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Intensive Care of Patients with HIV Infection
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     To the Editor: Huang et al. (July 13 issue)1 suggest several factors to consider before the initiation of antiretroviral therapy in critically ill patients with HIV infection, but they do not discuss the implications of such therapy regarding adherence issues. Although adherence approaches 100% during hospitalization, a subgroup of patients will not take their medications after discharge. Factors associated with decreased adherence (substance abuse, depression, a lack of social support, and a lack of insurance coverage to pay for medications) should be addressed before antiretroviral therapy is begun.2 It is extraordinarily difficult to try to resolve these issues during hospitalization for a critical illness. Patients who are critically ill are usually unable to express commitment and readiness to begin antiretroviral therapy, which leads to suboptimal adherence. Many patients are unable to assimilate the information provided during adherence counseling. Without convincing data that antiretroviral therapy has beneficial effects in the setting of critical illness, we should apply the same guidelines regarding adherence that are used in the clinic. This approach should reduce both the risk of treatment failure and selection for drug-resistant viruses.

    Michael Saccente, M.D.

    University of Arkansas for Medical Sciences

    Little Rock, AR 72205

    saccentemichael@uams.edu

    References

    Huang L, Quartin A, Jones D, Havlir DV. Intensive care of patients with HIV infection. N Engl J Med 2006;355:173-181.

    AIDSinfo. Guidelines for the use of antiretroviral agents in HIV-1 infected adults and adolescents. Rockville, MD: Department of Health and Human Services. (Accessed September 21, 2006, at http://www.AIDSinfo.nih.gov.)

    To the Editor: In reviewing the treatment of patients with HIV infection in the intensive care unit (ICU), it is important to mention adrenal insufficiency as an important condition that can easily be overlooked. The adrenal gland is the endocrine organ that is most commonly involved in patients with HIV infection.1 Adrenal insufficiency is common in critically ill patients with HIV infection2 and is associated with increased mortality if the condition is not properly recognized and treated.3 Careful clinical evaluation and laboratory assessment of adrenal function should be considered in the intensive care of patients with HIV infection.

    Mohsen S. Eledrisi, M.D.

    King Abdulaziz National Guard Medical Center

    Alahsa 31982, Saudi Arabia

    Abraham C. Verghese, M.D.

    University of Texas

    San Antonio, TX 78229

    References

    Eledrisi MS, Verghese AC. Adrenal insufficiency in HIV infection: a review and recommendations. Am J Med Sci 2001;321:137-144.

    Marik PE, Kiminyo K, Zaloga GP. Adrenal insufficiency in critically ill patients with human immunodeficiency virus. Crit Care Med 2002;30:1267-1273.

    Annane D, Sébille V, Charpentier C, et al. Effect of treatment with low doses of hydrocortisone and fludrocortisone on mortality in patients with septic shock. JAMA 2002;288:862-871.

    The authors reply: In critically ill patients with HIV infection, both the principal goal and the urgency of initiating antiretroviral therapy differ from those in outpatients. In outpatients, the primary goals of antiretroviral therapy are to reduce HIV-related morbidity and mortality, improve the quality of life, restore and improve immunologic function, and maximally and durably suppress the viral load.1 In an asymptomatic patient with preserved immune function, the initiation of antiretroviral therapy can be deferred for weeks, months, and occasionally years until the patient indicates a willingness and a readiness to begin therapy and the patient's CD4 cell count or HIV RNA level reaches the threshold at which antiretroviral therapy is generally recommended. Adherence to an antiretroviral regimen is a critical factor in achieving these long-term goals.

    In contrast, the principal goal of initiating antiretroviral therapy in critically ill patients is to improve survival among those with a life-threatening condition. We suggest that the initiation of antiretroviral therapy be considered for a subgroup of patients who are admitted to the ICU with an AIDS-associated diagnosis. Specifically, patients whose condition is worsening despite optimal management and treatment of the AIDS-associated condition have a high mortality rate and few therapeutic options. In these patients, the decision to initiate antiretroviral therapy must be made urgently and decisively. Although there are no randomized clinical trials to guide this decision, limited alternative therapeutic options compel a careful consideration of the risks and benefits of antiretroviral therapy. Studies demonstrate that homeless persons, who are traditionally believed to have a low likelihood of adherence, can have levels of adherence similar to those of persons without such conditions.2 In addition, a recent meta-analysis reported that favorable levels of adherence were achieved by persons with HIV infection who reside in sub-Saharan Africa, where factors such as the lack of formal education and limited financial resources that would lead to nonadherence and the potential development of drug-resistant HIV have been used to argue against the use of antiretroviral therapy.3 Thus, we believe that the perception that a patient cannot or might not adhere to antiretroviral therapy should not be a consideration when decisions are made about the initiation of antiretroviral therapy in the ICU.

    Laurence Huang, M.D.

    Diane V. Havlir, M.D.

    University of California, San Francisco

    San Francisco, CA 94110

    lhuang@php.ucsf.edu

    References

    AIDSinfo. Guidelines for the use of antiretroviral agents in HIV-1 infected adults and adolescents. Rockville, MD: Department of Health and Human Services. (Accessed September 21, 2006, at http://www.AIDSinfo.nih.gov.)

    Moss AR, Hahn JA, Perry S, et al. Adherence to highly active antiretroviral therapy in the homeless population in San Francisco: a prospective study. Clin Infect Dis 2004;39:1190-1198.

    Mills EJ, Nachega JB, Buchan I, et al. Adherence to antiretroviral therapy in sub-Saharan Africa and North America: a meta-analysis. JAMA 2006;296:679-690.