Hospital days attributable to immune reconstitution inflammatory syndrome in persons living with HIV before and after the 2012 DHHS HIV guidelines

Abstract

BackgroundImmune reconstitution inflammatory syndrome (IRIS) can manifest with initiation or reintroduction of antiretroviral therapy (ART) in persons living with HIV (PLWH). In 2012, updated United States treatment guidelines recommended initiation of ART for all PLWH regardless of CD4 count. The objectives of this study were to quantify hospital usage attributable to IRIS and assess the reasons for hospitalization in PLWH before and after the guideline update.MethodsSubjects were PLWH between 18–89 years of age who were hospitalized between November 1, 2009 and July 31, 2014. Equivalent time periods before and after updated treatment guidelines were considered, and designated as Time Period 1 and Time Period 2, respectively. IRIS-attributable hospitalizations were identified by ICD9 codes and electronic medical record searches with subsequent review and confirmation. For hospitalizations that were not confirmed as being IRIS-attributable, primary discharge diagnoses were reviewed.ResultsA total of 278 PLWH were hospitalized 521 times throughout the study period. Time Period 1 had 9 PLWH with 12 IRIS-attributable hospitalizations while Time Period 2 had 6 PLWH with 9 IRIS-attributable hospitalizations. A larger proportion of IRIS-attributable hospital days was observed in Time Period 1 compared to Time Period 2 (7.5 vs 4.2%; p < 0.001). Median length of stay for IRIS-attributable hospitalizations was longer than for other diagnoses, particularly during Time Period 1 (12.0 vs 4.0; p = 0.05). The most common causes for hospitalizations in PLWH were non AIDS-defining infection, AIDS-defining malignancy, and gastrointestinal. PLWH who had HIV viral suppression (<200 copies/mL) accounted for 34 and 24% of hospitalizations in Time Periods 1 and 2 respectively.ConclusionsHospitalizations for PLWH continue at high rates and IRIS is a significant contributing factor. In our single-center study, there was a lower number of IRIS-attributable hospitalizations and IRIS-attributable hospital days in Time Period 2 compared with Time Period 1. The hospital burden of IRIS may decrease over time as more PLWH are started on ART earlier in the course of infection. This study highlights the continued importance of early diagnosis and linkage to care of those infected with HIV, so that morbidity and costs associated with IRIS continue to decline.

Impact of comorbidity on the risk and cost of hospitalization in HIV-infected patients: real-world data from Abruzzo Region

“…Second, we found that cardiovascular, renal and pulmonary CMs, as well as HCV coinfection, are significantly associated with an increased risk of acute hospitalizations among PWL-HIV, in line with other reports in the literature. 18 , 20 , 46 , 48 These findings contribute to the idea that a more stringent control of such CMs may well be necessary in the setting of chronic management of HIV infection. Although much has been done in terms of research and development of newer antiretrovirals, with a more favorable profile of toxicity in all lines of HAART, efforts to reduce the prevalence of CMs in HIV patients need to be increased rather than reduced.…”

“…Acknowledging the paucity of information about this issue, in our country as well as in other countries, our analysis may be relevant to understand how HIV infection may still be causing health care resources utilization as well as health care expenditure in the present setting, beyond HIV testing, HAART expenditure and continuous efforts to improve high quality retention in care. 18 – 20 , 46 …”

Cryptococcal Immune Reconstitution Inflammatory Syndrome: From Blood and Cerebrospinal Fluid Biomarkers to Treatment Approaches

“…Mortality from CM-IRIS can be reduced significantly if patients initiated antiretroviral therapy during the phase of moderate immunosuppression, and before significant CD4+ T cell count loss [134,135]. The morbidity and costs associated with IRIS in people living with HIV continue to decline in the USA since 2012 (< 8%), with no fatality [3]. Although much research is being done on the mechanisms that modulate the immunopathogenesis of CM-IRIS, no biomarkers for this condition have been validated to produce a sufficient level of evidence to enter clinical practice.…”

“…Cryptococcus species are the most common cause of meningitis in adults and one of the leading causes of HIV-related mortality in the world, with a global incidence estimated at 223,100 cases per year [1,2]. In countries with limited resources, cryptococcosis drives up to 40% of all hospitalizations and deaths associated with the advanced stage of HIV infection [3][4][5]. Immune reconstitution inflammatory syndrome (IRIS) associated with cryptococcosis is a common complication that manifests after the initiation of antiretroviral therapy (ART) [6,7].…”

Cryptococcal Immune Reconstitution Inflammatory Syndrome: From Blood and Cerebrospinal Fluid Biomarkers to Treatment Approaches

“…Cryptococcus species are the most common cause of meningitis in adults and one of the leading causes of human immunodeficiency virus (HIV)-related mortality in the world, with a global incidence estimated at 223,100 cases per year [ 1 , 2 ]. In countries with limited resources, cryptococcosis drives up to 40% of all hospitalizations and deaths associated with the advanced stage of HIV infection [ 3 , 4 , 5 ]. Immune reconstitution inflammatory syndrome associated with cryptococcosis (C-IRIS) is a common complication that manifests after the initiation of antiretroviral therapy (ART) [ 6 , 7 ].…”