Abstract
BackgroundZambia recently achieved UNAIDS 90-90-90 treatment targets for HIV epidemic control; however, inpatient facilities continue to face a large burden of patients with advanced HIV disease and HIV-related mortality. Management of advanced HIV disease, following guidelines from outpatient settings, may be more difficult within complex inpatient settings. We evaluated adherence to HIV guidelines during hospitalization, including opportunistic infection (OI) screening, treatment, and prophylaxis.MethodsWe reviewed inpatient medical records of people living with HIV (PLHIV) admitted to the University Teaching Hospital in Lusaka, Zambia between December 1, 2018 and April 30, 2019. We collected data on patient demographics, antiretroviral therapy (ART), HIV biomarkers, and OI screening and treatment—including tuberculosis (TB), Cryptococcus, and OI prophylaxis with co-trimoxazole (CTX). Screening and treatment cascades were constructed based on the 2017 WHO Advanced HIV Guidelines.ResultsWe reviewed files from 200 charts of patients with advanced HIV disease; of these 92% (184/200) had been on ART previously; 58.1% (107/184) for more than 12 months. HIV viral load (VL) testing was uncommon but half of VL results were high. 39% (77/200) of patients had a documented CD4 count result. Of the 172 patients not on anti-TB treatment (ATT) on admission, TB diagnostic tests (either sputum Xpert MTB/RIF MTB/RIF or urine TB-LAM) were requested for 105 (61%) and resulted for 60 of the 105 (57%). Nine of the 14 patients (64%) with a positive lab result for TB died before results were available. Testing for Cryptococcosis was performed predominantly in patients with symptoms of meningitis. Urine TB-LAM testing was rarely performed.ConclusionsAt a referral hospital in Zambia, CD4 testing was inconsistent due to laboratory challenges and this reduced recognition of AHD and implementation of AHD guidelines. HIV programs can potentially reduce mortality and identify PLHIV with retention and adherence issues through strengthening inpatient activities, including reflex VL testing, TB-LAM and serum CrAg during hospitalization.
Highlights
Global scale up of antiretroviral therapy (ART) has attained high coverage levels and prevented over 12.1 million Human immunodeficiency virus (HIV)-related deaths worldwide, yet many clients still present with advanced HIV disease [1,2,3,4]
In Zambia, mortality among people living with HIV (PLHIV) following linkage to care remains high, at 10.3 per 100 person-years among men with at least 18 months of ART which is slightly higher than the 6.7 and 6.9 per 100 person years reported in South Africa and Ethiopia respectively [7,8,9]
While there is growing interest in noncommunicable diseases among PLHIV [4], it is likely that HIV-associated mortality is partly driven by the prevalence of advanced HIV disease, defined as HIV infection with CD4 count < 200 cells/mm3 or World Health Organization (WHO) clinical stage 3 or 4 disease [10]
Summary
Global scale up of antiretroviral therapy (ART) has attained high coverage levels and prevented over 12.1 million HIV-related deaths worldwide, yet many clients still present with advanced HIV disease [1,2,3,4]. Guidelines were developed by the World Health Organization (WHO) for the detection and management of advanced HIV in 2017, based on randomized controlled trials and expert opinion [10,11,12]. These guidelines emphasize the need for CD4 count testing and diagnosis, treatment, and prevention of opportunistic infections (OIs) such as tuberculosis and cryptococcosis, the OIs that are responsible for a large proportion of HIV-related morbidity and mortality [10]. Zambia recently achieved UNAIDS 90-90-90 treatment targets for HIV epidemic control; inpatient facilities continue to face a large burden of patients with advanced HIV disease and HIV-related mortality. We evaluated adherence to HIV guidelines during hospitalization, including opportunistic infection (OI) screening, treatment, and prophylaxis
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