HIV-related Burden on South African Hospitals in the Era of Large-scale Access to Antiretroviral Therapy

Abstract

Background: Prior to the large scale roll out of antiretroviral therapy (ART) for HIV in South Africa (RSA), HIV-related conditions were estimated to be responsible for at least half of all inpatient admissions to medical wards of public hospitals. Since 2004, RSA has actively expanded its HIV treatment program and in 2009 had an estimated ART coverage of 56% under the WHO 2006 guidelines. Currently it has 1.4 million patients on ART. We analyzed inpatient records at a large, urban, secondary hospital in Johannesburg to quantify the burden of HIV inpatient care in a population with good access to ART. Methods: The study population included all medical patients admitted to the hospital between 1 Jan 2010 and 1 Jun 2010 (N = 8,272). We selected a random sample of 491 patients, of whom 397 (81%) had accessible files. Mortuary and laboratory records indicated that patients with inaccessible files had similar HIV status and mortality as those whose files were found. Age, sex, HIV status, ART status, length of stay, vital status, and CD4 count were collected from patient files. Results: 174 patients (44%) had a confirmed HIV+ status (82 HIV-, 141 missing and assumed negative) on admission. 55% of admissions were among females with little difference by HIV status. HIV+ patients presented at a younger mean age (39 v 51 years old). There was no difference in mean length of admission (8.7 days). HIV+ patients with CD4 count reported (153/174, 88%) had a median CD4 count of 104 cells/mm3. Of those with CD4 count reported, 63% had CD4 counts below the treatment threshold of 200 cells/mm3 but only 23% were on treatment at the time of the admission. Patients with CD4 count <200 cells/mm3 had longer inpatient stays than those > 200 cells/mm3 (mean 9.9 v 6.6 days). The majority (57%) of the deaths were amongst those who were HIV+. Amongst HIV+ patients who survived only 67% had a CD4 < 200 cells/mm3 compared to 95% amongst those who died. Conclusions: Even with large treatment programs, at least 44% of medical admissions continued to be for HIV+ patients and 28% for patients with CD4 counts below the ART initiation threshold. ART scaleup has not yet substantially reduced the burden of inpatient care in South African hospitals. Interventions to promote earlier treatment initiation are needed to reduce utilization of inpatient resources.

Conference: CROI 2012, Seattle, USA