Kitenge Marcel K, Fatti Geoffrey, Eshun-Wilson Ingrid, Nyasulu Peter S
Division of Epidemiology and Biostatistics, Department of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa.
Division of Infectious Diseases, School of Medicine, Washington University in St. Louis, Missouri, United States of America.
PLoS One. 2025 Feb 18;20(2):e0317674. doi: 10.1371/journal.pone.0317674. eCollection 2025.
Advanced HIV disease (AHD) remains a persistent public health challenge. Data regarding the burden, characteristics and predictors of AHD is scarce specifically for rural settings of sub-Saharan Africa. This study aimed to describe trends in annual CD4 count distribution and to characterise adult persons living with HIV (PLWH) on ART who have AHD in rural KwaZulu-Natal, South Africa.
A retrospective cohort design of annual CD4 count distribution was conducted among antiretroviral therapy (ART) patients aged 18 years and older. We used routinely collected data from adults receiving ART in Eshowe and Mbongolwane areas in KwaZulu-Natal, South Africa, between January 1, 2008, and June 30, 2021. Fine-Greys competing risks regression with proportional sub-distribution hazard models was used to determine factors associated with time to CD4 recovery.
A total of 34,729 patients were included of which 68.5% were females. The median age of the study sample was 33.5 years (interquartile range [IQR] 27-41 years), and the median CD4 count was 277 cells/μL (IQR, 149-452 cells/μL). The proportion of patients entering care with AHD declined over time from 62% in 2008 to 20% in 2021. Across all periods, those entering care with AHD were more likely to be men when compared to women (Relative risk [RR] 1.49; 95% 1.33-1.67). In addition, the proportion of patients with AHD who were ART-experienced increased from 4% in 2008 to 63% in 2021. Among ART-experienced, men were more likely to present with AHD compared to women (RR 1.79; 95% CI 1.52-2.11). Among those with AHD, the cumulative incidence of CD4 recovery to > 350 cells/μL was 3.21 (95% CI 3.13-3.29) per 100 adult-years follow-up time.
Over time fewer patients with AHD are entering care in KwaZulu-Natal, South Africa. However, the proportion of PLWH entering care with AHD remains consistently high, affecting 1 in 4 PLWH accessing HIV services. In addition, there is an increasing number of ART-experienced patients with AHD. Implementation of male-friendly services, combined with intensified adherence support and re-engagement initiatives should be considered to reduce mortality risk for PLWH in rural regions in South Africa.
晚期艾滋病（AHD）仍然是一个持续存在的公共卫生挑战。关于撒哈拉以南非洲农村地区AHD的负担、特征和预测因素的数据稀缺。本研究旨在描述南非夸祖鲁 - 纳塔尔农村地区接受抗逆转录病毒治疗（ART）的成年艾滋病病毒感染者（PLWH）的年度CD4细胞计数分布趋势，并对患有AHD的PLWH进行特征描述。
对18岁及以上接受抗逆转录病毒治疗（ART）的患者进行年度CD4细胞计数分布的回顾性队列研究。我们使用了2008年1月1日至2021年6月30日期间在南非夸祖鲁 - 纳塔尔省埃绍韦和姆邦戈瓦内地区接受ART的成年人的常规收集数据。使用带有比例子分布风险模型的Fine - Greys竞争风险回归来确定与CD4恢复时间相关的因素。
共纳入34729名患者，其中68.5%为女性。研究样本的中位年龄为33.5岁（四分位间距[IQR]为27 - 41岁），中位CD4细胞计数为277个/μL（IQR，149 - 452个/μL）。随着时间的推移，进入护理时患有AHD的患者比例从2008年的62%下降到2021年的20%。在所有时期，与女性相比，进入护理时患有AHD的患者更可能是男性（相对风险[RR] 1.49；95% 1.33 - 1.67）。此外，有AHD且有ART治疗经验的患者比例从2008年的4%增加到2021年的63%。在有ART治疗经验的患者中，男性比女性更可能患有AHD（RR 1.79；95% CI 1.52 - 2.11）。在患有AHD的患者中，每100个成人年随访时间内CD4恢复到>350个/μL的累积发病率为3.21（95% CI 3.13 - 3.29）。
随着时间的推移，南非夸祖鲁 - 纳塔尔进入护理的AHD患者越来越少。然而，进入护理时患有AHD的PLWH比例仍然持续很高，影响了每4名获得艾滋病毒服务的PLWH中的1名。此外，有AHD且有ART治疗经验的患者数量在增加。应考虑实施对男性友好的服务，结合强化的依从性支持和重新参与举措，以降低南非农村地区PLWH的死亡风险。
