Journal Article Annotations
2020, 3rd Quarter

HIV Psychiatry

Annotations by John Grimaldi, MD, Mary Ann Cohen, MD, FACLP, Kelly Cozza, MD, DFAPA, FACLP and Luis Pereira, MD
July, 2020

Outcomes Among HIV-Positive Patients Hospitalized With COVID-19.
Patterns of Prescribing Antiretroviral Therapy Upon Discharge to Psychiatry Inpatients With HIV/AIDS at a Large Urban Hospital.

Also of interest:

- Four Decades of HIV/AIDS – Much Accomplished, Much to Do.

PUBLICATION #1 — HIV Psychiatry

Outcomes Among HIV-Positive Patients Hospitalized With COVID-19.

Savannah Karmen-Tuohy, Philip M Carlucci, Fainareti N Zervou, Ioannis M Zacharioudakis, Gabriel Rebick, Elizabeth Klein, Jenna Reich, Simon Jones, Joseph Rahimian

Abstract: J Acquir Immune Defic Syndr . 2020 Sep 1;85(1):6-10. doi: 10.1097/QAI.0000000000002423.

Background:
SARS-CoV-2 infection continues to cause significant morbidity and mortality worldwide. Preliminary data on SARS-CoV-2 infection suggest that some immunocompromised hosts experience worse outcomes. We performed a retrospective matched cohort study to characterize outcomes in HIV-positive patients with SARS-CoV-2 infection.

Methods:
Leveraging data collected from electronic medical records for all patients hospitalized at NYU Langone Health with COVID-19 between March 2, 2020, and April 23, 2020, we matched 21 HIV-positive patients with 42 non-HIV patients using a greedy nearest-neighbor algorithm. Admission characteristics, laboratory test results, and hospital outcomes were recorded and compared between the 2 groups.

Results:
Although there was a trend toward increased rates of intensive care unit admission, mechanical ventilation, and mortality in HIV-positive patients, these differences were not statistically significant. Rates for these outcomes in our cohort are similar to those previously published for all patients hospitalized with COVID-19. HIV-positive patients had significantly higher admission and peak C-reactive protein values. Other inflammatory markers did not differ significantly between groups, although HIV-positive patients tended to have higher peak values during their clinical course. Three HIV-positive patients had superimposed bacterial pneumonia with positive sputum cultures, and all 3 patients died during hospitalization. There was no difference in frequency of thrombotic events or myocardial infarction between these groups.

Conclusions:
This study provides evidence that HIV coinfection does not significantly impact presentation, hospital course, or outcomes of patients infected with SARS-CoV-2, when compared with matched non-HIV patients. A larger study is required to determine whether the trends we observed apply to all HIV-positive patients.

Annotation

Outcomes Among HIV-Positive Patients Hospitalized With COVID-19

Findings:
This retrospective observational study of HIV-positive patients hospitalized with COVID-19 compared clinical characteristics at admission, hospital course, and outcomes with a matched cohort of non-HIV patients with SARS-CoV-2 infection. The following findings were reported. Overall, there were no statistically significant differences between cohorts in clinical characteristics on admission, hospital course or hospital outcomes. Clinical characteristics of both cohorts were similar to those found in the general population. Notable non-significant trends observed among HIV-positive patients included higher rates of ICU admissions, mechanical ventilation, and mortality. C-reactive protein (CRP) on admission and peak CRP were significantly higher in the HIV-infected cohort. There was a weakly significant association between peak CRP and mortality in both cohorts. Additionally, 3 patients among a total of 4 patients who developed bacterial pneumonia were HIV-positive. All 3 patients died during hospitalization. The majority of HIV-infected patients had a cd4 cell count > 200/microliter and viral load < 50 copies/mL and most were prescribed antiretroviral medications (ARVs).

Strengths and limitations:
Recent research suggests that being immunocompromised or having a comorbid medical condition such as diabetes, hypertension, cardiovascular disease, pulmonary disease or cancer is associated with worse COVID-19 outcomes. This study is the first to investigate the effect of comorbid HIV disease on the course and outcome of infection with SARS-CoV-2. Because a large majority of HIV-infected patients were prescribed ARVs and were virologically suppressed, it is not possible to generalize findings to patients with more advanced HIV disease and poorly controlled viremia. Only one patient was being prescribed a protease inhibitor, thus limiting insight into the possible benefit of this class of antivirals on COVID-19. The study’s retrospective and observational design renders findings susceptible to confounding variables. Its small sample size risks missing small differences between cohorts. For example, the study was not powered to illuminate the predictive value of superimposed bacterial infection on mortality. The study involved 4 medical centers in New York City, all of which were affiliated with the same academic healthcare system, thus limiting generalizability to other medical settings and geographic locations.

Relevance:
Understanding the effect of HIV on co-occurring COVID-19-associated morbidity and mortality is relevant from prevention, public health policy and disease management perspectives. This study begins to fill a significant gap in knowledge about vulnerabilities faced by HIV-infected individuals in the COVID-19 pandemic. It lays the groundwork for future exploration of the effect of different degrees of immunologic dysfunction on susceptibility to and course of infection with SARS-CoV-2. Larger scale studies will be required to detect differences between not only AIDS vs nonAIDS groups but also among minority populations. The finding that 3 of the HIV-infected patients with superimposed bacterial pneumonia died suggests the need for future studies investigating the predictive value and treatment implications of this and other medical complications. Just as important, it is reassuring to find that overall, being infected with HIV does not appear to confer additional medical risk, compared to non-HIV individuals with COVID-19.

Type of study:
This was a retrospective observational study conducted at 4 medical centers in New York City in March and April, 2020.

PUBLICATION #2 — HIV Psychiatry

Patterns of Prescribing Antiretroviral Therapy Upon Discharge to Psychiatry Inpatients With HIV/AIDS at a Large Urban Hospital.

Amanda Momenzadeh, Martha Shumway, Betty J Dong, James Dilley, Jonathan Ny, Christina Mangurian

Abstract: Ann Pharmacother. 2020 Sep 4;1060028020954924. doi: 10.1177/1060028020954924. Online ahead of print.

Background:
HIV infection is more prevalent among people with severe mental illness (SMI) than in the general population. People with SMI may lack access to recommended antiretroviral therapy (ART), and inpatient psychiatric admissions may be opportunities to ensure that individuals receive recommended treatment.

Objective:
To evaluate ART prescription patterns on an inpatient psychiatry service.

Methods:
In this retrospective, observational study, patient and admission characteristics and ART prescriptions were obtained for 248 HIV-positive inpatients between 2006 and 2012. Receipt of any ART, any recommended ART regimen, and ART with potentially harmful adverse events and drug interactions were examined. General estimating equation models were used to evaluate prescription patterns in relation to patient and admission characteristics.

Results:
ART was prescribed at 39% of discharges and increased by 51% during the study. Prescription was more common in admissions with an AIDS diagnosis and age greater than 29 years and less common in admissions associated with a psychotic diagnosis and shorter inpatient stays. When ART was prescribed, regimens were consistent with guideline recommendations 91% of the time. Prescription of potentially harmful regimens was limited.

Conclusion and relevance:
In an acute inpatient psychiatry setting in an urban HIV/AIDS epicenter, where psychotic disorders and brief and involuntary admissions were the norm, guideline-recommended ART regimens were prescribed at almost 60% of discharges by the end of the study. Future studies should explore interventions to increase ART for high-risk subpopulations with SMI, including younger individuals or those with brief inpatient psychiatry hospitalizations.

Keywords:
HIV/AIDS; antiretrovirals; clinical pharmacy; psychiatry; schizophrenia.

Annotation

Patterns of Prescribing Antiretroviral Therapy Upon Discharge to Psychiatry Inpatients With HIV/AIDS at a Large Urban Hospital

Findings:
This retrospective 6 year observational study of HIV-infected, psychiatrically hospitalized, patients at a large, urban academically-affiliated hospital investigated antiretroviral (ARV) prescribing practices over time and at time of hospital discharge. In addition to demographic and clinical characteristics, data collected included ARVs prescribed and their associated potential for neuropsychiatric complications and drug-drug interactions, length of hospital stay, psychiatric diagnoses, legal status at admission and adherence to Department of Health and Human Services (DHHS) recommendations for ARV treatment regimens. Patients were predominantly male and were diagnosed with schizophrenia, related psychotic disorder or a mood disorder. The percentage of patients that received ARVs at hospital discharge tended to rise over time and peaked at 59% by the end of the study period. Specific ARV regimens prescribed were generally consistent with contemporaneous DHHS guidelines. Only a small proportion of patients were prescribed an efavirenz (EFV)–containing regimen, whose association with neuropsychiatric adverse events is well documented, and among those taking EFV, adverse effects were uncommon. Nearly one-half of patients were taking a single pill containing emtricitabine and tenofovir disoproxil fumarate (FTC/TDF) plus a second pill containing a protease inhibitor (PI). In step with changing DHHS recommendations, use of the integrase strand inhibitor (INSTI) raltegravir (RAL) increased over time. Patients with a diagnosis of AIDS and who were older were significantly more likely to be discharged on ARVs, while a diagnosis of a psychotic disorder and shorter length of hospital stay were significantly associated with not receiving ARVs. A large proportion of hospital admissions were involuntary.

Strengths and limitations:
This study explores psychiatric inpatient level of care as a setting for initiating and maintaining patients in HIV care. It highlights barriers to provision of HIV care such as youth, having an active psychotic disorder and a shorter length of hospital stay. Several study characteristics limit application of findings to other geographic regions and healthcare settings. Study subjects were drawn from a single inpatient service in a large, urban academic healthcare system where HIV clinical consultation and care are readily accessible. Generalizability is also limited by location in a relatively high HIV seroprevalence area and by having a higher representation of women compared to the general local population. Thus patients with severe mental illness living in rural, resource-limited areas might face an entirely different set of barriers to accessing expert HIV care. The absence of data collected on CD4 cell count, viral load, and clinical and psychosocial factors that could have affected ARV prescription, limits a more nuanced interpretation of data. The study period ended in 2012, at a time when newer single pill ARV medication regimens were being introduced, thus findings may not generalize to current HIV medical practice.

Relevance:
Individuals with severe mental illness (SMI) are at risk for medical comorbidity and higher mortality due in part to problematic access to adequate healthcare. This situation is intensified by higher than expected HIV prevalence among SMI. Economic pressures and wish to facilitate patient autonomy contribute to shorter length of inpatient psychiatric hospital stays. Yet, this point along the continuum of psychiatric care may serve as an opportunity to improve HIV care and promote achievement of the ultimate goal of sustained viral suppression. Future efforts will need to explore interventions aimed at overcoming HIV treatment obstacles such as brief inpatient stays, acute psychotic symptomatology, and involuntary treatment.

Type of study:
This was a retrospective observational study conducted at a psychiatric inpatient service in a large, urban medical center from 2006 to 2012.

Also of interest – PUBLICATION #3 — HIV Psychiatry

Four Decades of HIV/AIDS – Much Accomplished, Much to Do

Anthony S Fauci, H Clifford Lane

Abstract: N Engl J Med. 2020 Jul 2;383(1):1-4. doi: 10.1056/NEJMp1916753.

In this NEJM perspective piece, Drs. Fauci and Lane summarized basic scientific and clinical advances in HIV medicine beginning with the first reported case of AIDS in 1981. Landmark events were noted and included the discovery of HIV as the causative agent of AIDS, delineation of the HIV replication cycle and HIV pathogenesis, the introduction of the first antiretroviral azidothymidine (AZT), now called zidovudine, and the eventual discovery of drug combinations that led to sustained viral suppression, clinical improvement and dramatic decline in mortality. The importance of collaboration among government, academia, industry and civil society was emphasized at both national and global levels. These remarkable achievements were framed within current HIV biomedical and population-level prevention strategies and the US plan to end the HIV epidemic in America by 2030. The authors stressed that the development of a safe and effective vaccine was central to wining the global fight against HIV.