Incidence of HIV-positive admission and inpatient mortality in Malawi (2012–2019)

Abstract

Objective To investigate trends in population incidence of HIV positive hospital admission and risk of in-hospital death among adults living with HIV between 2012 and 2019 in Blantyre, Malawi. Design Population cohort study using an existing electronic health information system (‘SPINE’) at Queen Elizabeth Central Hospital and Blantyre census data. Methods We used multiple imputation and negative binomial regression to estimate population age- and sex-specific admission rates over time.We used a log-binomial model to investigate trends in risk of in-hospital death. Results Of 32,814 adult medical admissions during Q4.2012-Q3.2019, HIV status was recorded for 75.6%. HIV-positive admissions decreased substantially between 2012 and 2019. After imputation for missing data, HIV positive admissions were highest in Q3.2013 (173 per 100,000 adult Blantyre residents) and lowest in Q3.2019 (53 per 100,000 residents). An estimated 10,818 fewer than expected people living with HIV (PLHIV) (95%CI 10,068-11,568) were admitted during 2012-2019 compared to the counterfactual situation where admission rates stayed the same throughout this period. Absolute reductions were greatest for women aged 25-34 years (2,264 fewer HIV-positive admissions, 95%CI 2,002-2,526). In-hospital mortality for PLHIV was 23.5%, with no significant change over time in any age-sex group, and no association with ART use at admission. Conclusions Rates of admission for adult PLHIV decreased substantially, likely due to large increases in community provision of HIV diagnosis, treatment and care. However, HIV-positive in-hospital deaths remain unacceptably high, despite improvements in ART coverage. A concerted research and implementation agenda is urgently needed to reduce inpatient deaths among PLHIV.

Interventions to reduce deaths in people living with HIV admitted to hospital in low- and middle-income countries: A systematic review

“…People living with HIV who are unwell enough to require hospital admission likely have healthcare needs that are substantially different to people attending outpatient services, due to clinical acuity, extremely high probability of opportunistic infections and high risk of poor outcomes [10,13]. Whilst the numbers of people living with HIV being admitted to hospital are likely decreasing due to community availability of ART, and newer ART regimens [12], people in hospital contribute disproportionately to AIDS deaths. For example, about one quarter of all AIDS related deaths in Blantyre, Malawi in 2018 occurred in a government hospital [12].…”

“…Whilst the numbers of people living with HIV being admitted to hospital are likely decreasing due to community availability of ART, and newer ART regimens [12], people in hospital contribute disproportionately to AIDS deaths. For example, about one quarter of all AIDS related deaths in Blantyre, Malawi in 2018 occurred in a government hospital [12]. There is no evidence of improvement in outcomes for PLHIV admitted to hospital over time [10,12,13].…”

“…Increasingly, inpatients admitted with advanced HIV disease have been previously diagnosed and started on ART, rather than being newly diagnosed with HIV, but have either stopped taking ART or have treatment failure [7][8][9][10], often related to virological resistance [3,11]. Under these circumstances, the causes and outcomes of hospital admissions may be relatively unchanged by the availability of ART in communities, even if hospitalisation rates and the proportion of admissions accounted for by PLHIV decline [4,12].…”

Effect of resistance to third-generation cephalosporins on morbidity and mortality from bloodstream infections in Blantyre, Malawi: a prospective cohort study

“…The number of patients admitted to QECH with HIV infection decreased between 2012 and 2019, but the prevalence of HIV in Blantyre remains high at 53 per 100 000 residents in 2019. 10 …”

Design and protocol for a cluster randomised trial of enhanced diagnostics for tuberculosis screening among people living with HIV in hospital in Malawi (CASTLE study)

“…Adults living with HIV who require admission to hospital in high-HIV prevalence, low-income countries have a very high risk of death with 31% pooled in-hospital mortality in a meta-analysis of African hospital cohorts 2007–2015 [ 1 ]. Advanced HIV and high mortality among people living with HIV (PLHIV) admitted to hospital is a persistent problem, despite improvements in antitretroviral thereapy (ART) regimens and widespread availability of ART at primary care [ 2 ]. Tuberculosis (TB) is the leading cause of hospital admission and inpatient death [ 3 ].…”