The fall -- and rise -- in hospital-based care for people with HIV in South Africa: 2004-2017

Background ART scale-up has reduced HIV mortality in South Africa. However, less is known about trends in hospital-based HIV care, which is costly and may indicate HIV-related morbidity. Methods We assessed trends in hospital-based HIV care using a novel database: the National Health Laboratory Service (NHLS) National HIV Cohort. Our study included all adults ≥18 years receiving care in South Africa’s public sector HIV program from 2004 to 2017 with at least one CD4 count/viral load test in the NHLS database. We compared trends in the number of patients presenting for and receiving HIV care by facility type: hospitals vs. primary care clinics. We then assessed trends and predictors of incident hospitalization, defined as 2 or more hospital-based lab tests taken within 7 days. Finally, we assessed whether trends in incident hospitalizations could be explained by changes in patient demographics, CD4 counts, or facility type at presentation. Results Data were analyzed on 9,624,951 patients. The percentage of patients presenting and receiving HIV care at hospitals (vs. clinics) declined over time, from approximately 60% in 2004 to 15% in 2017. Risk of hospitalization declined for patients entering care between 2004-2012 and modestly increased for patients entering care after 2012. The risk of hospitalization declined the most in age groups most affected by HIV. Over time, patients presented with higher CD4 counts and were more likely to present at clinics, and these changes explained almost half the decline in hospitalizations. Conclusions The percentage of HIV care provided in hospitals declined as patients presented in better health and as treatment was increasingly managed at clinics. However, there may still be opportunities to reduce incident hospitalizations in people with HIV. Funding This work was supported by grant R01AI152149 from the National Institute of Allergy and Infectious Diseases. NIH had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. ### Competing Interest Statement The authors have declared no competing interest. ### Funding Statement This work was supported by grant R01AI152149 from the National Institute of Allergy and Infectious Diseases. NIH had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. ### Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes The details of the IRB/oversight body that provided approval or exemption for the research described are given below: Approval for analysis of de-identified data was granted by Boston University’s Institutional Review Board (Protocol No. H-31968), Human Research Ethics Committee of the University of the Witwatersrand (Protocol No. M200447) and NHLS Academic Affairs and Research Management System (Protocol No. PR2010539). I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable. Yes Access to primary data is subject to restrictions owing to privacy and ethics policies set by the South African Government. Requests for access to the data can be made via the Office of Academic Affairs and Research at the National Health Laboratory Service through the AARMS research project application portal: http://www.aarms.nhls.ac.za.