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Explore this issue:Supplement: Hospital Medicine and Infectious Diseases
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An estimated 850,000 to 950,000 persons in the United States are living with human immunodeficiency virus (HIV), 280,000 of whom are unaware of their infection and another 43,000 of whom meet the definition of acquired immunodeficiency syndrome (AIDS) (www.cdc.gov). The use of highly active antiretroviral therapy (HAART) has produced significant declines in morbidity and mortality from AIDS. Compared with the first 2 decades of the HIV pandemic, the number of HIV-related hospital admissions has declined. However, recently, this rate of decline has markedly slowed (1-3). The reasons for this plateau are many including a steady number of admissions for complications related to HAART, treatment failures, and the overall increased prevalence of HIV infection. Not only will HIV-infected patients still frequently require admission to the hospital, but the complexity of their inpatient care will continue to increase with the advancements in multiple drug regimens, aging of the HIV-infected population, and the interaction of HIV infection with medical comorbidities, many of which are attributable to HAART.
The hospitalist caring for the inpatient with AIDS is presented with several challenges including not only the diagnosis and management of opportunistic infections, but also the complications of HAART. In this article we review the guidelines for the initiation and continuation of HAART in the hospital, review important clinical complications of antiretroviral therapy, and review conditions that may result in the hospitalization of AIDS patients.
Initiation of HAART in the Hospital
In those who do not have access to health care, the initial diagnosis of HIV infection frequently occurs during a hospitalization for an AIDS-defining illness. Initiation of antiretrovirals is contingent on several issues, including CD4 count, viral load, clinical status, likelihood of continued adherence, and the concurrent treatment of opportunistic infections (OIs). All patients with HIV infection and a CD4 count <200 cells/mm3 or an AIDS-defining illness should receive antiretroviral therapy. Controversy exists as to whether a patient admitted for the treatment of an opportunistic infection should begin antiretroviral therapy immediately, or whether this therapy should be deferred until after acute treatment of the OI. The potential detrimental effects of drug-drug interactions, the need for treatment interruptions, and drug-related toxicity between antiretrovirals and OI-specific therapy may support initiating HAART after control of an OI is achieved. Conversely, for some opportunistic infections, such as cryptosporidiosis, the use of HAART is essential for successful treatment of the infection.