Impact of HIV on Perioperative Organ Injury and Surgical Outcomes in 41 Million Surgical Patients: A Retrospective Cohort Study

BACKGROUND: While antiretroviral therapy has improved surgical safety for people living with HIV, comprehensive data on perioperative organ injury and its impact on patient safety remain limited. This study aimed to compare the incidence of perioperative organ injury, in-hospital mortality, hospital length of stay, and hospitalization costs between people living with HIV and HIV-negative individuals undergoing surgery in the United States. METHODS: This retrospective cohort study used data from the National Inpatient Sample (NIS) from 2016 to 2021. The population-based sample included adult patients (age >18 years) identified via International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) codes. Of 41,622,004 eligible surgical admissions, 2,088,307 (5.0%) were people living with HIV and 39,533,697 were HIV-negative. Primary outcomes were perioperative organ injury incidence and associated mortality; secondary outcomes included hospital length of stay and total hospital charges. Adjusted models accounted for baseline characteristics and surgical complexity. RESULTS: Among the 41,622,004 surgical admissions, people living with HIV were found to be older and carried a significantly higher comorbidity burden, with a Charlson Comorbidity Index of 8 compared to 1 in the HIV-negative group. Perioperative organ injury occurred in 1,348,363 of 2,088,307 people living with HIV (64.6%) compared with 7,867,547 of 39,533,697 HIV-negative patients (19.9%). Acute myocardial infarction (33.5%) and acute kidney injury (22.0%) were the most common injuries among people living with HIV. In-hospital mortality occurred in 66,935 of 2,088,307 people living with HIV (3.2%) compared with 872,170 of 39,533,697 HIV-negative patients (2.2%). Hospital length of stay and hospital charges were also significantly higher. Adjusted analyses demonstrated that HIV status was independently associated with higher in-hospital mortality (odds ratio [OR], 1.66; 95% confidence interval [CI], 1.54-1.78), longer hospital length of stay (β = 2.73 days; 95% CI, 2.56-2.90), a decreased likelihood of home discharge (hazard ratio [HR], 0.73; 95% CI, 0.72-0.73), and increased hospitalization costs (β = $18,423; 95% CI, 16,712-20,134). Sensitivity analyses demonstrated that elevated perioperative risk persisted among patients with asymptomatic HIV infection, although the greatest risk was observed among patients with symptomatic HIV disease/AIDS. CONCLUSIONS: People living with HIV incur a significantly higher risk of perioperative organ injury and worse surgical outcomes despite advances in antiretroviral therapy. HIV status was independently associated with adverse perioperative outcomes in adjusted models, supporting its inclusion as a risk stratification variable in surgical planning. Future research should incorporate immunologic markers, such as CD4 count and viral load, to further refine perioperative risk prediction and optimize outcomes for this population.