Challenges in Managing Hospitalized HIV Infected Persons with Low Absolute CD4 and Preserved CD4 Percentage

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.