To the Editor: Huang et al. (July 13 issue)1 suggest severalfactors to consider before the initiation of antiretroviraltherapy in critically ill patients with HIV infection, but theydo not discuss the implications of such therapy regarding adherenceissues. Although adherence approaches 100% during hospitalization,a subgroup of patients will not take their medications afterdischarge. Factors associated with decreased adherence (substanceabuse, depression, a lack of social support, and a lack of insurancecoverage to pay for medications) should be addressed beforeantiretroviral therapy is begun.2 It is extraordinarily difficultto try to resolve these issues during hospitalization for acritical illness. Patients who are critically ill are usuallyunable to express commitment and readiness to begin antiretroviraltherapy, which leads to suboptimal adherence. Many patientsare unable to assimilate the information provided during adherencecounseling. Without convincing data that antiretroviral therapyhas beneficial effects in the setting of critical illness, weshould apply the same guidelines regarding adherence that areused in the clinic. This approach should reduce both the riskof treatment failure and selection for drug-resistant viruses.
Michael Saccente, M.D. University of Arkansas for Medical Sciences Little Rock, AR 72205 saccentemichael{at}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. [Free Full Text]
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 HIVinfection in the intensive care unit (ICU), it is importantto mention adrenal insufficiency as an important condition thatcan easily be overlooked. The adrenal gland is the endocrineorgan that is most commonly involved in patients with HIV infection.1Adrenal insufficiency is common in critically ill patients withHIV infection2 and is associated with increased mortality ifthe condition is not properly recognized and treated.3 Carefulclinical evaluation and laboratory assessment of adrenal functionshould be considered in the intensive care of patients withHIV 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. [Web of Science][Medline]
Marik PE, Kiminyo K, Zaloga GP. Adrenal insufficiency in critically ill patients with human immunodeficiency virus. Crit Care Med 2002;30:1267-1273. [CrossRef][Web of Science][Medline]
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. [Free Full Text]
The authors reply: In critically ill patients with HIV infection,both the principal goal and the urgency of initiating antiretroviraltherapy differ from those in outpatients. In outpatients, theprimary goals of antiretroviral therapy are to reduce HIV-relatedmorbidity and mortality, improve the quality of life, restoreand improve immunologic function, and maximally and durablysuppress the viral load.1 In an asymptomatic patient with preservedimmune function, the initiation of antiretroviral therapy canbe deferred for weeks, months, and occasionally years untilthe patient indicates a willingness and a readiness to begintherapy and the patient's CD4 cell count or HIV RNA level reachesthe threshold at which antiretroviral therapy is generally recommended.Adherence to an antiretroviral regimen is a critical factorin achieving these long-term goals.
In contrast, the principal goal of initiating antiretroviraltherapy in critically ill patients is to improve survival amongthose with a life-threatening condition. We suggest that theinitiation of antiretroviral therapy be considered for a subgroupof patients who are admitted to the ICU with an AIDS-associateddiagnosis. Specifically, patients whose condition is worseningdespite optimal management and treatment of the AIDS-associatedcondition have a high mortality rate and few therapeutic options.In these patients, the decision to initiate antiretroviral therapymust be made urgently and decisively. Although there are norandomized clinical trials to guide this decision, limited alternativetherapeutic options compel a careful consideration of the risksand benefits of antiretroviral therapy. Studies demonstratethat homeless persons, who are traditionally believed to havea low likelihood of adherence, can have levels of adherencesimilar to those of persons without such conditions.2 In addition,a recent meta-analysis reported that favorable levels of adherencewere achieved by persons with HIV infection who reside in sub-SaharanAfrica, where factors such as the lack of formal education andlimited financial resources that would lead to nonadherenceand the potential development of drug-resistant HIV have beenused to argue against the use of antiretroviral therapy.3 Thus,we believe that the perception that a patient cannot or mightnot adhere to antiretroviral therapy should not be a considerationwhen decisions are made about the initiation of antiretroviraltherapy in the ICU.
Laurence Huang, M.D. Diane V. Havlir, M.D. University of California, San Francisco San Francisco, CA 94110 lhuang{at}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. [CrossRef][Web of Science][Medline]
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. [Free Full Text]
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