HIV Treatment Substantially Decreases Hospitalization Rates: Evidence From Rural South Africa

The rapid scale-up of antiretroviral treatment (ART) for HIV in sub-Saharan Africa starting in the mid-2000s is one of the largest public health achievements in recent history. By suppressing viral replication, ART reduces disease progression and infectiousness in people living with HIV. Initiation of ART at an early disease stage also results in a lower probability of developing AIDS-defining illnesses later in life.

South Africa is home to the largest HIV epidemic in the world. The rapid scale-up of ART since 2004 resulted in about 3.3 million people on ART in 2016 and has greatly improved general life expectancy in the country. Yet over ten years into the ART scale-up in sub-Saharan Africa, the causal effect of HIV treatment on rates of hospitalization for HIV-infected people has never been established.

In a new journal article published in Health Affairs, Jacob Bor and coauthors quantified this effect in a rural South African community for the period 2009–13. They linked clinical data on HIV treatment start dates for more than 2,000 patients receiving care in South Africa’s public-sector treatment program with five years of longitudinal data on self-reported hospitalizations from a community-based population cohort of more than 100,000 adults. 

Main findings:

• Hospitalization rates were the highest in the first year of treatment, while they were lowest in the fifth year or more on treatment.
• In addition, rates in the period before initiating ART were higher than rates after the second year of ART.
• HIV-infected people three or more years before ART initiation were almost five times as likely to be hospitalized, compared to people on ART for four years or more.
• By preventing high rates of hospitalization in the first year of ART, earlier treatment initiation could save more than $300,000 per 1,000 person-years over the first four years of ART, and could free up scarce healthcare resources.

The results suggest that early ART initiation could save substantial financial resources, challenging concerns about the long-term sustainability of ART programs in South Africa and other countries. Additionally, the results show that expanding guidelines and initiating treatment of HIV-infected people at an earlier stage would reduce hospitalization and free up scarce resources such as hospital beds and medical staff. As well as facing one of the world’s most severe HIV epidemics, South Africa also faces a high burden of noncommunicable disease, which is expected to further increase as the HIV epidemic matures. Freeing up hospital capacity is essential to meeting the challenges of this complicated epidemiological transition.