Hospitalisations and deaths down in US, slight increase in number of admissions due to liver problems

Hospital admissions and inpatient deaths in HIV-positive patients fell dramatically in the United States between 1996 and 2000, according to a study published in the December 15^th edition of the Journal of Acquired Immune Deficiency Syndromes. Investigators looked at data from over 300,000 hospital admissions following the introduction of potent antiretroviral therapy from twelve US states. As well as observing a fall in admissions and deaths, they also found that the reasons why individuals were admitted to hospital changed significantly, with opportunistic infections causing proportionately fewer admissions and liver-related illnesses proportionately more.

It is well recognised that effective antiretroviral therapy has led to a fall in the amount of HIV-related illness and death in HIV-positive individuals. Yet, even when anti-HIV therapy is readily available, people with HIV still get ill and die and several studies from the US and Europe suggest that the reasons why HIV-positive individuals are hospitalised or die has changed since potent HIV therapy became available, with AIDS-related illnesses accounting for less illness and death and liver disease and HIV treatment side-effects more.

Investigators from the Healthcare Cost and Utilization Project (HCUP) examined records of hospital admissions and inpatient deaths for HIV-positive individuals aged over 18 in twelve US states in 1996, 1998, and 2000. Just under 317,000 admissions were available for analysis.

Consistent with the introduction of potent anti-HIV treatment, admissions fell from 129,000 in 1996 by 25% to 97,000 in 1998 and by a further 6% to 92,000 in 2000.

There were significant demographic differences in hospital admission rates. The decline in admissions was proportionately greater in men (33%) than women (18%), and for younger patients (18 – 30 years, 56%) than older patients (over 50s, fall in admissions, 8%). Admissions for white patients fell by 40%, whereas admissions for African Americans only fell by 20%.

The investigators then looked at the reasons for admission to hospital. Admissions for opportunistic infections fell from 51,000 in 1996 to 25,000 in 2000. Admissions related to injecting drug use remained broadly stable at 6,400 in 1996 and 5,200 in 2000. However, the proportion of admissions due to liver disease increased from 8% (10,500) in 1996 to 13% (11,500) in 2000, and proportion of hospital admissions related to hepatitis C virus increased from 1% in 1996 to 5% in 2000.

Attention was then turned to hospital admissions that could be due to the long-term side-effects of anti-HIV therapy. The proportion of admissions which were diabetes-related increased from 3% (4,000) to 5% (4,500) in 2000. Heart disease was responsible for 462 admissions in 1996, and this increased to 800 admissions in 2000, but even with this increase these admissions still account for less than 1% of all hospitalisations and the increase was not statistically significant.

Overall mortality was 7%, falling from 9% in 1996 and levelling off at approximately 6% in 1998 and 2000. The odds of death were 27% lower in 1998 than 1996 and 30% lower in 2000 than in 1996.

“Admission diagnoses for HIV-related hospitalizations changed significantly between 1996 and 2000”, conclude the investigators. They add, “consistent with the introduction of HAART, there was a concomitant decrease in opportunistic illnesses, suggesting that HIV patients are benefiting from HAART.” However, “treatment complications of HAART, including diabetes and cardiovascular, and cerebrovascular complications, have increased during this period, but they still comprise a relatively small proportion of the total number of HIV hospitalizations”.