Morbidity and mortality in the modern antiretroviral treatment era in a tertiary teaching hospital in Durban, South Africa.

Abstract

Background: Human Immunodeficiency Virus (HIV) and Acquired Immunodeficiency Syndrome (AIDS) is recognized as the chief cause of morbidity and mortality in Sub-Saharan Africa. South Africa is known to bear the highest number of people living with HIV globally, while KwaZulu-Natal is the worst affected province in this country. Aim: To identify the determinant of morbidity and mortality in the modern antiretroviral therapy (ART) era in South Africa. Study design: A cross-sectional study. To achieve the objective, a mixed data acquisition method was applied using qualitative and quantitative data. These included a systematic review and a retrospective chart review. Data collection and analysis: For the systematic review, relevant studies were searched from the following databases: Google Scholar, PubMed, CINAHL. Two review authors independently screened titles abstracts and full-text articles in duplicate, extract data and assess the bias. Discrepancies were resolved by discussion or arbitration of a third review author. The study used the Preferred Reporting Item of Systematic Review (PRISMA 2015) guideline. This study used R software version 3.6.2. to synthesis the data, graphic displays were used to visually compare the prevalence of comorbidities across the study region. With the retrospective chart review, we conducted a study of all patients admitted at King Edward medical wards, Durban, South Africa from January to December 2018. Data were obtained from medical records, including demographic profile, clinical attributes and laboratory records. Data were analysed using R software version 3.6.2. In addition, the association between the covariates was tested either with the Chi-Square test, Kruskal Wallis or Wilcoxon rank-sum test depending on the type of variables. A p-value < 0.05 was used as a benchmark for determining the level of statistical significance Results: For the systematic review a total of 409 articles were obtained from the database search, finally12 articles were eligible for data extraction. All 12 studies included were published between 2008 and 2018 in English and they were conducted in Sub-Saharan Africa. Among them, three were conducted in Nigeria, two were conducted in Uganda, three were conducted in South Africa, one in Gabon, one in Ethiopia, one in Ghana, and one in Burkina Faso. In most of the included studies, tuberculosis was the first commonest causes of hospitalization accounted for 40.7% followed by anaemia with 34.2% and toxoplasmosis with 29.3%. It was as well the first cause of death accounted for 44.3% followed by anaemia with 30.2% and toxoplasmosis 27.5%. Contrary one study reported anaemia as the first causes of hospitalization and two studies reported each respectively wasting syndrome and meningitis as the first causes of death. With regards to the chart review, a total of 577 (50.6%) females and 564 (49.4%) males were included in the study. The mean age of all the participants was 39.6±12.2, 506 (44.3%) patients had CD4 less than 200 cells /mm3 and 273 (23.9%) had VL ˃ 1000 copies/ml. Male gender [OR 1.39(1.07-1.8) p=0.015], age [OR1.02(1.01-1.03) p˂ 0.001], CD4 <200 cells/mm3 [OR 2.14(1.37-3.45) p=0.001], VL ˃ 1000 copies/ml [ OR 1.93(1.08-3.63) p=0.032] were associated with mortality among HIV infected patients admitted in the cohort. Tuberculosis (TB) was the most common diagnosis on admission and the leading cause of death which accounted for 257 (22.5%) and 73 (24.3%) respectively, followed by kidney disease with 83(7.2%) for admission and with 38(12.6) for death. Only 70% of patients had been reported to be on ART. Age, men gender, CD4 cell and viral load were associated with mortality. Association between CD4 cell count and viral load was found. Conclusion: Despite the recent improvement of modern antiretroviral treatment, HIV/AIDS still causes hospitalization and death among HIV infected patients. For the systematic review as well as for the chart review, tuberculosis was the commonest cause of hospitalization and death in Sub-Saharan Africa and South Africa, but it was always followed by other opportunistic infection and other non-AIDS related conditions. There is a need to prevent opportunistic infection (especially tuberculosis) and to tackle the non-communicable disease related to HIV infection. Also, a need to start antiretroviral treatment early for patients living with HIV. Keywords: Morbidity, Mortality, Antiretroviral therapy, Sub-Saharan Africa, South Africa.