HIV Insight: Prevalence & Hospital Discharge Status of HIV–Associated Pulmonary Arterial Hypertension in the United States

Pulmonary arterial hypertension (PAH) is a noninfectious complication of human immunodeficiency virus (HIV) infection that has gained in importance since the advent of antiretroviral therapy. HIV-associated PAH (HIV-PAH) has a higher prevalence than idiopathic PAH (IPAH), although the vascular pathology seen in HIV-PAH is virtually identical to that seen in IPAH.

Initiating therapy for PAH at an early stage is associated with a better prognosis; however, because of the nonspecific symptoms associated with PAH, the diagnosis is often delayed. In addition, because of the low prevalence of HIV-PAH, routine screening for this condition has never been recommended.

We hypothesize that the failure to create screening guidelines for HIV-PAH has resulted in underdiagnosis of the condition. This, in turn, results in individuals with HIV-PAH remaining undetected, allowing the disease to progress to more advanced stages or even remain unrecognized until death. If this hypothesis is correct, it may provide a strong argument for HIV-PAH screening guidelines, because HIV-PAH portends a poor prognosis and creates a significant economic burden if left untreated.

To address this issue, we conducted a retrospective review of the National Hospital Discharge Survey data and the multiple-cause mortality data to determine the prevalence of HIV-PAH at hospital discharge and death. Using these large data sets, we observed that the prevalence of HIV-PAH among HIV-infected individuals at hospital discharge and death was significantly lower than the reported prevalence in the literature. In addition, we found that PAH was designated as the most common cause of mortality in patients with HIV-PAH.

Below: Comparison of human immunodeficiency virus infection associated with pulmonary arterial hypertension (HIV-PAH) prevalence at hospital discharge and death versus reported HIV-PAH prevalence. AAs: African American patients; NHDS: National Hospital Discharge Survey; NVSS: National Vital Statistics Systems; Tot: total; Whites: white patients.

Below: Prevalence of human immunodeficiency virus infection associated with pulmonary arterial hypertension (HIV-PAH) by sex. NHDS: National Hospital Discharge Survey; NVSS: National Vital Statistics Systems.

Below: Prevalence of pulmonary arterial hypertension (PAH) among white and African American patients at hospital discharge, comparing patients with human immunodeficiency virus (HIV) infection versus patients without HIV infection (Non-HIV).

Below: Prevalence of human immunodeficiency virus infection associated with pulmonary arterial hypertension at death for National Vital Statistics Systems (NVSS) data overall and by white or African American race.

Below: Discharge status based on presence or absence of human immunodeficiency virus (HIV) or pulmonary arterial hypertension (PAH). Differences in the discharge status between patients with HIV-associated PAH (HIV-PAH) and HIV-infected patients without PAH (HIV Non-PAH) was statistically significant for all discharge categories with P value < 0.05. Differences in the discharge status between HIV-PAH and Non-HIV PAH were also statistically significant for all discharge categories with P value < 0.05. DC/TF long-term facility: discharged/transferred to long-term care institution; DC/TF short-term facility: discharged/transferred to short-term care facility; Left AMA: left against medical advice; Routine/DC home: routine/discharged home.

Below: National Hospital Discharge Survey in-hospital mortality rate. HIV-PAH: patients with human immunodeficiency virus infection–associated pulmonary arterial hypertension; HIV Non-PAH: patients with human immunodeficiency virus infection without pulmonary arterial hypertension.