Health-care providers in the United States are well aware that HIV patients who have access to treatment and adhere to antiretroviral treatment (ART) have a vastly improved quality and duration of survival compared to 1 or 2 decades ago. With 1.2 million patients with HIV infection currently alive in the United States,1 essentially all ICUs will manage patients with HIV infection over the course of a year.
ICUs see three very distinct populations of patients. Patients with opportunistic infections, such as Pneumocystis jirovecii pneumonia (PCP), toxoplasma encephalitis, or cryptococcal meningitis, continue to present to ICUs with severe disease. Some of these patients have known of their HIV infection, but have either been unable to access care or failed ART, and thus have low CD4 counts. A substantial fraction of these patients with opportunistic infections, however, present to emergency departments with life-threatening AIDS manifestations as the first indication of their HIV infection and have severe disease leading to ICU admission. These patients, so- called “late testers,” are not diagnosed with HIV until their CD4 counts are < 200 cells/μL. Such patients constitute approximately 35% of total new diagnoses annually, but in some cities, such as Washington DC, these patients represent 65% of the new diagnoses.2,3 Failure to get patients into care early in the course of their disease, when their CD4 counts are well > 200 cells/μL, subjects these patients to debilitating and potentially lethal problems that are largely avoidable with earlier intervention with ART and prophylactic antimicrobials.