Critical crossroads in the care of human immunodeficiency virus-infected persons*.

www.ccmjournal. org 1579 Thirty years after the first clinical description of the human immunodeficiency virus (HIV), there is unprecedented optimism regarding the health outcomes of HIV-infected adults in the United States. The reasons for this optimism are several-fold. There have been mathematical modeling studies projecting near-normal life expectancies for HIV-infected persons, relegating HIV to the status of a “chronic disease” (1, 2). In fact, one recent study suggests that a person diagnosed at age 25 yrs with early stage HIV infection (Centers for Disease Control and Prevention stage A) will have 53 more years of life, mirroring the life expectancy among the general population (2). Not only has the quantity of life improved but so has the quality, with most HIV patients leading productive and enjoyable lives. Further, combination antiretroviral treatment has never been so easy and tolerable, including formulations of a single pill daily (e.g., Atripla, Bristol-Myers Squibb, New York, NY; Complera, Gilead, Foster, City, CA; and Stribild, Gilead). Future years also elude a sense of hopefulness with a robust pipeline of novel anti-HIV agents in development as well as studies examining the possibility of a functional cure for HIV (3). However, as HIV-infected patients are aging (an estimated 50% of people living with HIV will be older than 50 years old by 2015) (4), they will face a variety of age-related diseases. Further, despite the remarkable advances in HIV care over the last several years, concern remains regarding disparate health issues between HIV-infected and HIV-uninfected persons. For example, those infected with HIV may have a higher risk of cardiopulmonary diseases, cancers (both AIDS-defining and non-AIDS defining), cirrhosis, and several other medical conditions (5, 6). As a systemic infection, HIV has been shown to directly or indirectly affect every major organ system. The combination of HIV itself, the potential toxicities of antiretroviral therapies, immune activation, and concurrent negative health behaviors (e.g., tobacco use) may result in HIV-infected persons experiencing a multitude of chronic health conditions (i.e., multimorbidity) and perhaps accelerated aging (7). As a result, HIV-infected persons may require more health care, including in the medical ICU (MICU), and have differing presentations than HIV-uninfected persons. In this issue of Critical Care Medicine, Akgün et al (8) report on the MICU admission characteristics and outcomes of HIVinfected and HIV-uninfected adults in the Veterans Aging Cohort Study (VACS). This study found that a greater percentage of HIV patients required MICU admission and that they were younger at admission compared with HIV-uninfected patients. Further, HIV patients were more likely to have respiratory and infectious diseases as the principal causes for MICU admission, more likely to require ventilator support, and had higher 30-day mortality rates (19% vs. 11%) compared with HIV-uninfected persons. Such data are important in highlighting the differences between HIV patients and the general population and suggest areas for future investigational research to reduce the gap in ICU requirements and outcomes. Recent studies have demonstrated that the causes of ICU admissions among HIV patients are usually due to HIV-related diseases but often not AIDS-defining conditions (8–10). Similar to other studies (11–14), Akgün et al found that respiratory diseases were the most common cause of MICU admission and were associated with a higher mortality rate, suggesting an unmet need in the care of HIV patients. Whether improved engagement into care, broader use of antiretroviral therapy, tobacco cessation programs, and enhanced vaccines to prevent respiratory pathogens would decrease MICU admissions among HIV patients requires further study. During the combination antiretroviral treatment era, mortality rates have dramatically declined among HIVinfected persons admitted to the MICU (14,15). Although the current study suggested that HIV patients suffer higher 30-day mortality rates compared with HIV-uninfected persons, one prior study showed similar rates but was limited by the lack of a matched comparator group and evaluated a different time frame from ICU admission (12). Further research comparing the ICU outcomes of HIV-infected vs. HIV-uninfected persons in varying populations is needed. Predictors of mortality among HIV patients admitted to the ICU in prior studies have included increasing age, low albumin, mechanical ventilation, low CD4 count, renal Critical Crossroads in the Care of Human Immunodeficiency Virus-Infected Persons* Banu K