Patrick Carr, Colm Bergin, June Craig, Sarah O’Connell 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] Ref 1: HPSC data

Aims Primary aim Secondary aims 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 OI – PCP, TB, CMV, Toxoplasmosis HIV-Related – sepsis, cellulitis, pyelonephritis HIV-unrelated – Hip fracture, hypothyroid, removal of JJ stent

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.

Presentation Total OI 62 HIV - Related 38 HIV - unrelated 67 2014 2015 2016 OI 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

P value – 0.001 P value – 0.009 These differences were found to be statistically significant Viral load as you would expect in line with the CD4 count 30% of the non-HIV related still had a detectable viral load

P value – 0.008 Median Bed Days [LOS] Median [IQR] length of stay was 7 [3,14] bed days.

Engagement in Care 129 [84%] patients engaged in care at the time of admission. P value - <0.0001 2014 2015 2016 p-value 40 [63%] 45 [85%] 44 [85%] 0.023

P value – 0.023 2014 2015 2016 P-value 12 [19%] 12 [23%] 14 [27%] 0.091

Hepatitis Co-infection 82 [49%] patients - hepatitis C co-infection 14 [8%] patients - hepatitis B co-infection P value – <0.001 2014 2015 2016 p-value Hep C 32 [51%] 26 [49%] 24 [46%] 0.034 Hep B 6 [10%] 6 [11%] 2 [2%]

Male 85 [51%] were male Age Age range was 24 to 75 years, median [IQR]; 41 [36, 48] years. 2014 2015 2016 Male 36 [57%] 24 [45%] 26 [49%] 2014 2015 2016 p-value Age 44 43 42 0.040

Smoking 104 [62%] patients smokers at time of admission. Active IVDU 29 [17%] patients actively injecting drugs at the time of admission. 2014 2015 2016 Smoker 38 [60%] 33 [62%] 2014 2015 2016 Active IVDU 11 [17%] 11 [21%] 7 [13%]

2014 2015 2016 p-value On ARVs 35 [55%] 40 [75%] 43 [83%] 0.008

Mode of Acquisition 29 [17%] patients were MSM, 101 [60%] patients were IVDU, 34 [20%] were heterosexual. P value – 0.016 Proportions for graph Not looking at % in each group Out of the OI group – the largest proportion of this group acquired their HIV via IVDU 2014 2015 2016 IVDU 32 [51%] 36 [68%] 33 [63%] HS 17 [27%] 8 [15%] 9 [17%] MSM 13 [20%] Other 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 Time Frame of the project Retrospective bias Occasionally missing data Time Frame of the project Retrospective bias: Alcohol excess – reliant on documentation of the doctor Unemployment – reliant on documentation of the doctor [not always noted if there had been a change in the documentation] Time Frame: - Done over the period of one month

Conclusion An improved care package for the IVDU, HCV co- infected 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 1 HSE. Health Protection Surveillance Centre. HIV in Ireland, 2015. Dublin: Health Protection Surveillance Centre; 2016. 2 Tuite H., Lee K., Bergin C.. (2011) Hospital admissions in HIV-infected patients. 3Hessamfar, 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. 4Greysen, 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. 5Lucero, 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. 6Falster, 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. 7SJH HIV Clinical measures audit (2015)