ICU Mortality of People Living With HIV Has Decreased Over Time

Mortality of critically ill people living with HIV (PLHIV) admitted to the intensive care unit (ICU) has decreased over time in Barcelona, indicating a difference in patient characteristics, according to a study published in Infection.¹

PLHIV have had an increase in quality of life in recent years as treatment and prevention methods have increased in availability and efficacy, including antiretroviral therapy (ART) improvements.² Survival rates, both in the short and long term, have also improved, even in PLHIV who are admitted to the ICU. The World Health Organization recommended in 2016 that all PLHIV receive early ART, due to the benefits displayed in several clinical trials. This study aimed to assess the short- and medium-term outcomes in PLHIV who were admitted to the ICU after the recommendation of universal ART was introduced in 2016. This study also aims to identify any changes in epidemiological and clinical characteristics of the PLHIV.

Mortality for PLHIV admitted to the ICU has decreased due to several characteristics | Image credit: Kiryl Lis - stock.adobe.com

PLHIV who were admitted to the ICU in the Hospital Clinic of Barcelona and were admitted for at least 12 hours were eligible for the retrospective, observational study. Patients admitted to the resuscitation areas or emergency boxes alone or were ICU readmissions during the same hospitalization or within 1 month of discharge were excluded from the study. All data from November 17, 2006, to December 31, 2019, were used for this study. All ICU admissions were divided into 2 groups: 2006 to 2015 and 2016 to 2019. This was done in order to evaluate temporal changes.

General information, ICU admission-related information, and HIV infection-related information were all collected from the patients with comorbidities also noted for each patient, with distinctions made for unrelated comorbidities as well as toxic habits, such as smoking, alcoholism, and intravenous drug use.

There were 502 admissions from 428 patients that were included in the study, of which 75% were men and the median age was 47.5 years. A total of 91% of the patients were diagnosed with HIV prior to their admission to the ICU with a median duration of diagnosis being 15.7 years. The emergency department made up 60% of the overall admissions, with most of them being from non-AIDS defining events (ADE) (78%). However, most ADE admissions were due to opportunistic infections (OI) (86%).

A total of 82% of the admissions were using ART prior to being admitted to the ICU; 53% were on ART during their ICU stay. ART was continued in 88% of the patients 12 months after discharge. The mortality rates were 18% during hospitalization and 12% in the ICU, with 1 year mortality being 14% in patients that survived after the ICU.

The second period (14% vs 7%; OR, 0.45; 95% CI, 0.23-0.88) and 1 year after discharge from the ICU (16% vs 12%; OR, 0.64; 95% CI, 0.36-1.14) displayed a lower mortality rate overall, though the latter association did not have statistical significance. More patients were on ART before their admission (OR, 2.03; 95% CI, 1.00-4.11), had fewer current or former intravenous drug users (OR, 0.41; 95% CI, 0.24-0.72), had less surgical admissions (OR, 0.55; 95% CI, 0.32-0.95), and had fewer complications in the ICU in the second period.

ICU mortality was predicted through ADE-related admissions (OR, 2.38; 95% CI, 1.09-5.22), complications in the ICU (OR, 2.28; 95% CI, 1.04-4.96), higher Sequential Organ Failure Assessment scores at admission (OR, 1.11; 95% CI, 1.01-1.23), invasive mechanical ventilation (OR, 7.51; 95% CI, 2.46-22.95), and renal replacement therapy requirement (OR, 3.79; 95% CI, 1.26-11.44). The only factor that protected from mortality was using ART during ICU admission (OR, 0.42; 95% CI, 0.21-0.88).

The design of the study, being single-center, retrospective, and observational, could affect the generalizability of the results.

The researchers concluded that the mortality of PLHIV who are admitted to the ICU has decreased due in part to the characteristics of the patients entering the ICU, including the usage of ART prior to their admittance to the ICU, which emphasizes the importance of the recommendation that all patients start early ART.

References

1. Martinez E, Foncillas A, Téllez A, et al. Epidemiological changes and outcomes of people living with HIV admitted to the intensive care unit: a 14-year retrospective study. Infection. Published online October 11, 2024. doi:10.1007/s15010-024-02402-x
2. Global HIV & AIDS statistics—fact sheet. UNAIDS. Updated August 2, 2024. Accessed October 11, 2024. https://www. unaids.org/en/resources/fact-sheet