Abstract
Background: Reduction in HIV-related morbidity and mortality in the highly active antiretroviral therapy (HAART) era has been unevenly distributed in the United States, and its impact on hospitalizations in urban minority populations in the public sector has been poorly characterized.
Methods: We conducted a retrospective analysis of clinical and administrative data sets of an urban public hospital HIV clinic from 1997 and 1998 to identify the correlates of hospitalization early in the HAART era.
Results: 2,647 unduplicated HIV-infected patients were seen in 1997 and 1998 at the CORE Center. There were 31.7 percent women, 71 percent African-Americans and 12 percent Hispanics, and the mean age was 38 years. Men who had sex with men (MSM), injection drug users (IDU), and heterosexuals each made up one third of the population. A majority of the patients had no health insurance, and 27 percent had Medicaid. The median CD4 T cell count was 266 cells/μL, and the median viral load was 1,901 copies/ml. Hospitalizations declined significantly from 1997 (1,579) to 1998 (1,160). Admissions were confined to 25 percent of clinic patients, and 16 patients (range 8-15) had eight or more admissions. African-Americans and Hispanics had significantly more and longer hospitalizations than whites, but there was no difference by gender. IDUs had significantly more admissions than non-IDUs (28 percent vs. 21 percent respectively). On multivariate analysis, lower CD4 T cell count and higher viral load predicted risk of admission in all periods. Unexpectedly, hospitalization rates were high in patients in the highest baseline CD4 T cell stratum, >500 cells/ml (45 of 353, 13 percent), and lowest viral load stratum, <500 copies/ml (103 of 675, 15 percent), and rose from 1997 to 1998. HAART (ie, 1 or 2 drug regimens) predicted fewer hospitalizations compared to 1 or 2 drug regimens. In a subset of patients who filled prescriptions on site, HAART increased from 72 percent to 85 percent and 1-2 drug regimens fell from 28 percent to 15 percent from 1997 to 1998. Regular care was associated with more frequent hospitalization and more hospital days per admission than no regular care. Hospitalized patients had significantly higher mortality than patients not hospitalized (12 percent vs. 2 percent respectively).
Conclusion: HIV-related hospitalizations were frequent in the HAART era and decreased over time. Older age, lack of HAART, lower CD4 T cell count, higher viral load, and minority race predicted hospitalization, while gender did not. However, patients with extremely favorable CD4 T cell and viral load counts also had higher than expected hospitalization rates. Three quarters of patients had no hospitalizations, and clustering of hospitalizations in a small number of patients may enable targeted programs to reduce recidivism.