Trends in rates and causes of hospitalization among people living with HIV in the antiretroviral therapy era: A retrospective cohort study in China, 2008-2020

Abstract

Background: The introduction of antiretroviral therapy (ART) has resulted in marked reductions in morbidity among people living with HIV (PLWH). Monitoring the hospitalizations of PLWH is important in evaluating the quality of healthcare and forecasting the co-morbidity pattern. We aimed to describe the trends in the rates and causes of hospitalization among PLWH who initiated ART in an HIV-designated hospital in China.

Methods: PLWH who initiated ART and were hospitalized in Beijing Ditan Hospital from 2008 to 2020 were selected for the study. Hospitalizations were classified based on AIDS-defining events (ADEs), non-AIDS-defining events (nADEs), and other causes. Hospitalization rates were calculated in terms of person-years, with risk factors determined by Poisson regression. The proportion of hospitalization causes at different ART treatment statuses was also evaluated.

Results: A total of 9,404 patients (94.7% were male patients) were included, contributing to 49,419 person-years. Overall, 1,551 PLWH were hospitalized for 2,667 hospitalization events, among which 60.4% of hospitalizations were due to ADEs, 11.4% were due to nADEs, and 28.2% were due to other causes. Unadjusted hospitalization rates decreased for all causes and all three diagnostic categories with year. After adjusting for the variables that changed substantially over time, ADE-related [IRR, 1.01 (0.96-1.05)] and nADE-related hospitalization rates [IRR, 0.92 (0.84-1.01)] appeared stable. Hospitalization for ADEs constituted an increasing proportion over time (36.3% in 2008-57.4% in 2020), especially in ART-naive inpatients (43.8% in 2008-83.3% in 2020). The proportion of nADE-related hospitalizations remained low (9.0% in 2008-15.4% in 2020). Hospitalization rate was highest for patients treated with ART during the first 6 months after ART initiation (46.2%) when ADEs were still the leading cause of hospitalizations (30.6%). Older age, non-men who have sex with men transmission, late presenters, HIV viral load (VL) > 50 copies/mL, and CD4 counts ≤ 200 cells/μL were associated with a higher hospitalization risk (all P < 0.05).

Conclusion: Despite some progress, ADEs remain the most common and serious problem among PLWH in China. In order to avoid deteriorating to the stage of needing hospitalization, more work is needed to diagnose and treat HIV infection earlier.

Keywords: AIDS-defining events; HIV; antiretroviral therapy; hospitalization; non-AIDS-defining events.

Figure 1

CDPCIS data and Tongren Medical Information System data set match process. HIV, human immunodeficiency virus; AIDS, acquired immune deficiency syndrome; PLWH, people living with HIV; CDPCIS, China Disease Prevention and Control Information System.

Figure 2

Median CD4 count (cells/μL) and percentage of patients with CD4 count < 200 cells/μL at ART initiation, 2008–2020. ART, antiretroviral therapy.

Figure 3

Incidence rate ratios (IRRs) and 95% confidence intervals (95% CI) calculated using Poisson regression models. Annual hospitalization rates and mean rate change, 2008–2020, for all-cause hospitalizations, ADE-related hospitalization nADE-related hospitalization and other-causes hospitalization. (A) Unadjusted annual all-cause and cause-specific hospitalization rates. (B) Annual all-cause and cause-specific hospitalization rates, standardized to age, sex, HIV transmission risk, CD4 count, and VL distribution of person-years in 2014. Standardization strata were defined according to the following categories: age 18–34, 35–49, and ≥50 years; CD4 count ≤ 200 and >200 cells/μL; viral load ≤ 50 and >50 copies/mL. ADE, AIDS-defining events; nADEs, non-AIDS-defining events.

Figure 4

Proportion of hospitalizations for ADEs, nADEs, and other causes among (A) all hospitalized cases and (B) ART-naive cases, 2008–2020. (C) Proportion of hospitalizations for ADEs, nADEs, and other causes among cases with different ART durations. ADE, AIDS-defining events; nADEs, non-AIDS-defining events; ART, antiretroviral therapy.

Figure 5

Proportion of hospitalized patients at ART initiation, 2008–2020. ART, antiretroviral therapy.