Human Immunodeficiency Virus and CKD in the Tenofovir Era: A Prospective Parallel-Group Cohort Study From Tanzania

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Rationale & ObjectiveLongitudinal research on chronic kidney disease (CKD) in sub-Saharan Africa is sparse, especially among people living with HIV. We evaluated the incidence of CKD among people living with HIV compared to HIV-uninfected controls in Tanzania. Study DesignProspective cohort study. Setting & Participants495 newly diagnosed people living with HIV who initiated antiretroviral therapy and 505 HIV-uninfected adults enrolled from public HIV clinics and followed from 2016 through 2021. The control group was recruited from HIV treatment partners from the same HIV clinics. ExposuresUntreated HIV (at baseline), antiretroviral therapy, socio-demographic information, health behaviors, hypertension, and diabetes. OutcomesIncident CKD, defined as follow-up eGFR <60 ml/min/1.73m2 with ≥25% reduction from baseline; annual eGFR change; incident albuminuria; three-year all-cause mortality. Analytical ApproachMultivariable Poisson and linear regression determined the association between HIV and other factors with baseline prevalent reduced eGFR and albuminuria, incident CKD and albuminuria, and annual eGFR change. Cox hazard regression assessed the association between baseline CKD and mortality. ResultsMedian age was 35 years and 67.5% were female. There were 101 incident CKD cases, 71 among people living with HIV and 30 among HIV-uninfected participants, equivalent to a CKD incidence of 57.9 per 1000 person-years (95% confidence interval (CI), 44.4-71.4) and 26.2 per 1000 person-years (95% CI, 16.8-35.5), respectively. People living with HIV had a more rapid eGFR decline (-6.65 versus -2.61 ml/min/1.73m2 per year). Female sex and older age were positively associated with incident CKD. Albuminuria incidence did not differ by HIV status. People living with HIV with albuminuria at baseline had higher mortality (hazard ratio, 2.13; 95% CI, 1.08-4.21). LimitationsAs an observational cohort study, there was no comparison group of HIV-positive participants on a non-tenofovir disoproxil fumarate-based antiretroviral therapy regimen. ConclusionsPeople living with HIV receiving tenofovir disoproxil fumarate-based antiretroviral therapy had a very high incidence of CKD and rapid eGFR decline. Conversely, albuminuria stabilized with antiretroviral therapy use. Expanding access to less nephrotoxic antiretroviral therapy, such as tenofovir alafenamide, is urgently needed throughout sub-Saharan Africa.