CD4+ cell count and outcomes among HIV-infected compared with uninfected medical ICU survivors in a national cohort.

Akgün KM, Krishnan S, Butt AA, Gibert CL, Graber CJ, Huang L, Pisani MA, Rodriguez-Barradas MC, Hoo GWS, Justice AC, Crothers K, Tate JP. CD4+ cell count and outcomes among HIV-infected compared with uninfected medical ICU survivors in a national cohort. AIDS (London, England). 2021 Nov 15; 35(14):2355-2365.

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Abstract:

BACKGROUND: People with HIV (PWH) with access to antiretroviral therapy (ART) experience excess morbidity and mortality compared with uninfected patients, particularly those with persistent viremia and without CD4+ cell recovery. We compared outcomes for medical intensive care unit (MICU) survivors with unsuppressed ( > 500?copies/ml) and suppressed ( = 500?copies/ml) HIV-1 RNA and HIV-uninfected survivors, adjusting for CD4+ cell count. SETTING: We studied 4537 PWH [unsuppressed? = 38%; suppressed? = 62%; 72% Veterans Affairs-based (VA) and 10 531 (64% VA) uninfected Veterans who survived MICU admission after entering the Veterans Aging Cohort Study (VACS) between fiscal years 2001 and 2015. METHODS: Primary outcomes were all-cause 30-day and 6-month readmission and mortality, adjusted for demographics, CD4+ cell category ( = 350 (reference); 200-349; 50-199; < 50), comorbidity and prior healthcare utilization using proportional hazards models. We also adjusted for severity of illness using discharge VACS Index (VI) 2.0 among VA-based survivors. RESULTS: In adjusted models, CD4+ categories < 350?cells/µl were associated with increased risk for both outcomes up to 6?months, and risk increased with lower CD4+ categories (e.g. 6-month mortality CD4+ 200-349 hazard ratio [HR]? = 1.35 [1.12-1.63]; CD4+ < 50 HR? = 2.14 [1.72-2.66]); unsuppressed status was not associated with outcomes. After adjusting for VI in models stratified by HIV, VI quintiles were strongly associated with both outcomes at both time points. CONCLUSION: PWH who survive MICU admissions are at increased risk for worse outcomes compared with uninfected, especially those without CD4+ cell recovery. Severity of illness at discharge is the strongest predictor for outcomes regardless of HIV status. Strategies including intensive case management for HIV-specific and general organ dysfunction may improve outcomes for MICU survivors.