In North America, Western Europe and Australia, the widespread availability of potent combination anti-HIV therapy, commonly called ART or HAART, has tremendously decreased the risk of death from AIDS-related infections. The power of ART is so profound that a person who is infected today and who becomes engaged in their care and treatment can expect to have a near-normal lifespan.
However, many HIV-positive people (and people at high risk for this infection) have other, often pre-existing health issues that need additional attention, including the following:
- smoking tobacco
- depression, anxiety, post-traumatic stress disorder and other mental health issues
- addiction to alcohol and other substances
- co-infection with liver-damaging germs such as hepatitis B and C viruses
Also, in some high-income countries, researchers estimate that about 20% of people who are infected with HIV are not aware of their serostatus. Therefore, more intensive HIV testing is needed in addition to care, treatment and support programs in order for HIV-positive people with addictions and co-infections to reap the full benefit of ART.
The situation in Winnipeg
Researchers in Winnipeg, Manitoba, have reported that some people in that city are finding out that they are HIV positive late in the course of this infection. In a 2010 report, nearly 50% of people had their first HIV-positive test result when they sought care for a life-threatening infection.
A team of researchers in Winnipeg has been collecting and analysing health-related information on the need for hospitalization among HIV-positive people in that city. Their findings are important not only because they underscore the multiple and complex medical needs among some HIV-positive people in Winnipeg, but also because they document a huge burden of poor health in this population that should not be occurring.
Study details
Researchers reviewed health-related data from the Winnipeg Regional Health Authority Medical Database and focused on HIV-positive participants who were hospitalized between October 2003 and May 2010. During this period, 307 HIV-positive people were hospitalized an average of two times. Their average age was 42 years old. In cases where participants’ race/ethnicity was noted, the majority of participants were Aboriginal.
Diagnosis on admission
Most participants were hospitalized for less than 10 days. Common diagnoses on admission were as follows:
- bacterial pneumonia
- severe bacterial infections of the skin
- blood poisoning from bacterial infections
Underlying issues
Researchers found that 46% of participants were co-infected with hepatitis C virus (HCV). Another common pre-existing issue was addiction to substances, including alcohol.
Poor health
That most participants were experiencing life-threatening or serious bacterial infections attested to their weakened immune systems. Indeed, when doctors reviewed the CD4+ T-cell counts of participants, they had, on average, 219 CD4+ cells/ml of blood. Such a low CD4+ count places people at high risk for life-threatening infections. Furthermore, nearly 28% of participants had extremely low CD4+ counts when they first sought care—less than 50 cells/ml. People with such low CD4+ counts are prone to multiple AIDS-related infections and cancers. Indeed, about 5% of participants also had cancer. Most participants should have been taking ART but were not.
About 4% of participants died despite receiving care in the city’s hospitals.
What is to be done?
The researchers note the “tremendous burden of disease” among participants in their study. Such a burden affects a person’s quality of life and lifespan. It is also expensive to treat people when their CD4+ counts are low because this burden of disease is sufficiently heavy that people require hospitalization.
At the very least, the dismal situation in Winnipeg points to the need for more resources and interventions that are specifically designed to meet the complex medical, psychological and social needs of that city’s population. Such interventions should have both short-term and long-term components.
In the short-term, interventions should strive to improve the overall health of HIV-positive people by assisting them to become engaged with testing, care and treatment for HIV. People who are diagnosed early in the course of HIV and HCV disease can receive ART and other medications as well as the counselling and support that they need to take meds daily and go for check-ups several times a year.
HIV-positive people also need advice and care to help reduce their susceptibility to pneumonia. Pneumonia prevention would be greatly increased by the use of ART, but additional interventions and resources are needed to enable people to break free from substance use and addiction, specifically the injection of street drugs. Bacterial pneumonia and skin and soft tissue infections are consequences of injecting street drugs, particularly among HIV-positive people.
Underlying issues
Ongoing psychological support is also needed so that individuals and communities can begin to heal from the effects of depression, post-traumatic stress disorder, abuse and other traumas that have placed them at risk for substance use and unprotected sex.
These interventions will require continued dialogue and cooperation among community-based groups, including Aboriginal people and the medical-healthcare and political systems. Future research projects will hopefully provide the evidence base that people in Winnipeg can use to build healthier communities over the long-term.
Resources for Manitobans
An excellent resource about HIV and hepatitis prevention and treatment for people in Manitoba is Nine Circles Community Centre in Winnipeg. They can be contacted through a toll-free telephone number: 1.888.305.8647. Their very useful website has links to local services for different communities: http://ninecircles.ca/
—Sean R. Hosein
REFERENCES:
- Hirschtick RE, Glassroth J, Jordan MC, et al. Bacterial pneumonia in persons infected with the human immunodeficiency virus. Pulmonary Complications of HIV Infection Study Group. New England Journal of Medicine. 1995 Sep 28;333(13):845-51.
- Boschini A, Smacchia C, Di Fine M, et al. Community-acquired pneumonia in a cohort of former injection drug users with and without human immunodeficiency virus infection: incidence, etiologies, and clinical aspects. Clinical Infectious Diseases. 1996 Jul;23(1):107-13.
- Curran A, Falcó V, Crespo M, et al. Bacterial pneumonia in HIV-infected patients: use of the pneumonia severity index and impact of current management on incidence, aetiology and outcome. HIV Medicine. 2008 Oct;9(8):609-15.
- Moore RD, Keruly JC, Chaisson RE. Differences in HIV disease progression by injecting drug use in HIV-infected persons in care. JAIDS. 2004 Jan 1;35(1):46-51.
- Lemstra M, Rogers M, Thompson A, et al. Risk indicators associated with injection drug use in the Aboriginal population. AIDS Care. 2012; in press.
- Thompson LH, Sochocki M, Friesen T, et al. Medical ward admissions among HIV-positive patients in Winnipeg, Canada, 2003-10. International Journal of STD and AIDS. 2012 Apr;23(4):287-8.