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Factors Associated with Admissions in HIV-1 Infected Individuals in the era of multiple HIV Interventions Patrick Carr, Colm Bergin, June Craig, Sarah O’Connell Background 30% increase in HIV diagnoses reported in Ireland between 2014 and 2015[1] Department of GU Medicine & Infectious Disease SJH 250 new cases in 2014 260 new cases in 2015 Total cohort attending SJH = 2035 2011 audit – 30.8% of HIV+ admissions were attributable to symptomatic HIV infection [2] Many studies are showing that the trends in HIV admissions are towards more non-AIDS defining admissions since the introduction of combination anti-retroviral therapy (cART).[3][4][5][6] Aims Primary aim Identify patient factors associated with admissions of HIV positive individuals to SJH, in a 3 month period over 3 years, April – June 2014 to April – June 2016. Secondary aims Examine trends of rates of opportunistic infection in those presenting over time Compare demographics associated with opportunistic infection [OI], HIV-related illness, and HIV-unrelated illness. Compare demographics over the 3 year time point Methods Single center retrospective cohort study All HIV-1 infected patients discharged from SJH between April to June, 2014 to 2016 respectively were identified Data was collected via electronic chart records and sorted on a confidential excel database. Statistical analysis was performed using SPSS version 24. T test for continuous variables and Chi Squared tests for catagorical variables Engagement in care was defined as at least one HIV care visit over one year preceding date of hospital discharge. Oppertunistic Infection [OI] was defined as AIDS defining illness HIV-Related Illness was defined as clinical conditions assoc. with HIV disease but not an OI HIV-Unrelated Illness was defined as clinical conditions not assoc. with HIV Results 168 patients with HIV infection were discharged from inpatient care for the months April to June 2014, April –June 2015, and April – June 2016. 2016: 52 patients (28.3%) [Total 2016* – 184 [*Oct]] 2015: 52 patients (21.7%) – [Total 2015 – 240] 2014: 63 patients (25.7%) – [Total 2014 – 245] 28 [17%] patients were admitted twice 3 [2%] patients were admitted 3 times or more. 14 [8%] patients presented as a new diagnosis. 62 [63%] of patients resided outside the SJH catchment area. 3 [2%] patients died during their admission. 23 [14%] patients were readmitted within one month following hospital discharge. Reason For Admission over Time Presentation 60 50 OI 62 HIV - Related 38 HIV - unrelated 67 2014 2015 2016 30 [48%] 18 [35%] 14 [27%] HIV - Related 16 [25%] 12 [23%] 10 [19%] HIV Unrelated 17 [27%] 22 [42%] 28 [54%] Total 63 52 52 40 OI 30 20 10 0 2014 OI 2015 HIV-Related 2016 Non-HIV Related Total Mean CD4 Count 600 500 Viral Load 100 90 P value – 0.001 P value – 0.009 80 70 400 60 300 50 40 200 30 20 100 10 0 0 Mean CD4 OI HIV Related Non-HIV Related % Viral Load Detectable OI HIV Related Non-HIV Related Mean Bed Days [LOS] 25 P value – 0.008 20 Median Bed Days [LOS] 15 Median [IQR] length of stay was 7 [3,14] bed days. 10 5 0 Mean Bed Days [LOS] OI HIV Related Non-HIV Related Engagement in Care 129 [84%] patients engaged in care at the time of admission. Engagement In Care 100 P value - <0.0001 90 Engaged In Care 80 100 90 70 80 70 60 60 50 50 40 30 40 20 10 30 0 2014 2015 2016 20 Engaged In Care 10 2014 40 [63%] 2015 45 [85%] 2016 44 [85%] pvalue 0.023 0 % Engagement in Care OI HIV Related Non-HIV Related C2H5OH Excess 100 P value – 0.023 90 C2H5OH Excess 100 90 80 80 70 70 60 50 60 40 30 50 20 10 40 0 2014 30 2015 2016 C2H5OH Excess 20 2014 2015 2016 P-value 10 12 [19%] 12 [23%] 14 [27%] 0.091 0 % Excess Alcohol Intake OI HIV Related Non-HIV Related Hepatitis Co-infection 82 [49%] patients - hepatitis C co-infection 14 [8%] patients - hepatitis B co-infection Hepatitis Co-infection 100 P value – <0.001 90 Hepatitis Co-infection 100 80 90 80 70 70 60 60 50 40 50 30 20 40 10 0 2014 2015 Hep C 2014 2015 2016 Hep B 2016 20 pvalue Hep C 32 [51%] 26 [49%] 24 [46%] 0.034 Hep B 6 [11%] 2 [2%] 0.034 6 [10%] 30 10 0 Hep B Co-infection OI HIV Related Hep C Co-infection Non-HIV Related Male Age 85 [51%] were male Age range was 24 to 75 years, median [IQR]; 41 [36, 48] years. Male [Gender] Age [Years] 100 70 90 60 80 50 70 60 40 50 Male [Gender] 40 30 Age [Years] 30 20 20 10 10 0 0 2014 Male 2015 2016 2014 2014 2015 2016 36 [57%] 24 [45%] 26 [49%] Age 2015 2016 2014 2015 2016 p-value 44 43 42 0.040 Smoking Active IVDU 104 [62%] patients smokers at time of admission. 29 [17%] patients actively injecting drugs at the time of admission. Smoker Active IVDU 100 100 90 90 80 80 70 70 60 60 50 50 Smoker 40 40 30 30 20 20 10 0 10 2014 0 2014 Smoker 2015 2016 Active IVDU 2016 2014 2015 2016 38 [60%] 33 [62%] 33 [62%] 2015 Active IVDU 2014 2015 2016 11 [17%] 11 [21%] 7 [13%] On ARVs 100 90 80 70 60 50 On AVRs 40 30 20 10 0 2014 On ARVs 2015 2016 2014 2015 2016 p-value 35 [55%] 40 [75%] 43 [83%] 0.008 Mode Of Acquisition 100 P value – 0.016 90 Mode of Acquisition 29 [17%] patients were MSM, 101 [60%] patients were IVDU, 34 [20%] were heterosexual. 100 80 90 80 70 70 60 60 50 40 50 30 20 40 10 0 30 2014 2015 IVDU 20 10 0 MSM OI IVDU HIV- Related Heterosexual Non-HIV Related HS MSM 2016 Other 2014 2015 2016 IVDU 32 [51%] 36 [68%] 33 [63%] HS 17 [27%] 8 [15%] 9 [17%] MSM 13 [20%] 8 [15%] 8 [15%] Other 1 [2%] 1 [2%] 2 [2%] Discussion Percentage of HIV-positive patients presenting with an OI is decreasing over time, while proportion with non-HIV associated illness is increasing. This trend is reflective of numerous international studies[2][3][4][5] Those who presented with an OI: Significantly lower CD4 count and higher HIV-1 viral load Less likely to be engaged in care. Discussion IVDU and HCV co-infected individuals were more likely to be admitted for a non-HIV related illness while the heterosexual risk group were more likely to present with OI. The high percentage of viral load in the non-HIV related admissions is note-worthy [31%] as this is not in line with the total cohort – of whom <10% have a detectable viral load[7] Limitations Retrospective cohort study Retrospective bias Occasionally missing data Time Frame of the project Conclusion An improved care package for the IVDU, HCV coinfected cohort needs to be developed to optimise patient care and prevent hospital admissions and healthcare costs. Need for improved screening and immediate ART given the ongoing rate of opportunistic infections and new diagnoses – especially amongst the heterosexual population. This project should be extended to look at all admissions over the 3 years and to review this on an annual basis This project should also be used to compare demographics of the HIV-inpatient population to the demographics of the total HIV+ cohort to gain a better understanding of the characteristics of HIV admissions Acknowledgements Dr Sarah O’Connell – ID Consultant Department of Genito Urinary Medicine and Infectious Diseases, SJH Professor Colm Bergin – Consultant Physician, Department of Genito Urinary Medicine and Infectious Diseases, SJH June Craig – GUIDE Clinic Data Manager, SJH HIV+ patients whom attend the SJH service References HSE. Health Protection Surveillance Centre. HIV in Ireland, 2015. Dublin: Health Protection Surveillance Centre; 2016. 1 2 3Hessamfar, 4Greysen, 5Lucero, 6Falster, 7SJH Tuite H., Lee K., Bergin C.. (2011) Hospital admissions in HIV-infected patients. M., Colin, C., Bruyand, M., Decoin, M., Bonnet, F., Mercié, P., Neau, D., Cazanave, C., Pellegrin, J., Dabis, F., Morlat, P. and Chêne, G. (2014). Severe Morbidity According to Sex in the Era of Combined Antiretroviral Therapy: The ANRS CO3 Aquitaine Cohort. PLoS ONE, 9(7), p.e102671. S., Horwitz, L., Covinsky, K., Gordon, K., Ohl, M. and Justice, A. (2013). Does Social Isolation Predict Hospitalization and Mortality Among HIV+ and Uninfected Older Veterans? Journal of the American Geriatrics Society, 61(9), pp.1456-1463. C., Torres, B., León, A., Calvo, M., Leal, L., Pérez, I., Plana, M., Arnedo, M., Mallolas, J., Gatell, J. and García, F. (2013). Rate and Predictors of Non-AIDS Events in a Cohort of HIV-Infected Patients with a CD4 T Cell Count Above 500 Cells/mm 3. AIDS Research and Human Retroviruses, 29(8), pp.1161-1167. K., Wand, H., Donovan, B., Anderson, J., Nolan, D., Watson, K., Watson, J. and Law, M. (2010). Hospitalizations in a cohort of HIV patients in Australia, 1999–2007. AIDS, 24(9), pp.1329-1339. HIV Clinical measures audit (2015)