Sepsis Shown to Be Prevalent Among Patients With High HIV Viral Load

Close to 6 million individuals die every year as a direct result of sepsis infection, with a majority of these death occurring in low- and middle-income countries. That equates to almost 20% of the total patient population (~30 million) who has sepsis. The HIV-positive population in sub-Saharan Africa has been disproportionately affected by this opportunistic infection, even while consistently adhering to their antiretroviral treatment (ART) regimens.

Chief among the countries affected is Zimbabwe, which has one of the highest rates of HIV infection (14.6% of its population) in the world. In light of recent successful efforts to increase ART use and adherence among this patient population—86.8% are now on ART—study authors wanted to investigate the resulting rates and outcomes of community-acquired sepsis and other opportunistic infections. Their primary outcome was 30-day all-cause mortality.

A total of 142 patients, at least 18 years old, were enrolled in the prospective cohort trial from Parirenyatwa Group of Hospitals in Zimbabwe. All had been admitted for suspected sepsis between February and November 2016. In cases of unconfirmed HIV status, national guidelines dictated counseling and testing services. All provided informed consent.

Results were recently published online in the International Journal of Infectious Diseases.

Patients were divided into 3 groups, based on their HIV status:

• HIV-negative
• HIV-positive, virally suppressed: less than 1000 copies/mL
• HIV-positive, high viral load: at least 1000 copies/mL

Overall, 68% (95% CI, 30%-75%) of patients presenting with sepsis were HIV-positive, but 41% (95% CI, 31%-50%) were not on ART. Also of this group, 27% did not know their disease status, so they were not receiving any treatment. Men were more likely than women to be ART-naïve (37% vs 14%). For those on ART, the median (interquartile range) time was 14 (1-60) months.

Among this group, 2 opportunistic infections were prevalent: tuberculosis lipoarabinomannan in 36% (95% CI, 24%-48%) and Cryptococcal in 15% (95% CI, 7%-23%).There were also high rates of what the authors termed “severe non-AIDS infections,” and these were Streptococcus pneumoniae in 12% (95% CI, 4%-20%) and bacteraemia in 17% (95% CI, 9%-24%). Bacteriologic evidence of infection was also more prevalent among the HIV-positive group compared with the HIV-negative group, for 72% versus 26%.

In addition, compared with the HIV-negative cohort, the 30-day mortality was higher for the HIV-positive group:

• High viral load: hazard ratio (HR), 3.59 (95% CI, 1.27-10.16; P = .02)
• Virally suppressed: HR, 1.88 (95% CI, 0.78-4.55; P = .06)
• ART-naïve: HR, 1.61 (95% CI, 0.64-4.09; P = .31)

Mortality was also affected by time on ART:

• Less than 6 months: HR, 3.70 (95% CI, 1.34-10.17)
• More 6 months: HR, 1.98 (95% CI, 0.92-4.27; P = .08)

The authors point to increasing levels of antimicrobial resistance as one of the culprits for the sepsis infections, with clinical bacterial isolates serving as the evidence. The urine and blood samples collected as part of the study showed signs of resistance to β-lactam antibiotics and ciprofloxacin.

“HIV and opportunistic pathogens, especially TB and cryptococcal infection, dominated the clinical presentation of patients presenting to the [casualty department] with suspected sepsis, and were associated with high mortality,” the study authors concluded. “Low-cost [point-of-care] testing to rapidly identify HIV and opportunistic pathogens in the [casualty department] should be routinely employed in patient management and therapeutic decisions.”

To make headway in this area, citing their small sample size, the team of investigators suggest larger studies to validate their findings.

Reference

Chaka W, Berger C, Huo S, et al. Presentation and outcome of suspected sepsis in a high-HIV burden, high antiretroviral coverage setting [published online April 11, 2020]. Int J Infect Dis. doi: 10.1016/j.ijid.2020.04.004