Outcomes of people living with HIV after hospital discharge: a systematic review and meta-analysis

Abstract

Background: The identification and appropriate management of people with advanced HIV disease is a key component in the HIV response. People with HIV who are hospitalised are at a higher risk of death, a risk that might persist after discharge. The aims of this study were to estimate the frequency of negative post-discharge outcomes, and to determine risk factors for such outcomes in people with HIV.

Methods: Using a broad search strategy combining terms for hospital discharge and HIV infection, we searched MEDLINE via PubMed and Embase from Jan 1, 2003 to Nov 30, 2021 to identify studies reporting outcomes among people with HIV following discharge from hospital. We estimated pooled proportions of readmissions and deaths after hospital discharge using random-effects models. We also did subgroup analyses by setting, region, duration of follow-up, and advanced HIV status at admission, and sensitivity analyses to assess heterogeneity.

Findings: We obtained data from 29 cohorts, which reported outcomes of people living with HIV after hospital discharge in 92 781 patients. The pooled proportion of patients readmitted to hospital after discharge was 18·8% (95% CI 15·3-22·3) and 14·1% (10·8-17·3) died post-discharge. In sensitivity analyses, no differences were identified in the proportion of patients who were readmitted or died when comparing studies published before 2016 with those published after 2016. Post-discharge mortality was higher in studies from Africa (23·1% [16·5-29·7]) compared with the USA (7·5% [4·4-10·6]). For studies that reported both post-discharge mortality and readmission, the pooled proportion of patients who had this composite adverse outcome was 31·7% (23·9-39·5). Heterogeneity was moderate, and largely explained by patient status and linkage to care. Reported risk factors for readmission included low CD4 cell count at admission, longer length of stay, discharge against medical advice, and not linking to care following discharge; inpatient treatment with antiretroviral therapy (ART) during hospitalisation was protective of post-discharge mortality.

Interpretation: More than a quarter of patients with HIV had an adverse outcome after hospital discharge with no evidence of improvement in the past 15 years. This systematic review highlights the importance of ensuring post-discharge referral and appropriate management, including ART, to reduce mortality and readmission to hospital among this group of high-risk patients.

Funding: Bill & Melinda Gates Foundation.

Translations: For the French and Spanish translations of the abstract see Supplementary Materials section.

Figure 1

Study selection

Figure 2

Post-discharge readmission by study setting n=number of readmissions. N=total number of patients. Black diamonds show point estimates, white diamonds show pooled estimates, and the dashed line shows the overall pooled estimate.

Figure 3

Post-discharge mortality and readmissions by setting, region, duration of follow-up, and advanced HIV status at admission n=number of events. N=total number of patients.

Figure 4

Post-discharge mortality by study setting n=number of deaths. N=total number of patients. Black diamonds show point estimates, white diamonds show pooled estimates, and the dashed line shows the overall pooled estimate.