Abstract
The aim of the present study was to determine the prevalence of human immunodeficiency virus (HIV) infection among acute burn patients and its impacts on patient's outcomes in an Iranian burn care hospital. A cross‐sectional study was conducted in a tertiary burn care hospital in Iran, retrospectively reviewing the data records of all patients admitted between February 2011 and February 2012. The HIV status of all the patients was assessed in relation to clinical outcomes and the patient's prognosis. A total of 969 patients were included in this study. Five patients (0·5%) were HIV positive, and all of them were male. Mean burn area was significantly larger in HIV‐positive patients than the healthy group (P < 0·05). HIV‐positive patients had a longer period of hospitalisation than HIV‐negative patients (23·2 ± 16·3 versus 13·1 ± 14·6, P = 0·008). Nonetheless, the average number of procedures and the mortality rate did not significantly differ between the study groups (P > 0·05). Comparison of age, sex and burn extent between HIV‐positive patients and HIV‐negative cases also revealed similar results. Prevalence of HIV infection among our burn population was 0·5%; thus, HIV status may be related with more extensive injuries and longer hospital stays.
Keywords: Burn injury, Human immunodeficiency virus, Outcome, Prevalence
Introduction
Burn injuries remain the major type of trauma in developing countries, accounting for a significant cause of morbidity and mortality 1. Coexistence of medical conditions may complicate the patient's outcome or delay wound healing 2. The human immunodeficiency virus (HIV) infection has been a growing problem in the world 3, 4. HIV infection is more prevalent in low‐income countries where burn injuries occur with more frequency 4. Moreover, depending on the underlying prevalence, risk of HIV exposure among health care providers could be remarkable 5.
In addition to suboptimal health services in developing countries because of limited resources, HIV seropositivity of burn patients may lead to discrimination in the care they receive from health care personnel. On the other hand, HIV has been shown to adversely affect the burn‐healing process and recovery outcome 4, 6, 7.
According to a recent report from the Joint United Nations Program on HIV/AIDS, the national prevalence of HIV in Iran is 0·02% 3. Nevertheless, there is not a single study assessing the prevalence of HIV among Iranian burn patients. The aim of this study was to establish the prevalence of HIV infection among acute burn patients admitted to one of the major burn care centers in Iran and to determine its association with patients' outcomes.
Methods and materials
Study design
This was a retrospective, cross‐sectional study performed between February 2011 and February 2012 in Motahari Burn Centre, a university hospital affiliated to the Iran University of Medical Sciences in Tehran, Iran. As the largest burn hospital in Iran, it provides sub‐specialised tertiary care to burn patients. This study was in accordance with the tenets of the Declaration of Helsinki. The institutional review board and the ethics committee of our hospital approved the study on human subjects.
Patients
All patients with acute burn injuries admitted to our hospital in a 1‐year period were included in this study. Patients with less than 15 years of age were excluded because of a lack of information regarding HIV status in this age population. Patients admitted to the hospital 2 days after injury or because of causes other than acute burns were also excluded. All admitted patients received standard burn care during the acute phase and later hospital stages.
Diagnostic procedures
A HIV rapid test (ABON®, ABON Biopharm (Hangzhou) Co., Zhejiang, China) was performed on all patients upon admission to the emergency department of the hospital. An enzyme‐linked immunosurbant assay (ELISA) test (IBL kit, IBL international, Hamburg, Germany) was conducted to confirm the positive HIV rapid test results.
Data collection
All medical records of our hospitalised patients during the study period were reviewed. Variables were recorded in the study database, including socioeconomic status, features of burn injury and hospital treatment and procedures. A trained nurse was responsible for data acquisition and collection.
Statistical analysis
Data were analysed using the Statistical Package for Social Sciences (SPSS 16, SPSS Inc., Chicago, US). An independent sample t‐test for quantitative continuous variables and χ 2 test for categorical variables were employed. Data are expressed as number (%) or mean ± standard deviation (SD) when appropriate, and a P value < 0·05 is considered statistically significant.
Results
A total of 1217 acute burn patients were admitted in Motahari Burn Hospital during the study period. Of these, 969 patients (79·6%) met the eligibility criteria and were included in our study. Five patients (0·5%) were HIV positive and considered the HIV‐positive group, while the remaining patients were included in the HIV‐negative group. None of the HIV‐positive patients were already on retroviral therapy.
The HIV‐positive patients (39·4 ± 2·4 years) were significantly older than the patients in the HIV‐negative group (37 ± 3·2 years) (P = 0·03). Moreover, all HIV‐positive patients were male and flame was the main cause of burn injury in them (Table 1). Mean burn area was significantly larger in HIV‐positive patients than the healthy group (P < 0·05).
Table 1.
Demographics and primary characteristics of the study patients
| Feature | HIV‐positive patients (n = 5) | HIV‐negative patients (n = 964) | P‐value |
|---|---|---|---|
| Age (years) | 39·4 ± 2·4 | 37 ± 3·2 | 0·03 |
| Gender | 0·02 | ||
| Male | 5 (100%) | 763 (79·14%) | |
| Female | 0 | 199 (20·86%) | |
| Mean burn size (%) | 29·3 ± 2·1 | 27·6 ± 4·3 | 0·04 |
| Mechanisms of burns | NS | ||
| Flame | 5 (100%) | 588 (60·99% | |
| Scald | 0 | 182 (18·8%) | |
| Contact | 0 | 4 (0·4%) | |
| Electrical | 0 | 181 (18·7 %) | |
| Chemical | 0 | 9 (0·9%) | |
| Antiretroviral therapy | 0 | _ | NS |
HIV, human immunodeficiency virus; NS, no significance.
With regard to patients' outcomes, which has been presented in Table 2, HIV‐positive patients had longer periods of hospitalisation than HIV‐negative patients (23·2 ± 1·1 days versus 13·1 ± 1·6 days, P = 0·008). However, the average number of procedures and the mortality rate did not significantly differ between the study groups (P > 0·05).
Table 2.
Comparison of the mechanisms of burns, mortality rate and number of the operations in each group
| Feature | HIVpositive (n = 5) | HIV negative (n = 964) | P‐value |
|---|---|---|---|
| Mean duration of hospital stay (days) | 23·2 ± 1·3 | 13·1 ± 1·6 | 0·008 |
| Average number of operations | 2 ± 1·7 | 2 ± 1·2 | NS |
| Mortality rate (%) | 0 | 179 (18·6%) | NS |
HIV, human immunodeficiency virus; NS, no significance.
As a result of a large difference in the number of HIV‐positive and HIV‐negative patients, we selected a group of HIV‐negative patients matching age, sex and burn extent to compare with the HIV‐positive group (Table 3). Similarly, the length of hospital stay was significantly shorter in HIV‐negative patients compared with HIV‐positive patients (15·6 ± 3·4 days versus 23·2 ± 6·3 days, P = 0·045). However, the mortality rate and average number of surgeries did not reveal a significant difference between the two groups (P > 0·05).
Table 3.
Comparison of HIV‐positive patients with age‐, sex‐ and burn surface‐matched patients
| HIV positive (n = 5) | HIV negative (n = 64) | P‐value | |
|---|---|---|---|
| Mean burn size (%) | 29·3 ± 2·1 | 28·86 ± 2·3 | 0·23 |
| Mechanisms of burns | NS | ||
| Flame | 5 (100%) | 36 (56·25%) | |
| Scald | 0 | 5 (7·8%) | |
| Contact | 0 | 7 (10·9%) | |
| Electrical | 0 | 12 (18·75%) | |
| Chemical | 0 | 4 (6·25%) | |
| Mean duration of hospital stay (days) | 23·2 ± 6·3 | 15·6 ± 3·4 | 0·045 |
| Average number of operations | 2 ± 1·8 | 1·8 ± 1·1 | NS |
| Mortality rate (%) | 0 | 12 (18·75%) | NS |
HIV, human immunodeficiency virus; NS, no significance.
Discussion
This is the first study from Iran demonstrating HIV prevalence among burn patients and its relation with the disease course and outcome. The results showed that prevalence of HIV infection was 0·5% in burn patients admitted in one of the major burn hospitals in Iran and that HIV patients had more extensive burn injuries and longer hospital stays. None of our patients were receiving antiretroviral treatment.
HIV frequency in our study population (0·5%) is higher than the national prevalence in Iran, which has been estimated to be 0·02% 3. However, this HIV infection rate is far lower than those studies from African nations that are a result of higher HIV infection and transmission rate. In a study from Zimbabwe, 39% of patients admitted to a burn care hospital were HIV‐infected, while concurrent national HIV prevalence had been reported to be between 25% and 33% 8. Another report from Malawi revealed an HIV prevalence of 31% among burn patients admitted during a 1‐year study period with inpatient HIV prevalence from 30% to 70% 7. Additionally, another study from Uganda showed that the overall seroprevalence of HIV infection was 13·1% and 6·5% in HIV burn patients and the general population, respectively 9. In another study, Sheyo 10 reported 16% of their burn patients with positive HIV infection, while the prevalence of HIV in burn patients was the same as in the general population. Mayala et al. 11 reported that the prevalence of HIV among their trauma patients was 11·6%. Regardless of the larger HIV infection frequency among burn patients in comparison to general population, which may be because of high risk behaviours in HIV‐infected individuals, health care workers appear to be exposed to a remarkable occupational hazard.
Our HIV‐positive patients had more extensive burn injuries than HIV‐negative patients. This may occur as a result of high risk behaviours, low socioeconomic conditions and poor health care in this group of patients. No study has demonstrated a relation between HIV status and burn extent. On the other hand, all HIV patients in this study were male. Although this finding could not be definitely interpreted in the absence of a large HIV population, other studies have shown that, similar to sex distribution in a specific burn unit, there may be a preponderance of the male or female gender in HIV‐positive burn victims of that unit 4, 7, 12, 13.
Several studies have demonstrated the fact that HIV status does not impact the duration of inpatient stay 4, 7, 9. However, in disagreement, our results showed that HIV‐positive patients have a significantly longer hospital stay than HIV‐negative individuals. Mayala et al. 11 found that HIV seropositivity was significantly associated with an increased length of hospital stay in their traumatic patients. Mzezewa et al. also reported a significantly longer inpatient stay for HIV‐positive patients related to graft failure and the need for frequent regrafting 8. Nonetheless, this cannot justify the difference in hospitalisation length in our study as the average number of operations was similar in both groups. One explanation could be the greater severity of injury in HIV patients in our study, which may lengthen hospitalisation and delay the process of recovery.
As per our study's findings, HIV patients had no mortality. Nevertheless, because of the small number of HIV‐positive patients, it is not clear if HIV status is independently related to burn‐related injuries. In contrast, a study by James et al. revealed higher mortality in HIV‐positive burn patients as a result of sepsis 7. Mayala et al. 11 have found HIV as a risk factor for mortality in their study. However, another study from South Africa compared equal number of HIV‐positive and HIV‐negative burn patients and found no difference between the two groups in terms of morbidity and mortality 4. In a recent study, Thombs et al. reported that acute burn injury patients with medical conditions are at a higher risk of mortality and require longer hospital stays 2. Sheyo 10 found that the HIV status of burn patients was not associated with patients' outcomes and mortality. Furthermore, HIV positivity with the stigmata of AIDS and decreased CD4+ counts has been reported to have a significant impact on the outcome of burn injuries 7. It should be noted that in regions with a high HIV‐infection rate and burn injuries, health service and socioeconomic conditions of victims may adversely affect clinical outcomes of admitted patients and put the conclusion at a huge bias. These parameters should be considered and appropriately adjusted in future studies.
Management of immunocompromised burn patients, such as HIV‐infected individuals, is a serious challenge for health care workers, especially when the burn unit personnel are at a higher risk of exposure to HIV contaminants. To avoid careless services to HIV‐positive burn patients and reduce the risk of HIV transmission, adherence to universal precautions should be emphasised and efficiently practiced in burn units of developing countries 5, 14.
This was the first study in Iran investigating HIV status in burn patients and exposing its relationship with clinical outcomes. However, the small number of HIV‐positive burn patients and lack of resources to perform specific haematological and laboratory tests limited the ability of this retrospective study to build a bridge between causes and casualties. Moreover, although Staphylococcus aureus and Clostridium perfringens were among the highly prevalent bacterial cultures in our burn populations, microbiological profiles were significantly missing in our hospital records. Future studies are required to evaluate the relationship between HIV status, CD4 cell count and antiretroviral therapies with the process of healing and clinical outcomes in burn patients.
In conclusion, the prevalence of HIV infection among our study population of burn victims was 0·5% and, thus, HIV status may play a role in more extensive burn injuries and longer hospital stays.
Acknowledgements
There were no conflicts of interest. No funds, grants or other support were received. This article has not been presented at a meeting or published or submitted for publication elsewhere. The authors take responsibility for all aspects of the reliability and freedom from bias of the data presented and their discussed interpretation.
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