CATIE News

19 November 2020 

North American study finds decreasing hospitalization rates for many HIV-positive people

  • Effective HIV treatment has reduced hospitalizations, say North American researchers
  • People with HIV are now more likely to be hospitalized for infections unrelated to AIDS
  • Researchers suggested these may be bacterial infections related to injection drug use

HIV treatment (ART) has improved tremendously over the past 30 years. Today, ART is generally simpler, safer and more effective than ever. As a result, the life expectancy of ART users in Canada and other high-income countries approaches that of HIV-negative people.

However, not all HIV-positive people are taking ART. Research by the Public Health Agency of Canada suggests that about 14% of HIV-positive people are not aware of their infection status (the figure is similar in the United States). Also, some HIV-positive people, particularly from vulnerable populations, have difficulty taking medicines and need help to stay engaged in their care. As a result, not all HIV-positive people in Canada and other high-income countries will reap the benefits of ART.

A team of researchers in Canada and the U.S. have pooled health-related information from their clinics. The team sought to find out about trends in hospitalizations of HIV-positive people between 2005 through 2015.

In analysing information on more than 28,000 HIV-positive people, the researchers found that ART has had a powerful impact on improving measures of health. ART strengthens the immune system and has decreased hospitalization from AIDS-related infections. The researchers also found that hospitalizations due to cardiovascular disease fell. However, infections unrelated to AIDS rose over the study. Bacteria caused many of the infections that required hospitalization, possibly a consequence of injecting street drugs.

Although incredible progress has been made in improving the health of many HIV-positive people, much work remains to be done, particularly for people who have problematic substance use.

Study details

For the present analysis, researchers from six major clinics—five in the U.S. and one in Calgary—cooperated in reviewing information on 28,057 HIV-positive people.

The average profile of participants upon study entry was as follows:

  • age – 43 years
  • 80% male, 19% female, 1% transgender female
  • major ethno-racial groups: White – 41%; Black – 32%; Hispanic – 16%
  • common populations: men who have sex with men – 52%; heterosexual people – 35%; people who inject street drugs – 13%
  • CD4+ count – 387 cells/mm3
  • a suppressed viral load – 37%

Results

Over the course of the study, improvements in common lab tests were seen. For instance, CD4+ cell counts approached 600 cells/mm3 by the end of the study and the proportion of people with a suppressed viral load increased to 85%.

Focus on hospitalizations

During the study, 7,503 people were hospitalized and there was a total of 21,230 hospitalizations (some people were hospitalized more than once). At the start of the study, people who were hospitalized were in their mid-40s; by the end of the study, the age had risen to 52 years.

The top 10 reasons that researchers provided for hospitalizations were as follows:

  • infections unrelated to AIDS – 25%
  • cardiovascular – 10%
  • liver/gastrointestinal – 9%
  • mental health – 8%
  • AIDS-related illness – 6%
  • cancers unrelated to AIDS – 6%
  • “injury/poisoning/complications of therapy” – 6%
  • kidney/genitourinary – 5%
  • hormonal/metabolic – 5%
  • lung – 4%

When investigating the infections unrelated to AIDS, the researchers found the following causes:

  • bacterial infection in the blood – 23%
  • bacterial pneumonia – 18%
  • skin infections – 12%

The researchers also found the following:

  • the most common AIDS-related infectious complication was PCP (pneumocystis pneumonia) – 18%
  • the most common category under mental health was major depression – 20%

Changes

Over the course of the study, hospitalization for AIDS-related infections and cardiovascular disease fell significantly.

In 2015, the final year of the study, the highest hospitalization rates were seen for the following conditions:

  • infections unrelated to AIDS
  • cardiovascular disease
  • mental health
  • liver/gastrointestinal
  • cancers unrelated to AIDS

In general, people who were hospitalized were older and had lower CD4+ cell counts and unsuppressed viral loads.

The researchers also examined trends in hospitalization rates among HIV-negative people in North America and found that these were relatively stable over the study period.

Infections unrelated to AIDS

Over the course of the study, researchers found that a large proportion of hospitalizations of HIV-positive people was due to infections unrelated to AIDS. Hospitalizations for this reason rose at a small but steady level.

Some, perhaps many of these infections, were caused by bacteria and are associated with weakened immunity and injecting street drugs. The researchers suspect that ongoing “opioid and methamphetamine epidemics in [North America]” might have played a role in the high rate of hospitalizations for bacterial infections. However, the researchers cannot be certain, as they did not collect information on current substance use from participants.

The researchers also noted that “chronic obstructive pulmonary disease (COPD), tobacco smoking, high alcohol intake, and opioid use, even when medically appropriate, can play a role in the incidence and severity of bacterial pneumonia and may be contributing to hospitalizations.”

Other factors listed by the researchers that may have played a role in serious infections unrelated to AIDS were type 2 diabetes and obesity, which they stated were “common” among HIV-positive people in North America.

Reducing future hospitalizations

To help reduce the risk of hospitalization in the future, the research team suggested that clinic staff continue to do the following:

  • offer or refer people to harm reduction services and/or substance dependency treatment
  • offer vaccinations against influenza and pneumonia
  • offer referrals to address “social and clinical barriers [to care],” such as homelessness, food insecurity, mental health services and transportation subsidies (to keep clinic appointments)

The present study confirms overall trends that have been reported from other studies in high-income countries: a decrease in hospitalizations from AIDS-related infections and cardiovascular disease. However, the study also underscores that hospitalizations continue, particularly for reasons unrelated to AIDS.

The present study provides a foundation for research that uncovers drivers of hospitalization in the current era among HIV-positive people and ways to address them.

—Sean R. Hosein

Resources

CATIE News

Why many people may not disclose substance use to healthcare providers

Intimate partner violence linked to poor health outcomes among women with HIV

Assessing the cascade of care for opioid use disorder in British Columbia

What’s causing deaths among HIV-positive people in San Francisco?

Some medically complex HIV-positive patients are not resuming HIV treatment after a hospital stay

Overdoses and smoking are taking the lives of people with HIV who have been cured of hepatitis C

Prescribed opioids associated with increased risk of pneumonia

REFERENCE:

Davy-Mendez T, Napravnik S, Hogan BC, et al. North American AIDS Cohort Collaboration on Research and Design of IeDEA. Hospitalization rates and causes among persons with HIV in the US and Canada, 2005-2015. Journal of Infectious Diseases. 2020; in press.