Disparities in Emergent Surgical Care in People Living with HIV

Author(s):
McKay Meyer; Savannah Skidmore; Heather Evans; Mike Mallah

Background:

People living with HIV (PLWHIV) have historically faced discrimination and unequal access to healthcare in the United States.This study aims to investigate differences in surgical intervention for common surgical emergencies among this population. Current literature suggests that HIV is not a contraindication to surgical intervention. Timely cholecystectomy and appendectomy are the current U.S. standard of care for cholecystitis and appendicitis, respectively. These procedures were chosen due to their prevalence and generally agreed upon indications.

Hypothesis:

We hypothesize that despite literature evidence that HIV is not a contraindication to surgery, there is still a discrepancy in PLWHIV receiving common surgical procedures.

Methods:

The study utilized a commercially available national dataset (TriNetXⓇ) to compare the rate of cholecystectomies or appendectomies among PLWHIV with diagnosed cholecystitis or appendicitis, respectively, compared to the people not living with HIV. Cohorts were created using ICD-10 codes from deidentified patient data. Inclusion criteria was an indication for surgical intervention, cholecystitis (K81) or appendicitis (K35-37). Cohorts were defined by HIV status, and analysis was stratified by procedure. Cohorts were propensity matched for age, race, leukocyte count, HIV 1 RNA volume, and substance abuse disorders. Outcomes were defined as patients receiving cholecystectomy or appendectomy in two separate analyses. Relative difference (RD) and relative risk (RR) were compared between HIV+ and HIV- cohorts.

Results:

The cholecystectomy analysis had 474,710 total patients, with 2,988 patients in each cohort after propensity matching. The appendectomy analysis had 502,601 total patients, with 2,010 patients in each cohort after matching. HIV+ patients with cholecystitis had a 22.222% risk of undergoing cholecystectomy compared to 25.535% risk in HIV- cholecystitis patients [RD: -3.313% (95% CI: -5.474%,-1.153%), p<0.0027, RR 0.87 (95% CI: 0.795,0.953)]. HIV+ patients with appendicitis had a 14.129% risk of undergoing appendectomy compared to 18.408% in HIV- appendicitis patients [RD: -4.279% (95% CI: -6.557%,-2.001%), p<0.0002, RR 0.768, (95% CI 0.666,0.884)]. Therefore, the HIV+ cohort was less likely to undergo cholecystectomy and appendectomy compared to the HIV- cohort.

Conclusions:

This study demonstrates a significant disparity in timely surgical intervention for PLWHIV. HIV+ status has not been shown to worsen surgical outcomes. Further investigation is needed to elucidate the etiology of demonstrated incongruencies and their clinical relevance.