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Correlations of HIV-related Morbidity and Mortality at a Hospital for the Indigent in California

Kristina Angelo, D.O.1
Christopher Dalinkus, D.O.1
Zhijun Wang, PhD.2
Daniel Pearce, D.O.3

Affiliations:
1Arrowhead Regional Medical Center Department of Internal Medicine
2Western University of Health Sciences College of Pharmacy
3Loma Linda University, School of Medicine, Western University of Health Sciences College of Osteopathic Medicine of the Pacific

Corresponding Author
Daniel Pearce, D.O., FACOI, AAHIVMS dpearce@llu.edu
HIV/AIDS EIP, Riverside County Public Health Department
Neighborhood Health Center
7140 Indiana Ave., Riverside, CA 92504
951-358-6037 Fax-951-358-6019
Declarations: The authors have no conflicts of interests in the material presented in this submission and there was no funding
Key words: HIV test, Mortality, Hospital, Indigent

SUMMARY

BACKGROUND: HAART has resulted in a decline in the morbidity and mortality of HIV positive patients, but there are barriers to obtaining HAART. The aim of this study was to identify predictors of morbidity and mortality with respect to taking or not taking HAART in our HIV population.
METHODS: We performed a retrospective, cross sectional study at Arrowhead Regional Medical Center (mainly indigent patients). Patient records over 3.5 years were reviewed for endpoints. Comparison was made between subjects currently on HAART and those not. Subgroup analysis by CD4 ranges at presentation was also performed. χ2 and two tailed T tests were used.
RESULTS: The main findings of HAART vs. No HAART groups: more insurance coverage (p<0.001), required less ICU care (p<0.001), and less ICU days, (p=0.001). No HAART had 11 times greater odds of dying (p=0.004).
The No HAART, lower CD4 count groups required more ICU care (p=0.035), increased ICU length of stay (p=0.023), were more male (p=0.045), and were more uninsured (p=0.004).
CONCLUSION: The greater degree of immunocompromise and viremia in the No HAART group was correlated with higher in-hospital morbidity and mortality. We should target the uninsured for testing and appropriate referral, e.g. in our own facilities.

INTRODUCTION

Limited institutional resources, barriers to access and linkage, along with inadequate health care follow-up, and other social problems, including poverty, discrimination, and sexual biases, may block treatment access and thereby increase the morbidity and mortality of patients with HIV.1 These barriers are well documented in less developed countries, but some are also present in the indigent health care system of the United States. Kahn, et al showed underutilization of AIDS Drug Assistance Program (ADAP) funds by some ethnic groups, in certain states, but Caucasians and Latinos utilized the resource to a greater degree to obtain proper treatment.2
In one paper, those who were tested and found to be in late stages of HIV were more likely to be African American or Hispanic and to have been exposed through heterosexual contact.3 In other words, they did not have the traditional risk factors, and the vast majority received their first positive test result late in their course, when ill at an acute care or referral medical center rather than at a primary care office or HIV testing site.3 Importantly, cohort studies have demonstrated that once aware of their positive HIV status, many infected persons decreased behaviors that contribute to transmission.4
Like other centers, an appreciable number of our HIV patients were linking to care at a very late stage of disease or just prior to death.5 Between 2001 and 2005, approximately 75% of those with advanced HIV when first tested, but without a history of high risk behaviors, had visited a provider a median of 4 times without an HIV test performed.6 If a patient links to HIV specialty care early enough, their life expectancy will only be shortened by a few years according to van Sighem and colleagues.7 It is estimated that about 20% of the HIV positive people in the United States are unaware of their infection.8

METHODS AND AIMS

This study’s aims were to investigate the effects of HAART (highly active antiretroviral treatment) vs. not being on HAART (No HAART) in our HIV positive population on mortality during hospital admission, and to identify predictors of morbidity and mortality for patients with HIV.
This was a retrospective, cross sectional study at Arrowhead Regional Medical Center (ARMC), a tertiary facility serving primarily indigent patients in Southern California. After ARMC’s Institutional Review Board’s approval, 129 medical records of HIV positive subjects from May, 2007 to December, 2010 were reviewed and data was abstracted and de-identified. The only excluded HIV subjects were those who acquired the virus via documented Mother-to-Child-Transmission. Unique subject visits numbered 84 and 45 were repeat visits. Only initial admission laboratory values were used.
We used χ2 and two tailed T tests to determine statistical significance (alpha <0.05) to compare the HAART and No HAART groups at admission with the Statistical Package for the Social Sciences, version 12.0.1. For multiple admissions, each was counted as an encounter. The two groups were compared by gender, ethnicity, the number of subjects who went to the ICU, insurance types, deaths, and means of: LOS (lengths of stay), absolute CD4 counts, CD4 percent, HIV RNA, and ICU LOS. The insurance types included private, federal, state, and county insurance.

RESULTS

Table 1 demonstrates the frequency and distribution of the subject visit endpoints of the 129 qualified subject visit records. Of the 84 unique subject visits, 8 were female and 7 of the 75 return visits were by females. Sixty-two subject visits were on HAART and 67 subjects had not received treatment greater than one month.
The distribution of insurance coverage demonstrated that of 129 subject visits, 81 visits were uninsured or “self pay”, but the others were counted as covered through some type of payment system.

Table 1: Frequency and Distribution of Subject Visit Endpoints

	All	ART	No ART	Significance
Number of Subjects	129	62	67	NS
Age (mean)^‡	41	42	40	0.507
Gender (%female)*	12	12	10	0.797
Anglo (number)*	18	8	10	0.145
African (number)*	26	14	12
Hispanic (number)*	40	12	28
CD4 (mean, number)^‡	151	216	98	0.05
CD4 (mean, %)^‡	13	16	11	0.105
Viral Load (log, mean)^‡	3.8	2.2	5.0	<0.001
LOS (days, mean)^‡	9.8	9.2	10.5	0.420
ICU Admissions (number)*	27	4	23	<0.001
ICU LOS (days, mean)^‡	5.5	0.3	2.2	0.001
Uninsured (number)*	81	30	51	<0.001
Death (number)^‡	12	1	11	0.004

*Chi square. ^‡ 2-tailed t-test. LOS=length of stay.

The odds ratio of dying after being on HAART the month prior to admission vs. not dying was 0.089 (95%CI: 0.011-0.715). The odds ratio of having insurance vs. no insurance and dying did not reach statistical significance. A significantly greater number of subjects receiving HAART had some form of insurance compared to those not receiving HAART.
The No HAART group was also correlated with greater degree of immunocompromise (low CD4), more viremia, higher in-hospital morbidity (ICU admissions and ICU LOS), and being uninsured. There were no other clinically important significant differences found between these two groups for the other endpoints.

DISCUSSION

Rephrasing the odds ratio of being on HAART at least a month prior to admission vs. not: our untreated patients had approximately 11 times (reciprocal of 0.089) greater odds of dying compared to the treated group.
Prior studies have shown differing outcomes in morbidity and mortality among HIV subjects based on gender, ethnicity, socioeconomic status, and geographic location.2,9 However, being indigent may supersede these variables.
One third of Ryan White CARE act funds are allocated to ADAP providing HAART to nearly one third of Americans being treated for HIV. Another large portion funds outpatient care for the HIV indigent. It is well established that early initiation of HAART has better long term outcomes than delaying until moderate or extreme immunocompromise and it is a great advancement in HIV transmission prevention.10
Many of the subject encounters in this study were return or repeat visits—highlighting missed opportunities for counseling and testing.
Limitations of this study: it is a retrospective chart review, and it may be difficult to generalize the results of this study. For some of the subjects we did not have CD4 or viral load data.
Areas for further investigation may be to examine other predictors of morbidity and mortality including type of opportunistic infection, and to evaluate longer term outcomes such as using a death index or a follow up phone survey.
CONCLUSIONS
Being on HAART at least one month prior to hospital admission for a serious illness was a great advantage for survival and immune function. These results should further inspire greater attention to the indigent-uninsured, to ensure access to counseling and testing and then linkage to HIV specialty clinics for HAART to avoid death, improve overall health, and limit further transmission of HIV from inadequately controlled infection. U.S. government funds are available for these activities, including HAART.

REFERENCES

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2. Kahn JG, Zhang X, Cross LT, Palacio H, Birkhead GS, Morin SF. Access to and use of HIV antiretroviral therapy: variation by race/ethnicity in two public insurance programs in the US. Public Health Reports. 2002;117(3):252. PMID: 12432136 http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1497435/?tool=pubmed
3. Branson BM, Handsfield HH, Lampe MA, et al. Revised recommendations for HIV testing of adults, adolescents, and pregnant women in health-care settings. MMWR Recomm Rep. Sep 22 2006;55(RR-14):1-17; quiz CE11-14. PMID: 16988643 http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5514a1.htm
4. Cleary PD, Van Devanter N, Rogers TF, et al. Behavior changes after notification of HIV infection. Am J Public Health. Dec 1991;81(12):1586-1590. PMID: 1746654 http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1405297/?tool=pubmed
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6. Vital signs: incidence and trends of infection with pathogens transmitted commonly through food --- foodborne diseases active surveillance network, 10 u.s. Sites, 1996--2010. MMWR Morb Mortal Wkly Rep. Jun 10 2011;60(22):749-755. PMID: 1659984 http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6022a5.htm?s_cid=mm6022a5_w
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8. Results of the Expanded HIV Testing Initiative --- 25 Jurisdictions, United States, 2007--2010. MMWR Morb Mortal Wkly Rep. Jun 24 2011;60(24):805-810. PMID: 21697804 http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6024a2.htm
9. Meditz AL, MaWhinney S, Allshouse A, et al. Sex, Race, and Geographic Region Influence Clinical Outcomes Following Primary HIV-1 Infection. Journal of Infectious Diseases. 2011;203(4):442. PMID: 21697804 http://jid.oxfordjournals.org/content/203/4/442.long
10. Network HIVPT. HPTN. 052: A randomized trial to evaluate the effectiveness of antiretroviral therapy plus HIV primary care versus HIV primary care alone to prevent the sexual transmission of HIV-1 in serodiscordant couples. Available: http: www. hptn. org/research_studies/hptn052. asp. Accessed. 2006;3. http://www.hptn.org/research_studies/hptn052.asp

First Published February 2012

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