Risk factors for COVID-19-related in-hospital mortality in a high HIV and tuberculosis prevalence setting in South Africa: a cohort study

Abstract

Background The interaction between COVID-19, non-communicable diseases, and chronic infectious diseases such as HIV and tuberculosis is unclear, particularly in low-income and middle-income countries in Africa. South Africa has a national HIV prevalence of 19% among people aged 15-49 years and a tuberculosis prevalence of 0•7% in people of all ages. Using a nationally representative hospital surveillance system in South Africa, we aimed to investigate the factors associated with in-hospital mortality among patients with COVID-19. MethodsIn this cohort study, we used data submitted to DATCOV, a national active hospital surveillance system for COVID-19 hospital admissions, for patients admitted to hospital with laboratory-confirmed SARS-CoV-2 infection between March 5, 2020, and March 27, 2021. Age, sex, race or ethnicity, and comorbidities (hypertension, diabetes, chronic cardiac disease, chronic pulmonary disease and asthma, chronic renal disease, malignancy in the past 5 years, HIV, and past and current tuberculosis) were considered as risk factors for COVID-19-related in-hospital mortality. COVID-19 in-hospital mortality, the main outcome, was defined as a death related to COVID-19 that occurred during the hospital stay and excluded deaths that occurred because of other causes or after discharge from hospital; therefore, only patients with a known in-hospital outcome (died or discharged alive) were included. Chained equation multiple imputation was used to account for missing data and random-effects multivariable logistic regression models were used to assess the role of HIV status and underlying comorbidities on COVID-19 in-hospital mortality. FindingsAmong the 219 265 individuals admitted to hospital with laboratory-confirmed SARS-CoV-2 infection and known in-hospital outcome data, 51 037 (23•3%) died. Most commonly observed comorbidities among individuals with available data were hypertension in 61 098 (37•4%) of 163 350, diabetes in 43 885 (27•4%) of 159 932, and HIV in 13 793 (9•1%) of 151 779. Tuberculosis was reported in 5282 (3•6%) of 146 381 individuals. Increasing age was the strongest predictor of COVID-19 in-hospital mortality. Other factors associated were HIV infection (adjusted odds ratio 1•34, 95% CI 1•27-1•43), past tuberculosis (1•26, 1•15-1•38), current tuberculosis (1•42, 1•22-1•64), and both past and current tuberculosis (1•48, 1•32-1•67) compared with never tuberculosis, as well as other described risk factors for COVID-19, such as male sex; non-White race; underlying hypertension, diabetes, chronic cardiac disease, chronic renal disease, and malignancy in the past 5 years; and treatment in the public health sector. After adjusting for other factors, people with HIV not on antiretroviral therapy (ART; adjusted odds ratio 1•45, 95% CI 1•22-1•72) were more likely to die in hospital than were people with HIV on ART. Among people with HIV, the prevalence of other comorbidities was 29•2% compared with 30•8% among HIV-uninfected individuals. Increasing number of comorbidities was associated with...

HIV status alters disease severity and immune cell responses in Beta variant SARS-CoV-2 infection wave

“…We observed that in our cohort, COVID-19 disease severity was higher in PLWH, consistent with some of the larger epidemiological studies ( Western Cape Department of Health in collaboration with the National Institute for Communicable Diseases, South Africa et al, 2021 ; Geretti et al, 2021 ; Bhaskaran et al, 2021 ; Tesoriero et al, 2021 ; Braunstein et al, 2021 ; Jassat et al, 2021a ), although in this study differences were detected in the frequency of participants requiring supplemental oxygen and not in mortality. Our cohort may not be a typical ’hospitalized cohort’ as the majority of participants did not require supplemental oxygen.…”

“…PLWH on supplemental oxygen also had lower frequencies of hypertension and diabetes. Age, hypertension, and diabetes are risk factors for more severe COVID-19 disease ( Yang et al, 2020 ; Guan et al, 2020 ; Ambrosioni et al, 2021 ; Jassat et al, 2021a ), and their absence may indicate that the more severe outcome is driven by another factor, with HIV infection being the simplest explanation.…”

“…Results from epidemiological studies of the interaction between HIV and SARS-CoV-2 from other locations are mixed. Several large studies observed that disease severity and/or mortality risk is increased with HIV infection ( Western Cape Department of Health in collaboration with the National Institute for Communicable Diseases, South Africa et al, 2021 ; Geretti et al, 2021 ; Bhaskaran et al, 2021 ; Tesoriero et al, 2021 ; Braunstein et al, 2021 ; Jassat et al, 2021a ) while others found no statistically significant differences in clinical presentation, adverse outcomes, or mortality ( Huang et al, 2021 ; Sigel et al, 2020 ; Shalev et al, 2020 ; Vizcarra et al, 2020 ; Stoeckle et al, 2020 ; Dandachi et al, 2021 ; Härter et al, 2020 ; Karmen-Tuohy et al, 2020 ; the Northwell COVID-19 Research Consortium et al, 2020 ; Inciarte et al, 2020 ; Hadi et al, 2020 ). Worse outcomes for PLWH tended to be in patients with low CD4 ( Hoffmann et al, 2021a ; Dandachi et al, 2021 ; Braunstein et al, 2021 ) and low absolute CD4 count was a risk factor for more severe disease ( Western Cape Department of Health in collaboration with the National Institute for Communicable Diseases, South Africa et al, 2021 ).…”

Innovations, contestations and fragilities of the health system response to COVID-19 in the Gauteng Province of South Africa

“…These key informant perspectives on the missed opportunity to strive for greater equity between the private and public health sectors were supported by the document analysis [ 41 , 49 ]. Although the private health sector provides care to less than 20% of the South African population, it accounted for the majority of COVID-19 tests during the first wave of infections [ 49 ].…”

“…Although the private health sector provides care to less than 20% of the South African population, it accounted for the majority of COVID-19 tests during the first wave of infections [ 49 ]. Evidence suggests that there is a lower threshold for admission to private hospitals, thus exacerbating inequities in access to COVID-19 treatment and care [ 41 ].…”