High Proportions of Patients With Advanced HIV Are Antiretroviral Therapy Experienced: Hospitalization Outcomes From 2 Sub-Saharan African Sites

Abstract

BackgroundHuman immunodeficiency virus (HIV) remains an important cause of hospitalization and death in low- and middle- income countries. Yet morbidity and in-hospital mortality patterns remain poorly characterized, with prior antiretroviral therapy (ART) exposure and treatment failure status largely unknown.MethodsWe studied HIV-infected inpatients aged ≥13 years from cohorts in Kenya and the Democratic Republic of Congo (DRC), assessing clinical and demographic characteristics and hospitalization outcomes. Kenyan inpatients were prospectively enrolled during hospitalization; identical retrospective data were extracted for Congolese patients meeting the study criteria using routine medical information.ResultsAmong 338 HIV-infected patients in Kenya and 411 in DRC, 83.7% (95% confidence interval [CI], 79.4%–87.3%) and 97.3% (95% CI, 95.2%–98.5%), were admitted with advanced disease (defined as CD4 <200 cells/µL or World Health Organization stage 3/4 illness). Among inpatients with advanced HIV, 35.4% and 21.7% were ART-naive at admission. Patients under care had a median time of 44.1 (interquartile range [IQR], 18.4–90.5) months and 55.9 (IQR, 28.1–99.6) months on treatment; 17.2% (95% CI, 13.5%–21.6%) and 29.6% (95% CI, 25.4%–34.3%) died, 25.9% (95% CI, 16.0%–39.0%) and 22.5% (95% CI, 15.8%–31.0%) of these within 48 hours.ConclusionsAcross 2 diverse clinical contexts in sub-Saharan Africa, advanced HIV inpatients were frequently admitted with low CD4 counts, often failing first-line ART. Earlier identification of treatment failure and rapid switching to second-line ART are needed.

Proportions of CD4 test results indicating advanced HIV disease remain consistently high at primary health care facilities across four high HIV burden countries

“…In South Africa, 56.7% of patients entering care in 2017 with very advanced HIV disease were treatment experienced (20). The prevalence of advanced HIV disease was lower in the current study than reported in the literature [18][19][20][21]; however, this could have been due to the variable uses of CD4 testing across included countries within the current study. During the study period, CD4 was still used to monitor treatment as access to viral load testing was significantly below coverage rates in South Africa [5].…”

“…Further, reviewing CD4 data in nearly one million patients attending health care facilities within the IeDEA and COHERE cohorts across 55 countries found that not only has the proportion of patients entering care remained high across settings (31% in low-income countries, 40% in low-and middle-income countries, 29% in high-income countries), but these rates have plateaued over the past few years [19]. Interestingly, many patients entering, or re-entering care, are treatment experienced [20,21]. In South Africa, 56.7% of patients entering care in 2017 with very advanced HIV disease were treatment experienced (20).…”

“…Patients with advanced HIV disease are at increased risk of HIV-related morbidity and mortality-tuberculosis and cryptococcal meningitis are the leading causes of mortality [8,14,21,22]. Rapid and early identification of patients with advanced HIV disease will be critical to reduce the risk of death.…”

Retention in clinic versus retention in care during the first year of HIV care in Nairobi, Kenya: a prospective cohort study

“…In this study, a higher CD4 was associated with a reduced risk of attrition from care, which is similar to findings from other studies . Those with lower CD4 cell counts are more likely to be lost to programme because of increased mortality . Similar to Mugglin et al .…”

Mortality from HIV‐associated meningitis in sub‐Saharan Africa: a systematic review and meta‐analysis

“…In 28 studies with details on ART status, 26% (1792/6777) had a history of current or previous ART use. Reasons for exclusion are detailed in Appendix S1; these included non-representative sampling [24,[75][76][77], high loss to follow-up or duration of follow-up not clear [62,78], antifungal treatment not available [23,79,80] and use of treatment regimens not used or contraindicated in management [81][82][83].…”