Opportunistic infections remain a key problem
Comorbid conditions growing in importance
Although the most common reasons for hospitalization among HIV patients in six hospitals nationwide are for comorbidities, there remains a significant rate of hospitalization for opportunistic infections (OIs), a new study says.
Investigators analyzed hospitalization rates for more than 10,000 patients, with a median age of 41, at six hospitals across the country, where there were large samples of HIV-positive patients who were part of the HIV Research Network, says Kelly Gebo, MD, MPH, assistant professor of medicine at Johns Hopkins University, School of Medicine in Baltimore. The study was presented at the recent 2004 annual meeting of the Infectious Diseases Society of America, held Sept. 30 to Oct. 3, 2004, in Boston.
In 2001, 17% of the cohort had one or more hospitalizations, and 23% of all hospitalizations were for AIDS-defining illnesses, she says.
The same data showed that 10% were for gastrointestinal problems, 9% for mental health problems, and 7% for circulatory disease, Gebo adds.
"Hospitalizations for opportunistic infections [OI] were higher than we anticipated. And these rates were higher in women and Hispanics. The next most common reasons for hospitalization were gastrointestinal disease, mental health problems including substance use, and circulatory disease, including cardiovascular disease," she says.
"Women had higher rates for gastrointestinal and mental health disease, but lower rates for circulatory problems," Gebo adds.
The most common reasons for hospitalization among those who had OIs were Pneumocystis carinii pneumonia (PCP) and bacterial pneumonia, she explains.
Pneumonia diagnoses were higher than researchers had expected, and this indicated a shift in HIV disease progression, Gebo notes.
"People are getting immune benefit from highly active antiretroviral treatment (HAART), but they’re still showing bacterial infections," she says. "They’re getting fewer traditional opportunistic illnesses, but the most common new OI is bacterial pneumonia."
Recurrent bacterial pneumonia was the most common of AIDS-defining illnesses, with a hospitalization rate of 3.86 per 100 patient years; PCP, by contrast, had a hospitalization rate of 1.63 per 100 patient years, Gebo says.
"I think recurrent bacterial pneumonia is more common in older people, and this reflects that our patients are getting older," she notes.
When data were adjusted for CD4 cell counts and viral load counts, it was found that patients with lower CD4 cell counts and higher viral loads were more likely to have AIDS-defining illnesses, just as might be expected, Gebo points out.
"And those on antiretrovirals were less likely to get AIDS-defining illnesses than those not on them," she adds. "Also, people who had more visits to their doctor were more likely to have AIDS-defining illnesses."
Other findings included these:
- Hispanics had higher rates of hospitalization for AIDS-defining illnesses than did whites or African Americans.
- African Americans were more likely to be hospitalized for a mental health condition than were whites or Hispanics.
- Older patients were more likely to be hospitalized for a circulatory disorder and for gastrointestinal disorders but not for AIDS-defining illnesses or for mental health conditions.
The hospitalization rates for substance-use disorders also were surprisingly high, Gebo says.
"I think a lot of our patients are actively using illicit drugs, causing toxicity, and needing hospitalization," she says.
Substance use had a hospitalization rate of 1.42 per 100 patient years, which was the highest rate among non-AIDS-defining illnesses, Gebo adds.
"I think there are two messages in these findings," she says. "One is that patients are suffering from traditional OIs less than they were before, and bacterial pneumonia is now the most common AIDS-defining illness and, two, patients are hospitalized for multiple comorbidities, with mental health, circulatory, and GI [gastrointestinal] the most common."
As HIV patients age, clinicians should expect to see more general comorbidities, including heart attacks, strokes, hepatitis-related complications, and substance-abuse disorders, Gebo says.
"They need to be aware of the fact that HIV patients will have general health problems that could be a result of therapy or the normal processes of aging, but we’ll be seeing more and more of these things," she adds.