Trends in Covid-19 Admissions and Deaths among People with Hiv in South Africa

ABSTRACT

Background: South Africa experienced five COVID-19 waves and over 90% of the population have developed immunity. HIV prevalence among adults is 19% and over 2 million people have uncontrolled viral loads, posing a risk for poor COVID-19 outcomes. Using national hospital surveillance data, we aimed to investigate trends in admission and factors associated with in-hospital COVID-19 mortality among people with HIV (PWH) in South Africa. Method(s) Data between March 5, 2020 and May 28, 2022 from the national COVID-19 hospital surveillance system, SARS-CoV-2 case linelist and Electronic Vaccine Data System were linked and analysed. A wave was defined as the period for which weekly incidence was >=30 cases/100,000 people. Descriptive statistics were employed for admissions and mortality trends. Postimputation random effect multivariable logistic regression models compared (a) characteristics of PWH and HIV-uninfected individuals, and (b) factors associated with mortality among PWH. Result(s) 68.7% (272,287/396,328) of COVID-19 admissions had a documented HIV status. PWH accounted for 8.4% (22,978/272,287) of total admissions, and 9.8%, 8.0%, 6.8%, 12.2% and 6.7% of admissions in the D614G, Beta, Delta, Omicron BA.1 and Omicron BA.4/BA.5 waves respectively. The case fatality ratio (CFR) among PWH and HIV-uninfected was 24.3% (5,584/22,978) vs 21.7% (54,110/249,309) overall, and in the respective waves was 23.7% vs 20.4% (D614G), 27.9% vs 26.6% (Beta), 26.2% vs 24.5% (Delta), 18.2% vs 9.1% (Omicron BA.1) and 16.8% vs 5.5% (Omicron BA.4/BA.5). Chronic renal disease, malignancy and past TB were more likely, and hypertension and diabetes were less likely in PWH compared to HIV-uninfected individuals. Among PWH, along with older age, male sex and presence of a comorbidity, there was a lower odds of mortality among individuals with prior SARS-CoV-2 infection (aOR 0.6;95% CI 0.4-0.8);>=1 dose vaccination (aOR 0.1;95% CI 0.1-0.1);and those admitted in the Delta (aOR 0.9;95% CI 0.8-0.9), Omicron BA.1 (aOR 0.5;95% CI 0.5-0.6) and Omicron BA.4/BA.5 (aOR 0.5;95% CI 0.4-0.7) waves compared to the D614G wave. PWH with CD4< 200 had higher odds of in-hospital mortality (aOR 1.9;95% CI 1.8-2.1). Conclusion(s) In South Africa, mortality among PWH was less likely in the Delta and Omicron waves but PWH had a disproportionate burden of mortality during the two Omicron waves. Prior immunity protected against mortality, emphasizing the importance of COVID-19 vaccination among PWH, particularly PWH with immunosuppression.