Managing the HIV-Infected Adult Patient in the Emergency Department (Infectious Disease CME, Pharmacology CME and HIV CME)

Table of Contents

 

About This Issue

Four decades since the identification of HIV and more than 3 decades since the development of highly active antiretroviral drug therapies, HIV is considered a manageable chronic disease. Nonetheless, transmission of new cases by patients who are not managing their disease or who are unaware of their status continues to be a concern. In addition, HIV patients are subject to diseases related to aging as well as side effects of antiretrovirals and a chronic inflammatory state. This issue updates the most current information regarding HIV management, including:

The circumstances and presentations that point to HIV transmission or acute seroconversion.

CD4 count and viral load: the role of HIV testing in the ED for HIV management.

Universal, risk-based, and non-risk-based testing: the high-risk patients who shouldn’t be missed.

What are the classes of antiretroviral drugs, and what are their most common adverse effects?

What are the inflammatory effects and system-based disease and medication side effects frequently seen in the ED? These can include cardiovascular, pulmonary, renal, neurologic, GI and hepatobiliary, hematologic, endocrine, musculoskeletal, psychiatric, and dermatologic effects.

Which class of antiretroviral medication produces radiolucent kidney stones?

What are the special cautions with regard to stopping drug therapy in patients with hepatitis B or C?

What are the pre-exposure prophylaxis drug regimen administration, follow-up, and guidelines?

How long after exposure to HIV is postexposure prophylaxis not recommended?

1. Abstract
2. Case Presentations
3. Introduction
4. Selected Abbreviations
5. Critical Appraisal of The Literature
6. Epidemiology and Pathophysiology
   1. Transmission of HIV
   2. Diagnosis of HIV and the Course of Disease
7. Prehospital Care
8. Emergency Department Evaluation
   1. Universal, Risk-Based, and Non–Risk-Based Screening for HIV
   2. History
   3. Physical Examination
9. Diagnostic Testing
   1. Laboratory Testing
   2. Imaging
10. Current Recommendations for HIV Treatment
11. Adverse Effects of HIV Medications
    1. Highly Active Antiretroviral Therapy
       1. Nucleoside Reverse Transcriptase Inhibitors and Nucleotide Reverse Transcriptase Inhibitors
          • Hepatitis B Virus Reactivation
       2. Nonnucleoside Reverse Transcriptase Inhibitors
       3. Protease Inhibitors
       4. Integrase Strand Transfer Inhibitors
       5. Entry Inhibitors
12. System-Based HIV Disease and Medication Effects
    1. Cardiovascular Disease
    2. Pulmonary Disease
    3. Renal Disease
    4. Neurologic Disease
    5. Gastrointestinal and Hepatobiliary Disease
    6. Hematologic Disease
    7. Endocrine Disease
    8. Musculoskeletal Disease
    9. Psychiatric Disease
    10. Dermatologic Disease
13. Special Circumstances
14. Summary
15. Key Points
16. Risk Management Pitfalls for Managing HIV-Infected Patients in the Emergency Department
17. Case Conclusions
18. Clinical Pathway for Management of Weakness in HIV-Infected Patients
19. Tables and Figures
    1. Table 2. Online Resources for Managing HIV Treatment and Drug-to-Drug Interactions
    2. Table 1. Common Antiretroviral Medications and Their Potential Adverse Effects
    3. Table 3. Rates of Psychiatric Complications in HIV/AIDS Patients
    4. Table 4. Preferred Regimens for HIV Postexposure Prophylaxis
    5. Figure 1. New Transmissions of HIV by Status of Care
    6. Figure 2. Chest X-Ray of Pneumocystis jiroveci Pneumonia
20. References

Abstract

As highly active antiretroviral therapies have advanced, HIV patients who are treatment-adherent can achieve undetectable viral loads, virtual elimination of opportunistic infection, improved quality of life, and normal life expectancy. This issue focuses on emergency department management of HIV patients both with successful disease suppression from long-term therapy as well as the patient with low CD4 counts in the context of lack of engagement with care, nonadherence, or undiagnosed disease. Optimal emergency department management of patients with HIV also includes identifying and treating undiagnosed patients, helping to re-establish care for those who have been lost to followup, and preventing new HIV infections with pre-exposure and postexposure prophylaxis.

Case Presentations

A 28-year-old HIV-infected man presents with productive cough and fever for 5 days…

• The patient states that he has well-controlled HIV and says his last CD4 count a few weeks ago was 550 cells/mcL.
• You wonder how to approach diagnosis and treatment for his respiratory infection in the setting of his HIV disease...

A 42-year-old HIV-infected woman presents complaining of diarrhea…

• She says she has had up to 3 episodes of diarrhea a day for the past 3 weeks. She denies pain, melena, rectal bleeding, and fever.
• Her laboratory test results are unremarkable.
• You wonder whether additional testing is needed and whether sending her home is appropriate...

A 31-year-old man is requesting testing for “all” sexually transmitted infections…

• The man denies having a diagnosis of HIV, but reports engaging in condomless insertive vaginal intercourse with a partner with unknown HIV status 12 hours earlier.
• In addition to being evaluated for STIs, he wants to make sure he does not contract HIV.
• You wonder what the most current recommendations for postexposure prophylaxis for HIV are...

Clinical Pathway for Management of Weakness in HIV-Infected Patients

Subscribe to access the complete flowchart to guide your clinical decision making.

Table and Figures

Table 2. Online Resources for Managing HIV Treatment and Drug-to-Drug Interactions

Subscribe for full access to all Tables and Figures.

Key References

Following are the most informative references cited in this paper, as determined by the authors.

1. * U.S. Centers for Disease Control and Prevention. “CDC Fact Sheet: Vital Signs, 2019.” Accessed June 10, 2021. (CDC data report)

2. * U.S. Centers for Disease Control and Prevention.“HIV in the United States and Dependent Areas.” Accessed June 10, 2021. (CDC statistics)

5. * U.S. Centers for Disease Control and Prevention.“PEP (Post-Exposure Prophylaxis).” Accessed June 10, 2021. (CDC information page)

7. * U.S. Department of Health and Human Services.“US Statistics and Fast Facts.” Accessed June 10, 2021. (Data report)

9. * U.S. Preventive Services Task Force.“Final Recommendation Statement: Human Immunodeficiency Virus (HIV) Infection: Screening. U.S. Preventive Services Task Force.” Accessed June 10, 2021. (Guidelines)

10. American College of Emergency Physicians.“Policy Compendium.” 2021; Accessed June 10, 2021. (ACEP policies)

17. * Saag MS, Gandhi RT, Hoy JF, et al. Antiretroviral drugs for treatment and prevention of HIV infection in adults: 2020 recommendations of the International Antiviral Society-USA panel. JAMA. 2020;324(16):1651-1669. (Guidelines) DOI: 10.1001/jama.2020.17025

18. * U.S. Department of Health and Human Services.“Guidelines for the Use of Antiretroviral Agents in Adults and Adolescents with HIV.” Accessed June 10, 2021. (Guidelines)

25. * Dominguez KL, Smith DK, Vasavi T, et al.“Updated Guidelines for Antiretroviral Postexposure Prophylaxis After Sexual, Injection Drug Use, or Other Nonoccupational Exposure to HIV—United States, 2016.” Accessed June 10, 2021. (Practice guideline)

28. * U.S. Centers for Disease Control and Prevention.“Interim Statement Regarding Potential Fetal Harm from Exposure to Dolutegravir – Implications for HIV Post-exposure rophylaxis (PEP).” Accessed June 10, 2021. (CDC statement)

29. * U.S. Centers for Disease Control and Prevention.“Preexposure Prophylaxis for the Prevention of HIV Infection in the United States—2017 Update: A Clinical Practice Guideline.” Accessed June 10, 2021. (CDC guidelines)

Subscribe to get the full list of 85 references and see how the authors distilled all of the evidence into a concise, clinically relevant, practical resource.

Keywords: HIV, AIDS, HAART, retroviral, antiretroviral, CD4, NRTI, PEP, PrEP, seroconversion, COPD, thromboembolism, MSM, opportunistic infection, OI, ABC, FTC 3TC, TAF, TDF, DOR, EFV, RPV, ATZ, DRV, BIC, DTG, EVG, RAL, NRTI, NNRTI, protease, integrase, hepatitis, pregnancy, renal, nephrolithiasis, diarrhea, rash