Epidemiology and outcome of HIV-infected patients admitted to the ICU in the current highly active antiretroviral therapy era

Epidemiological changes and outcomes of people living with HIV admitted to the intensive care unit: a 14-year retrospective study

PURPOSES

Since 2016, the World Health Organization has recommended universal antiretroviral therapy (ART) for all people living with Human Immunodeficiency Virus (PLHIV). This recommendation may have influenced the characteristics and outcomes of PLHIV admitted to the Intensive Care Unit (ICU). This study aims to identify changes in the epidemiological and clinical characteristics of PLHIV admitted to the ICU, and their short- and medium-term outcomes before and after the implementation of universal ART (periods 2006-2015 and 2016-2019).

METHODS

This retrospective, observational, single-center study included all adult PLHIV admitted to the ICU of a University Hospital in Barcelona from 2006 to 2019.

RESULTS

The study included 502 admissions involving 428 patients, predominantly men (75%) with a median (P25-P75) age of 47.5 years (39.7-53.9). Ninety-one percent were diagnosed with HIV before admission, with 82% under ART and 60% admitted from the emergency department. In 2016-2019, there were more patients on ART pre-admission, reduced needs for invasive mechanical ventilation (IMV) and fewer in-ICU complications. ICU mortality was also lower (14% vs 7%). Predictors of in-ICU mortality included acquired immunodeficiency syndrome defining event (ADE)-related admissions, ICU complications, higher SOFA scores, IMV and renal replacement therapy (RRT) requirement. ART use during ICU admission was protective. Higher SOFA scores, admission from hospital wards, and more comorbidities predicted one-year mortality.

CONCLUSIONS

The in-ICU mortality of critically ill PLHIV has decreased in recent years, likely due to changes in patient characteristics. Pre- and ICU admission features remain the primary predictors of short- and medium-term outcomes.

People living with HIV, HCV and HIV/HCV coinfection in intensive care in a German tertiary referral center 2014-2019

PURPOSE

The epidemiology of HIV-infected individuals on the Medical Intensive Care Units (MICU) has changed after profound progress in treatment of AIDS-defining illnesses and anti-retroviral therapy (ART). Changes of MICU utilization of Hepatitis C (HCV) patients following roll-out of direct-acting antivirals (DAA) are yet to evaluate.

METHODS

We performed a retrospective study on all patients with HIV, HIV/HCV and HCV admitted to the MICU of University Hospital Bonn 2014-2019. We assessed sociodemographic data, available clinical data from HIV patients (CDC stage, CD4 + lymphocyte cell count, HIV-1-RNA, ART) and HCV patients (HCV-RNA, stage of liver cirrhosis, treatment history) and outcome.

RESULTS

237 patients (46 HIV, 22 HIV/HCV, 169 HCV; 168 male, median age 51.3 years) with 325 MICU admissions were included. Admission criteria for HIV patients were infections (39.7% AIDS-associated, 23.8% with controlled HIV-infection) and cardiopulmonary diseases (14.3%). HIV/HCV coinfected patients had infections in controlled/uncontrolled HIV-infection (46.4%), cardiopulmonary diseases and intoxication/drug abuse (17.9% each). Reasons for HCV-mono-infected patients were infections (24.4%), sequelae of liver disease (20.9%), intoxication/drug abuse (18.4%) and cardiopulmonary diseases (15%). 60 patients deceased; most important risk factor was need for mechanical ventilation. The number of HCV-patients admitted to MICU with chronic active disease and sequelae of liver disease decreased while the proportion of patients with completed DAA-treatment increased.

CONCLUSION

Infections remain the most important reason for MICU admission in patients with HIV and/or HCV infection while non-AIDS related conditions increased. DAA roll-out has a beneficial effect on liver-associated morbidity in HCV patients admitted to MICU.

Characteristics of patients admitted to the ICU with Kaposi sarcoma herpesvirus-associated diseases

OBJECTIVE

There are four conditions caused by Kaposi sarcoma herpesvirus (KSHV): Kaposi sarcoma, KSHV-associated multicentric Castleman disease (MCD), primary effusion lymphoma (PEL), and KSHV inflammatory cytokine syndrome (KICS). These KSHV-associated disorders (KADs) often occur in people with HIV and can lead to multiorgan dysfunction requiring admission to the ICU. However, little is known about patient outcomes in this setting.

METHODS

A retrospective study of patients with KADs admitted to the ICU between 2010 and 2021 was conducted, examining KAD admission diagnoses, HIV characteristics, selected cytokine profiles, and ICU interventions. Primary outcomes were 60-day and median overall survival from ICU admission to death from any cause.

RESULTS

Forty-seven patients (all but one with HIV coinfection) were included. At ICU admission, 44 patients (94%) were on antiretroviral therapy with a median CD4 + count of 88 cells/μl and HIV viral load of 23 copies/ml. The most common presentation was respiratory failure alone (19%) or with hypotension (17%). Twenty-two (47%) patients had presumed KICS (with or without Kaposi sarcoma) at admission and an additional KAD was diagnosed in 36% of these patients. IL-6 levels did not vary across KAD subtype. Twenty (43%) patients received KAD-directed therapy in the ICU. Sixty-day survival was 70% and median overall survival was 9 months.

CONCLUSION

The majority of patients with HIV and KADs admitted to the ICU had well controlled HIV. Additional KAD were diagnosed during ICU admission in a proportion of patients who presented with presumed KICS. Critical illness did not preclude a subset of patients from receiving KAD-directed therapy in the ICU.

Mortality in patients with acquired human immunodeficiency virus infection hospitalized in an intensive care unit during the period 2017-2019

Identify risk factors associated with mortality in HIV patients admitted to an ICU in the city of Bogotá. Retrospective cohort study of patients treated in an ICU during the years 2017–2019. The analysis included descriptive statistics, association tests, and a logistic regression model. A predictive model of mortality at the time of admission to the ICU was developed. 110 HIV patients were identified. Association was found between a Charlson index ≥ 6 and mortality (OR = 2.3, 95% CI 1.0–5.1) and an increase in mortality in the first 21 days of ICU stay (OR = 2.2, 95% CI 1.0–4.9). In the logistic regression analysis, the absence of highly active antiretroviral therapy (HAART) upon admission to the ICU (OR = 2.5 95% CI 1.0–6.1) and the first 21 days of ICU stay (OR = 2.3 95% CI 1.0–5.4) were associated with an increase in mortality. The predictive mortality model established that mortality was higher in patients admitted to the ICU without having previously received HAART than in those who did receive therapy at the time of admission to the ICU. In patients with HIV admitted to the ICU, the absence of HAART will negatively impact mortality during their hospital stay.

Predictors of in-hospital mortality in a cohort of people living with HIV (PLHIV) admitted to an academic medical intensive care unit from 2009 to 2014: A retrospective cohort study

Outcomes for critically ill people living with human immunodeficiency virus (PLHIV) have changed with the use of antiretroviral therapy (ART). To identify these outcomes and correlates of mortality in a contemporary critically ill cohort in an urban academic medical center in Baltimore, a city with a high burden of HIV, we conducted a retrospective cohort study of individuals admitted to a medical intensive care unit (MICU) at a tertiary care center between 2009 and 2014. PLHIV who were at least 18 years of age with an index MICU admission of ≥24 hours during the 5-year study period were included in this analysis. Data were obtained for participants from the time of MICU admission until hospital discharge and up to 180 days after MICU admission. Logistic regression was used to identify independent predictors of hospital mortality. Between June 2009 and June 2014, 318 PLHIV admitted to the MICU met inclusion criteria. Eighty-six percent of the patients were non-Hispanic Blacks. Poorly controlled HIV was very common with 70.2% of patients having a CD4 cell count <200 cells/mm3 within 3 months prior to admission and only 34% of patients having an undetectable HIV viral load. Hospital mortality for the cohort was 17%. In a univariate model, mortality did not differ by demographic variables, CD4 cell count, HIV viral load, or ART use. Regression analysis adjusted by relevant covariates revealed that MICU patients admitted from the hospital ward were 6.4 times more likely to die in hospital than those admitted from emergency department. Other positive predictors were a diagnosis of end-stage liver disease, cardiac arrest, ventilator-dependent respiratory failure, vasopressor requirement, non-Hodgkin lymphoma, and symptomatic cytomegalovirus disease. In conclusion, in this critically ill cohort with HIV infection, most predictors of mortality were not directly related to HIV and were similar to those for the general population.

Impact of strength training on bone mineral density in HIV-positive patients

Abstract Introduction: Highly active antiretroviral therapy (HAART) transformed HIV from a fatal disease to a chronic one, but it has adverse effects, such as the lipodystrophy syndrome, characterized by morphological and metabolic changes, such as reduced bone mineral density (BMD), potentiating morbidities and mortality. Strength training (ST) aims to increase BMD, due to the osteogenic effect. Objective: To verify the impact of strength training on BMD in people with HIV. Methods: This is a quasi-experimental study, which included 40 people with a mean age of 50 ± 6 years, separated into trained group (TG, n = 20) and control group (CG, n = 20), with reduction in BMD, HIV-positive, using HAART and without exercising. BMD was assessed by DEXA in the lumbar spine, femoral neck and distal 1/3 of the radius, before and after 12 weeks, with the GT submitted to 36 ST and the CG without physical training in the DEXA evaluation in the same time interval. Results: TG had a significant increase with great effect on BMD in all segments: lumbar spine (p = 0.001; ES: 1.87), femoral neck (p = 0.003; ES: 2.20) and 1/3 distal of the radius (p = 0.001; ES: 1.81). Meanwhile, CG group showed a significant reduction with great effect on the femoral neck (p = 0.020; ES: 2.56) and 1/3 distal of the radius (p = 0.015; ES: 2.93), while the lumbar spine showed a great effect to reduce BMD (p = 0.293; ES: 1.78). Conclusion: ST can be used as a therapeutic resource to increase BMD in people with HIV, contributing to the advancement in the search for non-drug therapeutic practices.

Short- and medium-term prognosis of HIV-infected patients receiving intensive care: a Brazilian multicentre prospective cohort study

OBJECTIVES

The characteristics of critically ill HIV-positive patients and the causes of their admission to intensive care units (ICUs) are only known through retrospective and unicentric studies. This study aims to fill this knowledge gap.

METHODS

This is a prospective, multicentre cohort study of short- and medium-term prognostic factors. The setting consisted of ICUs of three tertiary referral hospitals from the three largest metropolitan areas in Brazil in the period January 2014 to November 2015. In all, 161 HIV patients over 18 years old were included.

RESULTS

The clinical data of the outcomes (ICU mortality, hospital mortality and 90-day survival) were extracted from medical records using the REDCap^®️ web-based form and analysed with the MedCalc^{® ️} application. Median age was 41.7 [interquartile range (IQR): 34-50] years, the Simplified Acute Physiologic Score 3 (SAPS 3) was 64 (IQR: 56-74), and the Sequential Organ Failure Assessment Score (SOFA) was 6 (IQR: 4-9) points. The main causes of admission were sepsis (54.5%) and acute respiratory failure (13.7%). ICU and hospital mortality rates were 32.3% and 40.4%, respectively. In a multivariate analysis, time until ICU admission ≥ 3 days (P = 0.0013), performance status (Eastern Cooperative Oncology Group score, P = 0.0344), coma (Glasgow Coma Scale ≤ 8 points, P = 0.0213) and sepsis (P = 0.0003) were associated with increased hospital mortality. Coma (P = 0.0002) and sepsis (P = 0.0008) were independently associated with 90-day survival.

CONCLUSIONS

Delayed ICU admission and the severity of critical illness determine the short- and medium-term mortality rates of HIV-infected patients admitted to the ICU, rather than factors associated with HIV infection. These results suggest that prognostic factors of HIV-infected patients in the ICU are similar to those of non-HIV-infected populations.