Outcomes of an Emergency Department Program to Identify and Link Patients at Increased Risk for Acquiring HIV Infection to Outpatient HIV Prevention Services: The HIV PreventED Program.

BACKGROUND: Emergency departments (EDs) provide care to patients at increased risk for acquiring HIV, and for many of them, the ED serves as their sole point of entry into the healthcare system. We implemented the HIV PreventED Program to increase access to HIV prevention services for ED patients. SETTING: ED in Oakland, CA with an annual census of 57,000 visits. METHODS: This cross-sectional study evaluated the first 9 months of the HIV PreventED Program. In this program, a navigator surveyed adult ED patients who tested HIV negative to determine their risk for acquiring HIV infection, incorporating HIV prevention counseling into their assessments. Patients at higher risk for acquiring HIV were referred to outpatient prevention services, if interested. The primary outcome measure was the number and proportion of ED patients at higher risk for acquiring HIV who followed up for outpatient prevention services. RESULTS: In this study, 1233 patients who tested HIV negative were assessed by the navigator and received ED-based HIV prevention counseling. Of these, 193 (15.7%) were identified at higher risk and offered an outpatient referral for prevention services, of which 104 accepted (53.9%), 23 (11.9%) attended the referral, and 13 (6.7%) were prescribed preexposure prophylaxis (PrEP). The median time to linkage was 28 days (interquartile range 15-41 days). CONCLUSION: A navigator focused on providing ED-based HIV prevention counseling and linkage to outpatient services is feasible. Strategies to more efficiently identify ED patients at higher risk for HIV acquisition, such as automated identification of risk data from the electronic health record, and policies to improve follow-up and the receipt of PrEP, such as same-day PrEP initiation, should be prospectively evaluated.

Implementing a Rapid Antiretroviral Therapy Program Using Starter Packs for Emergency Department Patients Diagnosed With HIV Infection.

Background: Emergency departments (ED) have been identified as essential partners in the national plan to end the HIV epidemic. The initiation of rapid antiretroviral therapy (ART) may be an important strategy to minimize the treatment barriers faced by many ED patients diagnosed with HIV. Methods: We describe the implementation and outcomes of a protocol to provide rapid ART by using starter packs for eligible ED patients testing HIV antigen/antibody (Ag/Ab) reactive. Eligible patients were not pregnant, were unlikely to have a false-positive Ag/Ab test result, were discharged home, were ART naive, had acceptable liver and renal function, lacked symptoms of an opportunistic infection, and were judged to be a good candidate. Results: During the 1-year study period, 10 606 HIV tests were performed, and 106 patients were HIV Ag/Ab reactive and assessed for ED rapid ART eligibility. Thirty-one patients (29.2%) were eligible for ED rapid ART; 26 (24.5%) were offered it; and 25 accepted and were provided starter packs for an overall ED rapid ART treatment rate of 23.6%. Two patients receiving ED rapid ART were confirmed to be HIV negative. Patients provided ED rapid ART were more likely to follow up by 30 days (82.6% vs 50.0%, P = .01) than patients not provided ED rapid ART. The 6-month incidence of immune reconstitution inflammatory syndrome was 4.3% among the 23 patients who were HIV positive and receiving ED rapid ART. Conclusions: The initiation of ED rapid ART for patients testing HIV Ag/Ab reactive is feasible, well accepted, and safe and may be an important facilitator of linkage to care.

Prevention of scar spread on trunk excisions: a rater-blinded randomized controlled trial.

IMPORTANCE: Wounds that heal under tension lead to wider and more conspicuous scars and result in decreased long-term patient satisfaction. We hypothesized that prolonged intradermal suture lifetime can decrease scar spread in wounds under tension. OBJECTIVE: To determine whether prolonged intradermal support would help decrease scar spread. DESIGN Prospective, randomized, controlled, rater-blinded, split-scar trial. SETTING: Outpatient dermatology clinic at Dallas Veterans Affairs Hospital, Dallas, Texas. PATIENTS: Patients presenting with skin cancer on the trunk were considered for the trial. We included 25 distinct surgical sites on a total of 22 patients. INTERVENTION: After excision, the wounds were closed with polyglactin 910 and poly-4 hydroxybutyrate (P4HB) sutures in opposite halves of the same wound. MAIN OUTCOME MEASURES: Quantitative scar spread at 12 months and qualitative assessment using a visual analog scale and Hollander Wound Evaluation Scale. RESULTS: We found a statistically significant difference in scar width between the 2 suture materials, with a mean difference of 2.3 (95% CI, 1.0-3.6) mm (P < .001) favoring P4HB. A clinically significant difference on the visual analog and Hollander Wound Evaluation scales was not identified. Suture reactions were more common with P4HB. CONCLUSIONS AND RELEVANCE: Prolonged intradermal suture support leads to significantly decreased scar spread. However, the use of a longer-acting absorbable suture increases the rate of suture reaction noted at 3 months. Further studies into less reactive, longer-acting biomaterials are needed. In clinical practice, excisions in high-tension areas that are classically known to spread over time can benefit from longer-acting intradermal sutures. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT00938691.