HIV-Related Medical Admissions to a South African District Hospital Remain Frequent Despite Effective Antiretroviral Therapy Scale-Up

Abstract

The public sector scale-up of antiretroviral therapy (ART) in South Africa commenced in 2004. We aimed to describe the hospital-level disease burden and factors contributing to morbidity and mortality among hospitalized HIV-positive patients in the era of widespread ART availability. Between June 2012 and October 2013, unselected patients admitted to medical wards at a public sector district hospital in Cape Town were enrolled in this cross-sectional study with prospective follow-up. HIV testing was systematically offered and HIV-infected patients were systematically screened for TB. The spectrum of admission diagnoses among HIV-positive patients was documented, vital status at 90 and 180 days ascertained and factors independently associated with death determined. Among 1018 medical admissions, HIV status was ascertained in 99.5%: 60.1% (n = 609) were HIV-positive and 96.1% (n = 585) were enrolled. Of these, 84.4% were aware of their HIV-positive status before admission. ART status was naive in 35.7%, current in 45.0%, and interrupted in 19.3%. The most frequent primary clinical diagnoses were newly diagnosed TB (n = 196, 33.5%), other bacterial infection (n = 100, 17.1%), and acquired immunodeficiency syndrome (AIDS)-defining illnesses other than TB (n = 64, 10.9%). By 90 days follow-up, 175 (29.9%) required readmission and 78 (13.3%) died. Commonest causes of death were TB (37.2%) and other AIDS-defining illnesses (24.4%). Independent predictors of mortality were AIDS-defining illnesses other than TB, low hemoglobin, and impaired renal function. HIV still accounts for nearly two-thirds of medical admissions in this South African hospital and is associated with high mortality. Strategies to improve linkage to care, ART adherence/retention and TB prevention are key to reducing HIV-related hospitalizations in this setting.

FIGURE 1

Study profile: this flow diagram shows the numbers of patients screened for the study, reasons for exclusion, number enrolled, primary clinical diagnoses, and 90-day outcomes.

FIGURE 2

Cascade of care at G.F. Jooste Hospital among all HIV-infected patients with a viral load result available (n = 569). These categories relate to patients’ status in the care cascade on the day of admission. “HIV status known” refers to patients who were diagnosed with HIV prior to the index admission.

FIGURE 3

(A) Kaplan–Meier 90-day mortality estimate among all HIV-infected patients by primary diagnosis category. (B) Kaplan–Meier 90-day mortality estimate among all HIV-infected patients by ART status at the time of admission. (C) Kaplan–Meier 90-day mortality estimate among all HIV-infected patients by viral load result (viral load performed on day of admission). AIDS-defining = acquired immunodeficiency syndrome-defining illnesses other than TB, HIV = human immunodeficiency virus, MOD = major organ dysfunction, NCD = noncommunicable disease, TB = tuberculosis, Worsening TB = clinical deterioration of TB cases during treatment.