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      Care Continuum and Postdischarge Outcomes Among HIV-Infected Adults Admitted to the Hospital in Zambia

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          Abstract

          Background

          We characterized the extent of antiretroviral therapy (ART) experience and postdischarge mortality among hospitalized HIV-infected adults in Zambia.

          Methods

          At a central hospital with an opt-out HIV testing program, we enrolled HIV-infected adults (18+ years) admitted to internal medicine using a population-based sampling frame. Critically ill patients were excluded. Participants underwent a questionnaire regarding their HIV care history and CD4 count and viral load (VL) testing. We followed participants to 3 months after discharge. We analyzed prior awareness of HIV-positive status, antiretroviral therapy (ART) use, and VL suppression (VS; <1000 copies/mL). Using Cox proportional hazards regression, we assessed risk factors for mortality.

          Results

          Among 1283 adults, HIV status was available for 1132 (88.2%), and 762 (67.3%) were HIV-positive. In the 239 who enrolled, the median age was 36 years, 59.7% were women, and the median CD4 count was 183 cells/mm 3. Active tuberculosis or Cryptococcus coinfection was diagnosed in 82 (34.3%); 93.3% reported prior awareness of HIV status, and 86.2% had ever started ART. In the 64.0% with >6 months on ART, 74.4% had VS. The majority (92.5%) were discharged, and by 3 months, 48 (21.7%) had died. Risk of postdischarge mortality increased with decreasing CD4, and there was a trend toward reduced risk in those treated for active tuberculosis.

          Conclusions

          Most HIV-related hospitalizations and deaths may now occur among ART-experienced vs -naïve individuals in Zambia. Development and evaluation of inpatient interventions are needed to mitigate the high risk of death in the postdischarge period.

          Abstract

          In Zambia, 86% of hospitalized HIV-infected adults were antiretroviral therapy–experienced, 50% were virally suppressed, and 71% had advanced HIV disease. Mortality within 3 months of discharge was 20%. Advanced HIV disease interventions should target inpatients in sub-Saharan Africa.

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          Most cited references18

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          Alcohol Use and Human Immunodeficiency Virus (HIV) Infection: Current Knowledge, Implications, and Future Directions.

          Emily C Williams, Judith Hahn, Richard Saitz … (2016)
          Alcohol use is common among people living with human immunodeficiency virus (HIV). In this narrative review, we describe literature regarding alcohol's impact on transmission, care, coinfections, and comorbidities that are common among people living with HIV (PLWH), as well as literature regarding interventions to address alcohol use and its influences among PLWH. This narrative review identifies alcohol use as a risk factor for HIV transmission, as well as a factor impacting the clinical manifestations and management of HIV. Alcohol use appears to have additive and potentially synergistic effects on common HIV-related comorbidities. We find that interventions to modify drinking and improve HIV-related risks and outcomes have had limited success to date, and we recommend research in several areas. Consistent with Office of AIDS Research/National Institutes of Health priorities, we suggest research to better understand how and at what levels alcohol influences comorbid conditions among PLWH, to elucidate the mechanisms by which alcohol use is impacting comorbidities, and to understand whether decreases in alcohol use improve HIV-relevant outcomes. This should include studies regarding whether state-of-the-art medications used to treat common coinfections are safe for PLWH who drink alcohol. We recommend that future research among PLWH include validated self-report measures of alcohol use and/or biological measurements, ideally both. Additionally, subgroup variation in associations should be identified to ensure that the risks of particularly vulnerable populations are understood. This body of research should serve as a foundation for a next generation of intervention studies to address alcohol use from transmission to treatment of HIV. Intervention studies should inform implementation efforts to improve provision of alcohol-related interventions and treatments for PLWH in healthcare settings. By making further progress on understanding how alcohol use affects PLWH in the era of HIV as a chronic condition, this research should inform how we can mitigate transmission, achieve viral suppression, and avoid exacerbating common comorbidities of HIV and alcohol use and make progress toward the 90-90-90 goals for engagement in the HIV treatment cascade.
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            The Continuing Burden of Advanced HIV Disease Over 10 Years of Increasing Antiretroviral Therapy Coverage in South Africa

            Meg Osler, Katherine Hilderbrand, Eric Goemaere … (2018)
            Abstract Background Antiretroviral treatment (ART) has been massively scaled up to decrease human immunodeficiency virus (HIV)–related morbidity, mortality, and HIV transmission. However, despite documented increases in ART coverage, morbidity and mortality have remained substantial. This study describes trends in the numbers and characteristics of patients with very advanced HIV disease in the Western Cape, South Africa. Methods Annual cross-sectional snapshots of CD4 distributions were described over 10 years, derived from a province-wide cohort of all HIV patients receiving CD4 cell count testing in the public sector. Patients with a first CD4 count <50 cells/µL in each year were characterized with respect to prior CD4 and viral load testing, ART access, and retention in ART care. Results Patients attending HIV care for the first time initially constituted the largest group of those with CD4 count <50 cells/µL, dropping proportionally over the decade from 60.9% to 26.7%. By contrast, the proportion who were ART experienced increased from 14.3% to 56.7%. In patients with CD4 counts <50 cells/µL in 2016, 51.8% were ART experienced, of whom 76% could be confirmed to be off ART or had recent viremia. More than half who were ART experienced with a CD4 count <50 cells/µL in 2016 were men, compared to approximately one-third of all patients on ART in the same year. Conclusions Ongoing HIV-associated morbidity now results largely from treatment-experienced patients not being in continuous care or not being fully virologically suppressed. Innovative interventions to retain ART patients in effective care are an essential priority for the ongoing HIV response.
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              Routine offering of HIV testing to hospitalized pediatric patients at university teaching hospital, Lusaka, Zambia: acceptability and feasibility.

              Chipepo Kankasa, Rosalind J Carter, Nancy Briggs … (2009)
              The difficulties diagnosing infants and children with HIV infection have been cited as barriers to increasing the number of children receiving antiretroviral therapy worldwide. We implemented routine HIV antibody counseling and testing for pediatric patients hospitalized at the University Teaching Hospital, a national reference center, in Lusaka, Zambia. We also introduced HIV DNA polymerase chain reaction (PCR) testing for early infant diagnosis. Caregivers/parents of children admitted to the hospital wards were routinely offered HIV counseling and testing for their children. HIV antibody positive (HIV+) children <18 months of age were tested with PCR for HIV DNA. From January 1, 2006, to June 30, 2007, among 15,670 children with unknown HIV status, 13,239 (84.5%) received counseling and 11,571 (87.4%) of those counseled were tested. Overall, 3373 (29.2%) of those tested were seropositive. Seropositivity was associated with younger age: 69.6% of those testing HIV antibody positive were <18 months of age. The proportion of counseled children who were tested increased each quarter from 76.0% in January to March 2006 to 88.2% in April to June 2007 (P < 0.001). From April 2006 to June 2007, 1276 PCR tests were done; 806 (63.2%) were positive. The rate of PCR positivity increased with age from 22% in children <6 weeks of age to 61% at 3-6 months and to 85% at 12-18 months (P < 0.001). Routine counseling and antibody testing of pediatric inpatients can identify large numbers of HIV-seropositive children in high prevalence settings. The high rate of HIV infection in hospitalized infants and young children also underscores the urgent need for early infant diagnostic capacity in high prevalence settings.
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                Author and article information

                Journal
                Journal ID (nlm-ta): Open Forum Infect Dis
                Journal ID (iso-abbrev): Open Forum Infect Dis
                Journal ID (publisher-id): ofid
                Title: Open Forum Infectious Diseases
                Publisher: Oxford University Press (US )
                ISSN (Electronic): 2328-8957
                Publication date Collection: October 2019
                Publication date (Electronic): 16 July 2019
                Publication date PMC-release: 16 July 2019
                Volume: 6
                Issue: 10
                Electronic Location Identifier: ofz336
                Affiliations
                [1 ] Department of Medicine, University Teaching Hospital , Lusaka, Zambia
                [2 ] School of Medicine, University of Zambia , Lusaka, Zambia
                [3 ] School of Medicine, University of Maryland at Baltimore , Baltimore, Maryland
                [4 ] Zambia National Public Health Institute , Lusaka, Zambia
                [5 ] University Teaching Hospital HIV AIDS Programme , Lusaka, Zambia
                [6 ] Department of Medicine, University of California at San Francisco , San Francisco, California
                [7 ] Johns Hopkins University , Baltimore, Maryland
                [8 ] Center for Global Health and Quality, Georgetown University School of Medicine , Washington, District of Columbia
                [9 ] Department of Medicine, University of Alabama at Birmingham , Birmingham, Alabama
                [10 ] Centre for Infectious Disease Research in Zambia , Lusaka, Zambia
                [11 ] School of Public Health, University of Alabama at Birmingham , Birmingham, Alabama
                Author notes
                Correspondence: M. J. Vinikoor, MD, THT 215, 1530 3rd Avenue South, Birmingham, 35294 AL ( mjv3@ 123456uab.edu ).
                Article
                Publisher ID: ofz336
                DOI: 10.1093/ofid/ofz336
                PMC ID: 6778319
                PubMed ID: 31660330
                SO-VID: 033b43dc-fa76-4056-89ec-e74a5b397c33
                Copyright © © The Author(s) 2019. Published by Oxford University Press on behalf of Infectious Diseases Society of America.
                License:

                This is an Open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs licence ( http://creativecommons.org/licenses/by-nc-nd/4.0/), which permits non-commercial reproduction and distribution of the work, in any medium, provided the original work is not altered or transformed in any way, and that the work is properly cited. For commercial re-use, please contact journals.permissions@oup.com

                History
                Date received : 21 May 2019
                Date accepted : 15 July 2019
                Date: 05 October 2019
                Page count
                Pages: 6
                Funding
                Funded by: National Institute of Allergy and Infectious Diseases 10.13039/100000060
                Award ID: P30AI027767
                Funded by: Fogarty International Center 10.13039/100000061
                Award ID: K01TW009998
                Categories
                Subject: Major Articles

                Keywords: africa,care continuum,health systems,hiv infection,hospitalization
                Data availability:
                Keywords: africa, care continuum, health systems, hiv infection, hospitalization

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