Characteristics of Individuals With Advanced HIV Disease and Risk Factors for Mortality in a Contemporary Cohort in South Africa

Background Advanced HIV disease is a major contributor to the slowing decline in HIV-related deaths globally. However, limited data exist on which individuals with advanced HIV are at highest risk of death. Methods A retrospective cohort study was nested within a larger cohort of 13 primary care HIV treatment facilities in Khayelitsha, South Africa. All adults who had a CD4 count Results Between 19% and 28% of the larger cohort (n = 72,102) were estimated to have advanced HIV disease at any point during the study period. Of these individuals, 20% were on treatment, 40% were disengaged from care, and 40% were treatment naive at enumeration. Overall mortality was 12%, with mortality highest in the first year (6.8%) after enumeration. There were 608, 371, and 370 deaths among those disengaged, on antiretroviral therapy (ART), and ART naive, respectively, representing 14%, 17%, and 8% of individuals in each group. More than a quarter of all participants were found to have current tuberculosis at enrollment into the cohort. Conclusions ART-exposed individuals with advanced HIV disease contribute substantially to ongoing HIV-related mortality in South Africa. Improved adherence and retention strategies within HIV programs could reduce this mortality.