovir 300 mg and fixed dose combination of emtricitabine 200 mg (Truvada) once daily with raltegravir 400 mg twice daily or dolutegravir 50 mg once daily [8]. Devi- ations from this regimen requires consultation with an HIV specialist. For EDs without access to an HIV specialist, PEP Consultation Services for Cli- nicians can be reached at 1-888-448-4911, 9 a.m.-2 a.m. Eastern Time seven days per week.

For EDs without Case Managers to provide information regarding obtainment of PEP, the CDC provides pertinent information at https:// For patients either without insur- ance or who cannot obtain insurance coverage for nPEP, healthcare pro- viders can apply for free PEP medicines either online or through special phone lines to insure immediate access to medicine (e.g., Gilead Sci- ences 1-877-505-6986, Merck 1-800-850-3430). The National Alliance of State and Territorial AIDS Directors provides a complete list of phar- maceutical company patient assistance programs and instructions for applications [9]. Since there can be a slight delay between free or subsi- dized coverage for PEP, it is important for EDs in areas of increased HIV prevalence to have a 3-5 day supply of PEP on-hand to immediately start therapy while applications for financial coverage are pending. Fi- nally, for patients who are at negligible exposure risk and for whom PEP is not indicated, ED providers should provide standardized dis- charge instructions on safe-sex practices and contact information to an HIV specialist for initiation of PrEP therapy in order to reduce the in- cidence of seroconversion in each community.

Conflict of Interest Disclosure

JN and JY have received funding from the AIDS Funding Collaborative, a non-profit in Cleveland, Ohio, for development of an HIV/Syphilis screening program in the Emergency Department at their institution.

Financial Support

Both authors report no financial support.


– Author Contributions: JY (identification of cases, conceptualization of commentary, and critical revision of manuscript for important in- tellectual content); JN (conceptualization of commentary, drafting of the manuscript, and critical revision of manuscript for important intellectual content)

Joshua D. Niforatos, MTS

Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, 9500 Euclid Avenue/NA21, Cleveland, OH 44195, United States Division of International Emergency Medicine, Department of Emergency Medicine, university hospitals Cleveland Medical Center, 11100 Euclid

Avenue, Cleveland, OH 44106, United States Corresponding author at: University Hospitals Cleveland Medical Center, Department of Emergency Medicine, 11100 Euclid Avenue,

Cleveland, OH 44106, United States.

E-mail address: [email protected].

Justin A. Yax, DO, DTMH Division of International Emergency Medicine, Department of Emergency Medicine, University Hospitals Cleveland Medical Center, 11100 Euclid

Avenue, Cleveland, OH 44106, United States

3 January 2018


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