HIV-associated morbidity and mortality in a setting of high ART coverage: prospective surveillance results from a district hospital in Botswana
HIV-associated morbidity and mortality in a setting of high ART coverage: prospective surveillance results from a district hospital in Botswana
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DOI：
10.1002/jia2.25428
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发表时间：
2019-12-01
影响因子：
6
通讯作者：
Shapiro, Roger
中科院分区：
文献类型：
--
作者：
Barak, Tomer;Neo, Dayna T.;Shapiro, Roger
简介近年来，抗逆转录病毒疗法(ART)显著提高了非洲的存活率。在博茨瓦纳，成人艾滋病毒感染率为21.9%，在最初广泛采用抗逆转录病毒疗法后，与艾滋病相关的死亡率估计在2005年至2013年期间下降了58%，抗逆转录病毒疗法的覆盖率稳步上升，2016年达到84%。然而，关于大多数死亡发生的医院环境中艾滋病毒的负担及其对死亡率的影响的数据仍然很少。我们的目标是描述在广泛的抗逆转录病毒疗法覆盖的时代，在博茨瓦纳南部一家地区医院住院的患者中艾滋病毒的负担以及相关的发病率和死亡率。方法我们前瞻性地回顾了苏格兰利文斯通医院2015年12月至2017年11月的住院病例，记录了HIV状况、人口学、临床特征以及出院、死亡或转移时的最终诊断。我们确定了结果并确定了与死亡率相关的因素。将结果与2011年至2012年在同一设施收集的类似监测数据进行比较。结果共入院2316例，涉及1969例患者，HIV阳性患者占42.4%，HIV阴性患者占46.9%，HIV状态不明患者占10.7%。与HIV阴性患者相比，HIV阳性患者的年龄更小(平均42岁比，P<；0.0001)，死亡率更高(22.2%比18.0%，P=0.03)。结核病是两组死亡病例中的主要诊断，但在艾滋病毒阳性住院患者中死亡的比例(44.5%)高于艾滋病毒阴性住院患者(19.4%，p<；0.0001)。与2011年至2012年的类似监测相比，艾滋病毒感染率较低(42.4%比47.6%，p<；0.0001)，在艾滋病毒阳性的入院患者中：抗逆转录病毒治疗覆盖率更高(72.2%比56.2%，p<；0.01)，病毒载量抑制相似(78.6%比80.3%，p=0.77)，CD_4细胞计数更高(55.0%比44.6%，CD_4&g；=200cell/mm(3)，p<；死亡率相似(22.2vs.22.7%，p=0.93)，结核病诊断率上升(27.5%vs.20.1%，p=0.001)，结核病相关死亡率更高(35.9%vs.24.7%，p=0.05)。结论：尽管博茨瓦纳的抗逆转录病毒治疗覆盖率很高，但艾滋病毒阳性患者在住院和死亡中的比例仍然不成比例。结核病死亡可能是住院死亡率未能降低的原因之一。我们的研究结果表明，控制艾滋病毒和结核病仍然是降低博茨瓦纳住院死亡率的首要任务。
Introduction Antiretroviral therapy (ART) has significantly improved survival in Africa in recent years. In Botswana, where adult HIV prevalence is 21.9%, AIDS-related mortality is estimated to have declined by 58% between 2005 and 2013 following the initial wide-spread introduction of ART, and ART coverage has steadily increased reaching 84% in 2016. However, there remains little data about the burden of HIV and its impact on mortality in the hospital setting where most deaths occur. We aimed to describe the burden of HIV and related morbidity and mortality among hospitalized medical patients in a district hospital in southern Botswana in the era of widespread ART coverage. Methods We prospectively reviewed medical admissions to Scottish Livingstone Hospital from December 2015 to November 2017 and recorded HIV status, demographics, clinical characteristics and final diagnoses at discharge, death or transfer. We ascertained outcomes and determined factors associated with mortality. Results were compared with similar surveillance data collected at the same facility in 2011 to 2012. Results A total of 2316 admissions occurred involving 1969 patients; 42.4% were of HIV-positive patients, 46.9% of HIV-negative patients and 10.7% of patients with unknown HIV status. Compared to HIV-negative patients, HIV-positive patients had younger age (mean 42 vs. 64 years, p < 0.0001) and higher mortality (22.2% vs. 18.0%, p = 0.03). Tuberculosis was the leading diagnosis among mortality cases in both groups but accounted for a higher proportion of deaths among HIV-positive admissions (44.5%) compared with HIV-negative admissions (19.4%, p < 0.0001). Compared with similar surveillance in 2011 to 2012, HIV prevalence was lower (42.4% vs. 47.6%, p < 0.01), and among HIV-positive admissions: ART coverage was higher (72.2% vs. 56.2%, p < 0.0001), viral load suppression was similar (78.6% vs. 80.3%, p = 0.77), CD4 counts were higher (55.0% vs. 44.6% with CD4 >= 200 cells/mm(3), p < 0.001), mortality was similar (22.2 vs. 22.7%, p = 0.93), tuberculosis diagnoses increased (27.5% vs. 20.1%, p < 0.01) and tuberculosis-associated mortality was higher (35.9% vs. 24.7%, p = 0.05). Conclusions Despite high ART-coverage in Botswana, HIV-positive patients continue to be disproportionately represented among hospital admissions and deaths. Deaths from tuberculosis may be contributing to lack of reduction in inpatient mortality. Our findings suggest that control of HIV and tuberculosis remain top priorities for reducing inpatient mortality in Botswana.