More, Better Linkage to Care Needed to Optimize HIV-Related Support Outcomes

For posthospitalization discharge outcomes to improve among individuals living with HIV, especially regarding risks of mortality and rehospitalization, there first need to be improvements to postdischarge referral resources and disease management, including toward antiretroviral therapy (ART).

Investigators reached this conclusion following their meta-analysis of data on 92,781 individuals living with HIV from 29 studies published between January 1, 2003—when ART scale-up in low-income countries began, the authors highlighted—and November 30, 2021, with PubMed and Embase, comparing outcomes between studies published before and after 2016. Their findings published recently in The Lancet HIV. Additional subanalyses compared outcomes according to region, setting, length of follow-up, and advanced HIV status at hospital admission; heterogeneity of findings was evaluated via sensitivity analyses.

“Several studies have identified factors associated with poor postdischarge outcomes among people living with HIV, including low CD4 cell count, lack of ART, and discharge against medical advice,” wrote the study authors. “The aims of this systematic review and meta-analysis were to assess postdischarge outcomes of people living with HIV and to summarize risk factors associated with poor outcomes.”

An overall 18.8% (95% CI, 15.3%-22.3%) of the persons living with HIV required readmission following initial hospitalization, and of this group, 14.1% (95% CI, 10.8%-17.3%) died. Results did not differ significantly between pre-2016 and post-2016 studies, and all studies included in the final analysis were required to report discharge outcomes data on at least 20 patients.

However, mortality following hospital discharge was more than 3 times as high according to study data from Africa compared with study data from the United States: 23.1% (95% CI, 16.5%-29.7%) vs 7.5% (95% CI, 4.4%-10.6%).

Further, among studies with findings on both postdischarge mortality and hospital readmission, the proportion of patients who died following readmission jumped to 31.7% (95% CI, 23.9%-39.5%). In connection with this finding, the most common risk factors for readmission were low CD4 cell count at admission, longer length of hospital stay, discharge against medical advice, and lack of linkage to care post discharge.

ART adherence had a positive correlation with decreased risk of mortality following discharge, while lower CD4 count and lack of linkage to care in the month after discharge were shown to increase mortality risk. In particular, in a study from the United States, higher rehospitalization rates were seen among injection drug users who had a new HIV diagnosis vs a known diagnosis.

Fifteen of the studies the authors analyzed were from North America, 9 from Africa, 2 each from southeast Asia and Europe, and 1 from Latin America. Just 1 study, from Mozambique, reported outcomes among children.

Thirty-eight percent of the studies contained data on patients with advanced disease, which the authors defined as a CD4 count below 200 cells/mcL. Among these studies, the proportion of patients with advanced disease ranged from 16% to 91%. Overall hospital lengths of stay ranged from 4 to 12 days in the 11 studies with that type of data.

The author’s analysis also revealed these findings:

• In-hospital mortality ranged from 1.7% to 26.7% among the 6 studies (4487 admissions) containing these data.
• Linkage-to-care totals ranged from 10.9% to 79.1% among the 7 studies investigating such an outcome.
• Postdischarge readmission ranged from 3.4% to 52.9% for the 20 studies with these data.
• Postdischarge mortality ranged from 1.1% to 50.5% within the 16 studies investigating this outcome.

Overall, one-third of the population in the authors’ study either required hospital readmission within 30 days of their initial discharge or died in that period, and mortality rates were higher in low- compared with high-income countries. In addition, whereas most adverse outcomes occurred within 30 days of discharge, among the studies that followed patients for longer periods, more patients did have adverse outcomes.

“It is important that programs are able to collect data and report outcomes for people with HIV who are admitted to hospital to better inform progress toward global targets,” the study authors emphasized. “Approaches are needed to identify individuals at the highest risk of poor outcomes and to provide adapted support.”

They suggested that patients be followed up with for more than 30 days, not only because this facilitates understanding of adverse outcomes but also because it enables for the introduction of interventions that could lessen the risk of such results, thereby increasing patient support services. Additional studies should also be conducted that evaluate and identify optimal outreach efforts to persons living with HIV who are at the highest risk of poor outcomes.

Reference

Ford N, Patten G, Rangaraj A, Davies MA, Meintjes G, Ellman T. Outcomes of people living with HIV after hospital discharge: a systematic review and meta-analysis. Lancet HIV. 2022;9(3):e150-e159. doi:10.1016/S2352-3018(21)00329-5