Treatment disparities in sickle cell disease among patients with asymptomatic HIV

Abstract Background: Sickle cell disease (SCD) often requires transfusion-based therapies to manage acute complications. Guideline directed simple and exchange transfusions are considered first-line, whereas dialysis, ventilation, and vasopressors reflect management of downstream organ failure. Whether in-hospital treatment is equitable for patients with co-occurring, asymptomatic HIV remains unclear. Methods: We conducted a retrospective cross-sectional analysis of the National Inpatient Sample (2016 – 2020) for SCD admissions, identifying asymptomatic HIV by ICD-10 Z21. Prespecified outcomes were any transfusion, exchange transfusion, dialysis, ventilation, and vasopressor use. Categorical variables were compared with chi square tests and continuous variables with t-tests (α = 0.05). Logistic regression assessed independent associations with HIV status. Results: Of 926,450 weighted discharges, 5,440 (0.6 %) involved HIV. HIV-positive patients were older (39.8 ± 13.7 vs 31.4 ± 16.7 yr), more often male (49.8 % vs 37.1 %), and concentrated in the South and lowest-income ZIP codes (all p < 0.001). They carried greater morbidity, with higher Charlson Comorbidity Index (1.83 vs 1.20), acute kidney injury (11.4 % vs 7.9 %), sepsis (7.7 % vs 4.9 %), multiorgan failure (30.7 % vs 19.3 %), and chronic kidney disease (18.4 % vs 9.6 %). Despite this, HIV-positive admissions had 38 % lower odds of exchange transfusion (9.8 % vs 15.5 %, p < 0.001) and 35 % lower odds of any transfusion (10.4 % vs 16.1 %, p < 0.001). Dialysis use was nearly three-fold higher (3.1 % vs 1.1 %, p < 0.001), while critical-care interventions such as mechanical ventilation (1.7 % vs 1.6 %, p = 0.458) and vasopressors (0.4 % vs 0.3 %, p = 0.731) showed no significant difference. In-hospital mortality (0.7 % vs 0.6 %, p = 0.396) and length of stay (-0.54 days) remained comparable or lower, suggesting similar resource utilization despite higher illness severity. Conclusion: Inpatients with SCD and asymptomatic HIV present with a higher comorbidity burden yet receive markedly fewer transfusion-based treatments, the mainstay of acute SCD care, while experiencing similar ventilation/vasopressor rates and unchanged mortality. The simultaneous rise in dialysis use among this group suggests that underuse of transfusions may have contributed to preventable end-organ damage, rather than reflecting lower clinical need. These findings highlight possible systemic undertreatment linked to socioeconomic and structural factors and underscore the urgency for standardized transfusion protocols and prospective studies to dismantle barriers to equitable care.