Subhead: Post-operative Mortality Rates Low Among ART Users
By Annette M. Boyle
WEST HAVEN, CT — Historically, high post-operative mortality rates among HIV-infected patients caused many physicians and patients to defer or avoid surgery all together. For today’s veterans with HIV; however, the infection poses no greater risk of death following surgery than a number of other conditions.
“Standard therapy for HIV changed dramatically between 1997 and 2002,” said Amy Justice, MD, PhD, section chief of general internal medicine at the VA Connecticut Healthcare System and professor of medicine at the Yale School of Medicine in New Haven, CT. With those improvements in therapy, “we’ve seen a dramatic increase in life span.”
With the longer life span come more comorbidities and other health issues. “HIV is a chronic disease, and its long-term survivors will develop conditions that require surgery,” said Joseph King, MD, chief of neurosurgery at the VA Connecticut Healthcare System and associate professor of neurosurgery at Yale School of Medicine.
The VA provides care to more than 40,000 veterans with HIV, one of the largest groups of HIV-infected patient cohorts in the world. About 89% of these veterans were taking antiretroviral medications as of 2013, according to the VA.
Approximately 78% of HIV-infected patients on ART in the United States achieve HIV-1 RNA suppression, according to research by the North American AIDS Cohort Collaboration on Research and Design (NA-ACCORD).1
“In the past, HIV-infected patients were less likely to receive surgery,” King told U.S. Medicine. Studies early in the HIV pandemic had found substantially higher morbidity and mortality following those procedures among HIV-infected individuals than among their uninfected counterparts. Until recently, it had been unclear how the current therapy for HIV would affect post-surgery survival rates.
In a study published in JAMA Surgery, King and his colleagues found that age and nutritional status had as much impact on postoperative mortality rates among patients receiving ART as their CD4 cell counts, typically used as a measure of immune system health.2
“For the vast majority of HIV-infected patients on ART, 30-day surgical mortality rates are only mildly elevated compared to uninfected patients,” King noted. “Characteristics other than HIV status, such as age and hypoalbuminemia, are also important determinants of outcomes.” Hypoalbuminemia is often a symptom of poor nutrition and a common problem in patients with a variety of acute or chronic medical conditions such as heart failure or cirrhosis.
Drawing on data from the VA’s national electronic medical record data, the researchers compared 30-day postoperative mortality in 1,641 veterans with HIV who received ART and underwent surgery to 3,282 uninfected patients matched by procedures. Patients were treated between 1996 and 2010.
HIV-infected veterans had 30-day postoperative mortality rates of 3.4%, slightly more than double the 1.6% rate seen in uninfected patients. The increased mortality relative to uninfected patients was seen across all CD4 cell-count levels. After adjustments for age, procedure year, Charlson comorbidity Index score, hemoglobin and albumin, the researchers found no mortality difference between veterans with CD4 cell counts above 500/uL and those slightly above 50/uL. Below 50/uL, however, mortality rates rose sharply.
Of the patients with HIV, 80% had CD4 cell counts above 200/uL, 16.3% had counts between 50/uL and 199/uL, and 3.7% had counts below 50/uL. Nearly three-quarters of the HIV-infected veterans had achieved viral suppression. While post-surgical mortality was inversely associated with CD4 cell counts, viral suppression as measured by HIV-1 RNA showed no association.
The most common procedures included cholecystectomy, hip arthroplasty, spinal surgery, hernia repair and coronary artery bypass grafting. The low mortality rate necessitated pooling of results across surgical procedures, precluding an analysis by type of surgery.
To put the numbers in context, the study authors wrote: “For example, after adjustment, HIV-infected individuals with a CD4 cell count higher than 200/μL can be expected to have a postoperative mortality rate similar to that in an uninfected individual 16 years older: surgery on a 50-year-old patient with HIV infection who is receiving ART has a 30-day mortality risk similar to that of a 66-year-old individual without the infection.”
Put another way, a 45-year-old patient with HIV and CD4 cell count of 200/uL or more had lower rate of 30-day postoperative mortality than a patient of the same age with hypoalbuminemia or any uninfected patient over 64 years of age.
Just as physicians would routinely recommend surgery to many patients in their 60s and 70s, King would “hope that more HIV-infected patients and their clinicians will consider surgical options” based on the study.
In the past few years, HIV therapies have been refined and new ones have been developed that have proven effective and more tolerable across a broader range of patients. “Survival and immune system reconstitution are improved with modern HIV therapies and, thus, surgery is even safer for HIV-infected patients in more recent years,” according to King.
The authors put it more directly: “Clinicians and patients should consider HIV infection and CD4 cell count as just two of many factors associated with surgical outcomes that should be incorporated into surgical decision making.”
1 Althoff KN, Rebeiro P, Brooks JT, Buchacz K, Gebo K, Martin J, Hogg R, Thorne JE, Klein M, Gill MJ, Sterling TR, Yehia B, Silverberg MJ, Crane H, Justice AC, Gange SJ, Moore R, Kitahata MM, Horberg MA; North American AIDS Cohort Collaboration on Research and Design (NA-ACCORD). Disparities in the quality of HIV care when using US Department of Health and Human Services indicators. Clin Infect Dis. 2014 Apr;58(8):1185-9. doi: 10.1093/cid/ciu044. Epub 2014 Jan 23. PubMed PMID: 24463281; PubMed Central PMCID: PMC3967825.
2 King JT Jr, Perkal MF, Rosenthal RA, Gordon AJ, Crystal S, Rodriguez-Barradas MC, Butt AA, Gibert CL, Rimland D, Simberkoff MS, Justice AC. Thirty-day postoperative mortality among individuals with HIV infection receiving antiretroviral therapy and procedure-matched, uninfected comparators. JAMA Surg. 2015 Apr;150(4):343-51. doi: 10.1001/jamasurg. 2014.2257. PubMed PMID: 25714794.
Legislation that would streamline VA’s community care programs into one program and expand VA’s caregiver program to veterans of all eras was signed into law earlier this month..
The good news from a recent consultant study is that, overall, the VA healthcare system is generally equal or better than others when inpatient and outpatient quality is measured.