Lauren Evelyn, Shumba Khumbo, Fox Matthew P, MacLeod William, Stevens Wendy, Mlisana Koleka, Bor Jacob, Onoya Dorina
Department of Biostatistics, Boston University School of Public Health, Boston, Massachusetts, United States of America.
Department of Internal Medicine, Health Economics and Epidemiology Research Office, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.
PLOS Glob Public Health. 2024 Sep 5;4(9):e0002127. doi: 10.1371/journal.pgph.0002127. eCollection 2024.
ART scale-up has reduced HIV mortality in South Africa. However, less is known about trends in hospital-based HIV care, which is costly and may indicate HIV-related morbidity. We assessed trends in hospital-based HIV care using the National Health Laboratory Service (NHLS) National HIV Cohort. Our study included all adults ≥18 years receiving care in South Africa's public sector HIV program from 2004 to 2017 with at least one CD4 count/viral load test in the NHLS database. We compared trends in the number of patients presenting for and receiving HIV care by facility type: hospitals vs. primary care clinics. We then assessed trends and predictors of incident hospitalization, defined as 2 or more hospital-based lab tests taken within 7 days. Finally, we assessed whether trends in incident hospitalizations could be explained by changes in patient demographics, CD4 counts, or facility type at presentation. Data were analyzed on 9,624,951 patients. The percentage of patients presenting and receiving HIV care at hospitals (vs. clinics) declined over time, from approximately 60% in 2004 to 15% in 2017. Risk of hospitalization declined for patients entering care between 2004-2012 and modestly increased for patients entering care after 2012. The risk of hospitalization declined the most in age groups most affected by HIV. Over time, patients presented with higher CD4 counts and were more likely to present at clinics, and these changes explained almost half the decline in hospitalizations. The percentage of HIV care provided in hospitals declined as patients presented in better health and as treatment was increasingly managed at clinics. However, there may still be opportunities to reduce incident hospitalizations in people with HIV.
扩大抗逆转录病毒治疗（ART）的规模已降低了南非的艾滋病毒死亡率。然而，对于以医院为基础的艾滋病毒护理的趋势了解较少，这种护理成本高昂，且可能表明与艾滋病毒相关的发病率。我们使用国家卫生实验室服务局（NHLS）的全国艾滋病毒队列评估了以医院为基础的艾滋病毒护理的趋势。我们的研究纳入了2004年至2017年在南非公共部门艾滋病毒项目中接受护理的所有18岁及以上成年人，他们在NHLS数据库中至少有一次CD4细胞计数/病毒载量检测。我们比较了不同设施类型（医院与初级保健诊所）中前来接受艾滋病毒护理和实际接受艾滋病毒护理的患者数量趋势。然后，我们评估了定义为在7天内进行2次或更多次基于医院的实验室检测的住院事件的趋势和预测因素。最后，我们评估了住院事件的趋势是否可以通过患者人口统计学特征、CD4细胞计数或就诊时的设施类型变化来解释。对9624951名患者的数据进行了分析。在医院（与诊所相比）接受艾滋病毒护理的患者比例随时间下降，从2004年的约60%降至2017年的15%。2004 - 2012年开始接受护理的患者住院风险下降，而2012年之后开始接受护理的患者住院风险略有增加。艾滋病毒影响最严重的年龄组住院风险下降幅度最大。随着时间的推移，患者就诊时的CD4细胞计数更高，且更有可能在诊所就诊，这些变化解释了近一半的住院率下降。随着患者健康状况改善以及治疗越来越多地在诊所进行管理，医院提供的艾滋病毒护理比例下降。然而，在艾滋病毒感染者中仍可能有机会减少住院事件。
