What are the current approaches to managing HIV in the inpatient population, including the continuation of antiretroviral therapy (ART) and the treatment of opportunistic infections?

Management of HIV in the Inpatient Setting: Current Approaches and Evolution

Antiretroviral therapy (ART) should be continued without interruption during hospitalization for all HIV-infected patients, and for those with opportunistic infections, ART should be initiated within the first 2 weeks of diagnosis to reduce mortality and improve outcomes. 1

Epidemiology of HIV in the United States

• Approximately 1.2 million people in the US are living with HIV
• Despite advances in treatment, less than 25% of HIV-infected individuals in the US are aware of their infection, linked to continuous care, prescribed effective ART, and virologically suppressed 1
• Geographic disparities exist, with more than half of all HIV-infected persons living in 12 urban areas where access to care is uneven 1
• The HIV treatment cascade reveals significant gaps in diagnosis, linkage to care, retention in care, and viral suppression

HIV in the Inpatient Population

Prevalence and Admission Patterns

• Patients with HIV may be hospitalized for:
  • Initial presentation with advanced disease and opportunistic infections
  • Complications of established HIV infection
  • Non-HIV related conditions requiring routine medical care

Management of Opportunistic Infections (OIs)

1. Common Inpatient OIs:

   • Pneumocystis pneumonia
   • Tuberculosis
   • Cryptococcal meningitis
   • Disseminated Mycobacterium avium complex
   • Cytomegalovirus retinitis
   • Toxoplasmosis

2. ART Timing with OIs:

   • For most OIs: Start ART within first 2 weeks after OI diagnosis 1
   • For tuberculosis with CD4 <50/μL: Start ART within first 2 weeks of TB treatment
   • For tuberculosis with CD4 ≥50/μL: Start ART within 2-8 weeks of TB treatment
   • For cryptococcal meningitis: Start ART within 2 weeks in settings with optimal antifungal therapy and monitoring 1

3. Immune Reconstitution Inflammatory Syndrome (IRIS):

   • Monitor for paradoxical worsening of OIs after ART initiation
   • May require aggressive management of inflammation while continuing ART

ART Continuation During Hospitalization

• Core principle: Maintain ART without interruption during hospitalization 1
• Rapid ART initiation: For newly diagnosed patients, consider starting ART rapidly (within 7 days, including same-day initiation when possible) 1
• Drug interactions: Carefully review all medications for potential interactions with ART
• Special considerations:
  • NPO status: Consult pharmacist for alternative formulations
  • Surgery: Continue ART through perioperative period when possible
  • Critical illness: Individualize based on ability to take oral medications and drug absorption

Evolution of HIV Management (1990s-Present)

Treatment Paradigm Shifts

1. Early Era (1990s):

   • Monotherapy with zidovudine (AZT)
   • Limited efficacy and rapid resistance development
   • High mortality from opportunistic infections

2. HAART Introduction (Mid-1990s):

   • Combination therapy with ≥3 antiretroviral drugs
   • Dramatic reduction in AIDS-related mortality
   • Complex regimens with high pill burden and significant side effects

3. Modern Era (2010s-Present):

   • Single-tablet regimens
   • Higher efficacy, lower toxicity
   • Long-acting injectable options
   • Focus on integrase strand transfer inhibitors (InSTIs) as preferred agents 1

Medication Evolution

1. First-generation agents:

   • Nucleoside reverse transcriptase inhibitors (NRTIs): zidovudine, didanosine, stavudine
   • High toxicity (bone marrow suppression, peripheral neuropathy, lactic acidosis)

2. Current preferred regimens:

   • InSTI-based regimens (bictegravir or dolutegravir) with 1-2 NRTIs 1
   • Lower toxicity, higher barrier to resistance
   • Once-daily dosing

3. Emerging options:

   • Long-acting injectable therapies for patients with adherence challenges 1

Practical Inpatient Management Algorithm

1. For patients on established ART:

   • Continue current regimen without interruption
   • Review for potential drug interactions with acute medications
   • Assess adherence and barriers to outpatient care

2. For patients with newly diagnosed HIV:

   • Obtain CD4 count, HIV viral load, resistance testing
   • Screen for opportunistic infections
   • Initiate ART within 7 days when possible, preferably with InSTI-based regimen 1
   • Ensure linkage to outpatient HIV care prior to discharge

3. For patients with active opportunistic infections:

   • Initiate appropriate antimicrobial therapy
   • Start ART within 2 weeks for most OIs 1
   • Monitor closely for IRIS
   • Consider prophylaxis for other opportunistic infections based on CD4 count

Common Pitfalls in Inpatient HIV Management

1. Unnecessary ART interruption:

   • Mistakenly holding ART during NPO status
   • Failure to restart ART after procedures

2. Missed drug interactions:

   • Acid-reducing agents with integrase inhibitors
   • Rifamycins with protease inhibitors
   • QT-prolonging medications with certain NNRTIs

3. Failure to recognize IRIS:

   • Mistaking IRIS for treatment failure or new infection
   • Inappropriate discontinuation of ART

4. Inadequate discharge planning:

   • Not ensuring access to medications
   • Lack of timely follow-up with HIV specialist

By following these evidence-based approaches to managing HIV in the inpatient setting, clinicians can significantly improve outcomes for this vulnerable patient population while reducing the risk of treatment interruptions, drug resistance, and complications.