AIDSWEEKLY Plus; September 23, 2002
AIDS Weekly editors from staff

Writing in the American Journal of Respiratory and Critical Care Medicine¹, Alison Morris, MD, formerly with the department of medicine, University of California, San Francisco, along with five associates, studied 295 HIV-infected patients admitted to the ICU at San Francisco General Hospital from 1996 to 1999. Morris is currently with the Division Of Pulmonary, Allergy, And Critical Care Medicine, Montefiore University Hospital, Pittsburgh, Pennsylvania.

The survival to hospital discharge of HIV-infected patients has improved significantly from early in the era of the AIDS epidemic (1981-1985) when it was 31%. Currently, the survival rate is 71%. From 1992-1995, 63% of the patients survived to hospital discharge. The improved rate has been especially marked among patients receiving highly active retroviral therapy (HAART).

According to the authors, the characteristics of the ICU HIV population has changed from homosexual white men during 1992 to 1995 to, more recently, African American men and women, along with intravenous drug users.

"These changes reflect the overall shift in the face of the epidemic with minorities and women now at increased risk of HIV and AIDS," said Morris.

Of the total study group, 89 patients were receiving HAART at the time of their ICU admission.

The median long-term survival time for all subjects in the study was 324 days. For those on HAART at the time of admission who were admitted with a non-AIDS-associated diagnosis, long-term survival was 971 days. For those not on HAART with a non-AIDS-associated diagnosis, it was 728 days.

"Median survival was poor for patients with an AIDS-associated diagnosis for admittance regardless of HAART status," said Morris. "It was 30 days for HAART patients and 26 days for those not on HAART."

Pneumocystis carinii pneumonia (PCP), use of mechanical ventilation, or pneumothorax were associated with worse survival in the ICU.

HAART was defined as the use of at least three antiretroviral drugs of at least two classes (i.e., nucleoside reverse transcriptase inhibitors, nonnucleoside reverse transcriptase inhibitors, or protease inhibitors) at the time of hospital admission.

In an editorial in the same issue directed at whether HIV-related admissions to the ICU will continue to decline, Henry Masur, MD, of the critical care department, National Institutes of Health, Bethesda, Maryland, noted that PCP currently accounted for only 10% of the ICU admissions compared with 63% in the 1981-1985 era, just after the start of the epidemic.

"After HAART, more and more patients were admitted to the ICU for problems unrelated to their AIDS, such as drug overdose, trauma, or gastrointestinal bleeding," said Masur. "These latter patients had an especially high likelihood of surviving their hospitalization."

However, in his editorial, Masur decried the large number of patients not under medical supervision who show up in the hospital emergency room with an acute opportunistic infection. For many patients, this acute opportunistic infection is their first clue that they have HIV infection.

Masur pointed to a recent survey of over 20,000 patients by the Adult Spectrum of Disease Study that reported 45% of all cases of PCP at their survey hospitals were occurring in patients not under regular medical supervision.

"This country can and should be able to perform far better in terms of educating its at-risk population and providing them with the care they need before they develop an acute opportunistic infection," said Masur.

Since patients receiving HAART can develop drug toxicities, he suggested that this group of individuals be further divided into either "good" or "poor" responders. Those who have had a good response are much more likely to have a non-HIV-related event cause their admission to the ICU. He mentioned that in most clinical trials evaluating drug regimens recommended by HIV guidelines, only 50-60% of the patients have a sustained response to HAART.

"This suggests that more patients will develop resistance to all currently available antiretroviral agents and will suffer progressive immunologic decline," Masur said. "As this occurs, ICUs are likely to see an upsurge in acute opportunistic infections."

This article was prepared by AIDS Weekly editors from staff and other reports.

Reference

1. Morris A, Creasman J, Turner J, et al., "Crosslinked HIV-1 envelope-CD4 receptor complexes elicit broadly cross-reactive neutralizing antibodies in rhesus macaques," Am J Respir Crit Care Med 2002 Aug 1;166(3):262-7

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