Long-Acting Preexposure Prophylaxis Injections: The Future of HIV Prevention From the Emergency Department?

HIV remains a critical public health issue encountered in the emergency department (ED), which serves as a key access point for screening and diagnosis. In the United States, EDs account for a substantial proportion of new HIV diagnoses. Although the percentage of positive HIV tests in EDs is relatively low, generally ranging from approximately 0.1% to 1.7% depending on the population and testing strategy, some studies report higher rates in high-prevalence areas, around 1.3% to 1.4%. This data suggests that many vulnerable patients presenting to the ED are at ongoing risk for HIV infection despite testing negative during ED screening. This population represents an important opportunity for HIV prevention through initiation of pre-exposure prophylaxis (PrEP). However, traditional PrEP regimens have required frequent laboratory monitoring, making initiation from the ED challenging. Recently developed long-acting injectable antiretroviral therapies, including some biannual dosing regimens, offer potential sustained protection without the need for daily oral adherence. Several long-acting injectable agents have received U.S. Food and Drug Administration (FDA) approval since 2021 and are unique because they can maintain stable concentrations in the body for much longer than most oral HIV medicines. Although these medications are relatively new and are still being incorporated into standard HIV prevention and treatment frameworks, they represent a paradigm shift in HIV management, with efficacy comparable to that of traditional oral therapies. In the ED setting, long acting injectables may provide a novel opportunity to initiate or bridge HIV prevention for patients who are disengaged from care (patient’s the ED has a unique access to more than other traditional touchpoints of HIV care). Vulnerable populations, including individuals experiencing homelessness, substance use disorders, or barriers to medication adherence, may particularly benefit from ED-based initiation or referral pathways. As more information comes out regarding these medications becomes available, the potential to integrating these therapies into emergency care workflows can continue to expand the ED’s role in HIV prevention and treatment while reducing downstream health disparities.