CHAPTER 69: Human Immunodeficiency Virus (HIV) and AIDS in the Intensive Care Unit

KEY POINTS

• The acquired immunodeficiency syndrome (AIDS) is caused by chronic infection with the human immunodeficiency virus (HIV), which through its relentless replication causes progressive depletion of T-helper lymphocytes leading to severe cellular immunodeficiency.

• In the absence of treatment, after a variable period, usually years from infection, multiple opportunistic infections or neoplasms characteristic of AIDS develop.

• Combination antiretroviral therapy has been shown to prolong survival as well as disease-free interval. Furthermore, antiretroviral therapy has emerged as an effective primary prevention. Despite substantial progress in antiretroviral therapy, cure of the disease remains elusive.

• Acute respiratory failure (ARF) secondary to Pneumocystis jirovecii pneumonia (PJP) is now less common than during the early years of HIV/AIDS as a cause of ICU admission among HIV-infected individuals with advanced HIV infection.

• PJP usually is diagnosed in the ICU using bronchoalveolar lavage (BAL). BAL fluid should always be processed to allow identification of P jirovecii, fungi, common bacteria, mycobacteria, and viruses.

• The mortality of PJP-related ARF has decreased substantially with the use of adjunctive systemic corticosteroids. Patients developing ARF despite corticosteroid treatment, however, continue to have a dismal prognosis.

• Because of better treatment and prolonged survival, more patients are admitted to ICU who have HIV/AIDS as an underlying illness as opposed to the cause of ICU admission.

• HIV cannot be transmitted through casual contact. Universal precautions, however, must be implemented and enforced routinely to minimize the risk of occupational exposure to HIV (as well as other infectious agents). The rate of seroconversion following a single accidental needle stick or mucous membrane exposure appears to be well below 1%.

• The issue of life support should be discussed early and reassessed frequently with HIV-infected individuals. Because the outlook of AIDS and its related diseases has improved dramatically, rigid policies regarding ICU admission are not appropriate.

INTRODUCTION

It has been over three decades since the initial reports of unusual opportunistic infections and malignancies heralded the onset of the human immunodeficiency virus (HIV) epidemic.^1,2 Over the last 30 years, our understanding of HIV transmission, pathogenesis, and viral replication has advanced considerably. The use of combination antiretroviral therapy (ART) has been shown to halt progressive immunologic decline with concomitant improvements in morbidity and mortality due to HIV-related acquired immunodeficiency syndrome (AIDS).^3,4 As a result, survival rates among HIV-infected individuals who are able to access ART may begin to approximate those of the general population.^5,6 In the United States, recent epidemiologic data suggest that mortality due to HIV infection has now dropped below that related to hepatitis C infection.⁷ Similar benefits have now also been demonstrated in resource-limited settings where ART programs have been implemented, such as in South Africa,⁸ Zambia,⁹ Uganda,¹⁰ and South East Asia.^11,12

The proportion of AIDS cases requiring either hospitalization or admission to the ICU has declined since the introduction of ART ...