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Late HIV Diagnosis Raises ICU Admission Rate 5 Times in London Group
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6th IAS Conference on HIV Pathogenesis, Treatment and Prevention, July 17-20, 2011, Rome
Mark Mascolini
Getting diagnosed with HIV at a CD4 count under 350 quintupled the risk of admission to the intensive care unit (ICU) at King's College Hospital, which serves a deprived area of London. The ICU admission risk rose with each lower CD4 bracket at diagnosis, whereas starting antiretroviral therapy cut the risk more than 85%.
Late diagnosis of HIV infection remains a persistent problem in countries rich and poor, despite efforts to expand HIV testing everywhere. To explore the impact of late diagnosis in a poor area of London, researchers at King's College Hospital planned this retrospective cohort study of 2869 people diagnosed with HIV from 2000 through 2009.
The study group had a median age of 35 years (interquartile range [IQR] 29 to 40], 57% were men, and 62% black. Initial median CD4 count stood at 305 (IQR 138 to 474), and median follow-up measured 3.1 years (IQR 0.8 to 6.6). More than half of these people got diagnosed with a CD4 count under 350.
During the study period, 2751 people received HIV care, including 118 (4.3%) who got admitted to the ICU 122 times. Two thirds of ICU admissions happened in the 3 months after HIV diagnosis. The overall ICU admission rate was 1.0 per 100 person-years, with rates of 12.4 per 100 person-years within 3 months of diagnosis and 0.37 per 100 person-years 3 or more months after diagnosis.
Median ICU stay stood at 3 days (IQR 3 to 15). Opportunistic infections accounted for 56 (46%) of ICU admissions, followed by other infections (20, 16%), malignancy (14, 11%), liver disease (6, 5%), neurologic disease (5, 4%), and others (21).
The King's College team figured risk factors for ICU admission two ways, first according to cohort-entry characteristics, then according to time-updated characteristics. In the cohort-entry analysis, four factors independently raised the risk of ICU admission at the following adjusted odds ratios (OR) (and 95% confidence intervals [CI]):
--Every 10 years of age: OR 1.29 (1.07 to 1.57), P = 0.007
--Female gender: OR 2.52 (1.60 to 3.98), P < 0.0001
--Hepatitis B surface antigen: OR 3.86 (1.95 to 7.65), P = 0.001
--HIV diagnosis below 350 CD4s: OR 5.16 (3.09 to 8.59), P < 0.0001
A positive hepatitis C antibody test lowered the risk of ICU admission almost 10% (OR 0.91, 95% CI 0.09 to 0.96, P = 0.002).
Five factors independently upped the risk of ICU admission in the time-updated analysis at the following adjusted incidence rate ratio (IRR) (and 95% confidence intervals):
--Female gender: IRR 2.69 (1.45 to 4.98), P = 0.002
--AIDS diagnosis: IRR 6.59 (3.59 to 12.1), P < 0.001
Compared with a CD4 count above 350 at HIV diagnosis:
--100 to 200 CD4s at diagnosis: IRR 2.30 (1.05 to 5.03), P = 0.038
--50 to 100 CD4s at diagnosis: IRR 3.15 (1.17 to 8.45), P = 0.023
--Under 50 CD4s at diagnosis: IRR 6.08 (2.97 to 12.5), P < 0.001
Starting antiretroviral therapy independently cut the risk of ICU admission more than 85% (IRR 0.13, 95% CI 0.08 to 0.22, P < 0.001).
Aside from the obvious clinical risks implicit in the need for ICU care, the researchers underlined the high monetary cost, noting that "the financial burden of ICU admissions associated with late HIV diagnosis has not been incorporated in economic models."
Reference
1. Shrosbree J, Campbell L , Ibrahim F, et al. Late HIV diagnosis is a major risk factor for intensive care unit (ICU) admission in HIV-positive patients. 6th IAS Conference on HIV Pathogenesis, Treatment and Prevention. July 17-20, 2011. Rome. Abstract MOPE126.
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