Pneumocystis carinii Pneumonia in HIV-Infected Patients in the HAART Era

Since the advent of highly active antiretroviral therapy (HAART), reported incidence of opportunistic infections (OI) in HIV patients has markedly decreased. And yet, the authors found large numbers of Pneumocystis carinii Pneumonia (PCP) cases at Chicago's Cook County Hospital, a medical facility serving a mostly poor and indigent population. To better understand this patient group, researchers performed a retrospective chart review of 104 pathologically proven cases of PCP from January 1998 to June 2001.

The doctors checked inpatient and outpatient medical and laboratory records for demographics, HIV risk factors, substance abuse on hospital admission, outcome and posthospital discharge data. They entered the data into a database and performed the following analyses: known HIV status for at least one year prior to admission versus not; substance abuse versus not; achievement of a viral load less than 1,000 copies per milliliter within 1 year of discharge versus not in patients who followed up in the outpatient clinic. The researchers evaluated nominal data by chi-square analysis; used independent t tests to evaluate parametric continuous variables; and used the Mann-Whitney U test to evaluate nonparametric continuous variables.

Most patients diagnosed with PCP were African-American, male, active substance abusers who reported heterosexual contact as the most common HIV risk factor. Fifty percent of patients knew their HIV status and 34 were known positive for more than a year. Fifty (48 percent) patients, including 25 percent of patients who did not know their HIV status, had contact with the Cook County medical system in the 12 months prior to the study. Less than 5 percent of the patients were on HAART therapy or PCP prophylaxis prior to admission. Only 16 patients had a history of a previous OI. Most patients were admitted from the emergency room. Fourteen percent of patients died in the hospital.

Of the 89 surviving patients, 80 percent were followed in the outpatient clinic and 30 percent were readmitted to the hospital. Of the study participants seen in the outpatient clinic, 58 (82 percent) received HAART therapy with 21 (32 percent) having a postdischarge CD4 cell count greater than 200 cells per milliliter, and 34 (58 percent) reaching a viral load of less than 1,000 copies per milliliter within a year of study admission. Of the 58 HAART patients, 35 (60 percent) had adherence problems with the therapy. Continued substance abuse was documented in 24 (39 percent) of 61 patients.

Factors that predicted failure to achieve a viral load less than 1,000 copies per milliliter in the year post discharge, the researchers found, were continued active drug use and a high viral load on presentation. "Our study shows that patients are still being admitted with PCP in the HAART era. Active substance abuse and failure to recognize HIV status contributed heavily to this late presentation of HIV disease. An aggressive approach toward HIV identification and substance abuse treatment may decrease admissions to the hospital for PCP and improve response to HAART therapy," they wrote.

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