The fall—And rise—In hospital-based care for people with HIV in South Africa: 2004–2017

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.