WJA  Vol.2 No.3 , September 2012
Challenges in Managing Hospitalized HIV Infected Persons with Low Absolute CD4 and Preserved CD4 Percentage
Abstract: Background: HIV infected persons are at risk for opportunistic illnesses based upon severity of immune deficiency. Management is generally based upon the most recent absolute CD4 count. We hypothesized there is a group of patients with a low absolute CD4 count and preserved CD4 percentage that are at low risk of AIDS-related opportunistic illnesses (OI). Methods: A retrospective review of medical records in HIV-infected persons hospitalized from 2004-2006. Individuals without CD4 counts available within 180 days of admission and during hospitalization were excluded. Patients with a decrease in the absolute CD4 count during hospitalization and stable CD4 percentage were compared to the rest of the cohort. Appropriate management was defined using DHHS guidelines for the prevention and treatment of opportunistic illnesses in HIV infection. Results: 464 patients had 978 hospitalizations. In 221 hospitalizations (N = 161 patients) inpatient and outpatient CD4 counts were available. In 35 hospitalizations (N = 25 patients) the absolute CD4 count declined with stable CD4 percent (cases). Cases had an average decline in CD4 of –197 cells/mm3 compared to –5 cells/mm3 in the comparator group. 30% of comparators had AIDS defining OI's compared to none in the case group (p = 0.01). Management outside of DHHS guidelines was more common in cases compared to the comparator group (49% vs 30%, p = 0.048). The median length of stay was prolonged in cases with management outside guidelines compared to appropriately managed persons in the comparator group (7 days vs 3.5 days, p = 0.03). Conclusion: In persons on potent antiretroviral therapy, abrupt declines in absolute CD4 counts without an accompanying change in CD4 percentage are associated with a low risk of AIDS related opportunistic infection, a higher rate of in-patient management outside DHHS guidelines, and a more prolonged length of stay.
Cite this paper: nullS. M. Bobula and C. J. Fichtenbaum, "Challenges in Managing Hospitalized HIV Infected Persons with Low Absolute CD4 and Preserved CD4 Percentage," World Journal of AIDS, Vol. 2 No. 3, 2012, pp. 237-244. doi: 10.4236/wja.2012.23031.

[1]   J. L. Fahey, J. M. G. Taylor, R. Detels, et al., “The Prognostic Value of Cellular and Serologic Markers in Infection with Human Immunodeficiency Virus Type 1,” The New England Journal of Medicine, Vol. 322, No. 3, 1990, pp. 166-172. doi:10.1056/NEJM199001183220305

[2]   J. P. Phair, A. Munoz, R. Detels, et al., “The Risk of Pneumocystis carinii Pneumonia among Men Infected with Human Immunodeficiency Virus Type 1,” The New England Journal of Medicine, Vol. 322, No. 3, 1990, pp. 161-165. doi:10.1056/NEJM199001183220304

[3]   J. E. Kaplan, H. Masur and K. K. Holmes, “Guidelines for Preventing Opportunistic Infections among HIV-Infected Persons: Recommendations of the U.S. Public Health Service and the Infectious Diseases Society of America,” MMWR—Recommendations and Reports, 51 (RR08), 14 June 2002, pp. 1-46.

[4]   C. A. Benson, J. E. Kaplan, H. Masur, A. Pau and K. K. Holmes, “Treating Opportunistic Infections among HIV-Infected Adults and Adolescents: Recommendations from CDC, the National Institutes of Health, and the HIV Medicine Association/Infectious Diseases Society of America,” MMWR—Recommendations and Reports, 53 (RR15), 17 December 2004, pp. 1-112.

[5]   J. A. Aberg, J. E. Gallant, J. Anderson, et al., “Primary Care Guidelines for the Management of Persons Infected with Human Immunodeficiency Virus: Recommendations of the HIV Medicine Association of the Infectious Diseases Society of America,” Clinical Infectious Diseases, Vol. 39, No. 5, 2004, pp. 609-629. doi:10.1086/423390

[6]   L. A. Mandell, R. G. Wunderink, A. Anzueto, et al., “Infectious Diseases Society of America/American Thoracic Society Consensus Guidelines on the Management of Community-Acquired Pneumonia in Adults,” Clinical Infectious Diseases, Vol. 44, Suppl. 2, 2007, pp. S27-S72. doi:10.1086/511159

[7]   J. S. Beck, R. C. Potts, T. Kardjito and J. M. Grange, “T4 Lymphopenia in Patients with Active Pulmonary Tuberculosis,” Clinical & Experimental Immunology, Vol. 60, No. 1, 1985, pp. 49-54.

[8]   R. C. Williams Jr., F. T. Koster and K. A. Kilpatrick, “Alterations in Lymphocyte Cell Surface Markers during Various Human Infections,” The American Journal of Medicine, Vol. 75, No. 5, 1983, pp. 807-816. doi:10.1016/0002-9343(83)90412-6

[9]   R. Seng, C. Goujard, L. Desquilbet, M. Sinet, C. Rouzioux, C. Deveau, F. Boufassa, J. F. Delfraissy, L. Meyer, A. Venet and The ANRS PRIMO and SEROCO Study Groups, “Rapid CD4+ Cell Decrease after Transient cART Initiated during Primary HIV Infection (ANRS PRIMO and SEROCO Cohorts),” Journal of Acquired Immune Deficiency Syndromes, Vol. 49, No. 3, 2008, pp. 251-258. doi:10.1097/QAI.0b013e318189a739