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HIV-positive mortality rates decreasing in ICU

Thursday May 24, 2012
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The expanded use of antiretrovirals has been linked to significant decreases in hospital mortality rates among severely ill HIV-positive patients nationwide, primarily due to a decrease in opportunistic infections, according to a study.

Despite these encouraging data, the study also revealed that chronic diseases and bloodstream infections are on the rise in this population.

"The national expansion of antiretroviral programs has appeared to yield benefits well beyond the outpatient setting," Monica Bhargava, MD, MS, the study’s lead author and an adjunct clinical instructor in Stanford University’s Division of Pulmonary and Critical Care Medicine, said in a news release.

"In the 1980s, HIV-positive patients were often declined ICU admission because their prognosis was deemed far too grave. Our work shows that this has changed substantially since the advent of the antiretroviral era. The broader use of such medications is having a wide-ranging impact."

Although previous studies have shown that the initiation in the mid-1990s of antiretroviral therapy for the treatment of HIV has led to sharp reductions in mortality nationwide, Bhargava said, the effect on critically ill HIV-positive patients had not been assessed with a nationally-representative sample.

For their study, the researchers used data spanning 1993 to 2008, culled from the Healthcare Cost and Utilization Project Nationwide Inpatient Sample, a database of hospital inpatient stays used by researchers and policymakers to identify, track and analyze national trends in healthcare. For each year, statistical analyses were performed to isolate the effect of HIV-positive status on mortality, controlling for socioeconomic, demographic and hospital characteristics.

Although nationally the number of HIV-positive patients requiring mechanical ventilation rose from 7,632 in 1993 to 10,775 in 2008, mortality in that population declined from more than 63% in 1993 to 41.4% in 2008, Bhargava said. The sharpest decline occurred in 1996-1997, the beginning of the ART era.

The decrease most likely stems from the concomitant decline in the occurrence of opportunistic infections, which are less likely in those on antiretroviral drugs, Bhargava said.

In this study, the researchers looked at one such infection commonly associated with patients on mechanical ventilation, Pneumocystis carinii pneumonia. They found that among HIV-positive patients who received mechanical ventilation, the rates of PCP infection nearly halved, from 29.2% in 1993 to 15.2% in 2008.

"It appears that the wider use of antiretroviral therapy has both decreased the percentage of patients with PCP and reduced mortality in those patients who develop it," Bhargava said. "That is quite encouraging."

The researchers also found that median length of hospital stay declined in the HIV-positive population during the study period, and this population experienced a slower rate of growth in hospital charges relative to the general population. Black race remained the strongest independent predictor of in-hospital death among HIV-positive patients.

"Our study confirms that major gains in in-hospital survival have occurred among HIV-positive patients with respiratory failure, though there is still much more progress that needs to be made," Bhargava said. "In addition, there has been a notable increase in the diagnoses of sepsis, chronic obstructive airway disease, liver disease and coronary artery disease."

"Our work shows that our national efforts should focus more on managing chronic diseases and sepsis in this population," she added. "Future studies should help clarify the reasons behind the surge in sepsis and why ICU survival remains poorer among HIV-positive ethnic minorities."

The study was presented May 23 in San Francisco at the American Thoracic Society’s 2012 international conference.

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