First-line ART failure common among hospitalised HIV-positive people in sub-Saharan Africa

The study investigators say that many of those now dying of AIDS are aware of their HIV status and have previous HIV treatment experience but their deteriorating health has not been recognised, either as the result of loss to follow-up or lack of monitoring of adherence and treatment efficacy.

Less than a third of those hospitalised with HIV-related illness had no previous treatment experience and around half had started treatment at least six months prior to hospital admission.

Investigators from Médecins Sans Frontières (MSF) examined the characteristics of HIV-positive people who received in-patient care at their facilities in Kenya and the Democratic Republic of Congo (DRC). Up to 87% of people had severe immune suppression at the time of their hospitalisation and between 65 and 78% were ART experienced, and many of these people had treatment failure. Infectious diseases were the major cause of admission and mortality rates were high.

“Our findings present 2 diverse inpatient contexts in sub-Saharan Africa where, nevertheless similar characteristics and outcomes emerged, particularly for those with advanced HIV,” comment the investigators. “HIV-infected inpatients were often hospitalised extremely immunosuppressed…these HIV patients were exposed to health systems that failed to identify their worsening conditions.”

Access to ART in low- and middle-income countries has expanded rapidly in recent years. However, HIV remains a major cause of hospitalisation in these settings. Little is known about the outcomes of these hospitalised HIV-positive people, especially individuals with advanced HIV disease.

Investigators from MSF therefore analysed the characteristics of HIV-positive people admitted to their facilities at Homan-Bay County, Kenya, and Kinshasa, Kenya.

Data were available for 338 people in Kenya and 411 in DRC. Median CD4 cell count at presentation was 122 and 67 cells/mm³, respectively. Advance HIV disease was present in 84% and 97% of people, with 45% and 54% having a CD4 cell count below 100 cells/mm³ on admission.

Approximately half the people (Kenya = 53%; DRC = 46%) had never initiated ART (35% and 22%) or had only done so within the previous six months.

Among people with more than six months of ART, the median duration of treatment was 44 months in Kenya and 56 months in DRC. The vast majority of people on long-term ART were taking a non-nucleoside reverse transcriptase inhibitor (NNRTI)-based regimen (93% in Kenya and 74% in DRC).

In both settings, infectious diseases, especially tuberculosis, were the main cause of hospitalisation.

People were hospitalised for a median of six days.

“Of Kenyan and Congolese patients on ART >6 months, 45.8% and 67.2%, respectively, were admitted in a state of immunological failure, and 80.7% and 83.4% of these patients also had a detectable viral load of  > 1000 copies/ml, suggesting either adherence problems or disease that was already resistant to treatment,” observe the authors. “Yet, during the course of research, few patients switched to second-line drugs.”

Overall, 17% of indivduals in Kenya and 30% of individuals in DRC died while in hospital. Between a fifth and a quarter of these deaths occurred within 48 hours of hospitalisation. Tuberculosis was the cause of 36% of deaths in Kenya and 67% of deaths in DRC. Between 22 and 28% of deaths involved people with a CD4 count below 25 cells/mm³ at the time of admission.

In Kenya, a further 30% of people died within nine months of discharge from hospital.

The authors believe their findings have implications for the care of people with advanced disease, including:

• The need for improved identification of individuals with treatment failure and symptoms of HIV-related disease in primary healthcare facilities.
• Expanded routine viral load testing to verify adherence and treatment efficacy.
• Use of CD4 counts to better target testing for opportunistic infections.
• Timely identification of treatment failure, adherence issues, and developed of protocols for provision of prophylactic therapies.

“AIDS deaths still haunt the inpatient wards in…sub-Saharan contexts,” conclude the investigators. “Despite impressive investments and advancements against HIV for 3 decades, the fight is not over.”