Case management and clinical outcomes of people living with HIV and admitted to a state-aided district hospital in Durban, South Africa in 2007.
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Date
2011
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Abstract
Title: Case Management and Clinical Outcomes of People Living with HIV and Admitted to
a State-aided District Hospital in Durban, South Africa in 2007.
Introduction: A proportion of the many patients who have advanced AIDS in South Africa
present for the first time requiring admission to hospital, the number of which are limited by
the availability of beds. Novel ways were developed to offer subacute inpatient care at
Siyaphila, a facility linked to McCord Hospital in Durban to provide expedited or immediate
antiretroviral therapy (ART) (exposed) for patients with advanced disease before their
discharge (ART group) . Different components of palliative care were offered for those who
did not enter the inpatient ART programme or who were terminally ill (non-ART group)
(non-exposed) .
Aim: The aim of the study is to describe the clinical condition, inpatient case
management and outcomes before discharge of people living with HIV admitted to
Siyaphila in order to assist in developing appropriate protocols for inpatient care.
Methods: This was an observational, analytic, cohort study using a convenience sample
of all patients consecutively admitted to Siyaphila during nine months in 2006/2007.
Prevalence of AIDS defining conditions at Siyaphila, time taken to progress from one
stage of care to another and outcomes for the two groups before discharge were
determined. Univariate and multivariate logistic regression analysis was performed on the
ART group to identify risk factors for mortality before discharge. A comparison between
the ART and non-ART group was also undertaken.
Results: Among the cohort of 405 PLHIV enrolled at Siyaphila during the study period
only 171 (42%) were initiated on ART immediately. In all patients, tuberculosis (251;
62%) was the most common opportunistic infection followed by cryptococcal meningitis
(68; 17%) and Pneumocystis pneumonia (28; 7%). The mean baseline CD4 cell count
was 84 celis/uL for the non-ART group and 55 celis/uL for the ART group. (p <0.01) The
median time from initial admission until discharge was 13 days in the non-ART group and
18 days in the ART group. The mortality before discharge among the non-ART group was
24% compared to 6% among the ART group. (p =0.001). The median number of days
before ART was initiated was 14 days. Immune reconstitution inflammatory syndrome
was diagnosed in seven patients (4%) among the admissions but caused no deaths. In
the multivariate analysis, the odds ratio for mortality for patients under 40 years was 0.1
(95% Confidence Interval: 0.01 - 0.9).
Conclusions: Subacute care offered at Siyaphila provides an entry point into the ART
programme for non-ambulatory patients who in the KwaZulu-Natal context have low ART
uptake after discharge. The findings of this study should be adopted as the best clinical
practice for PLHIV and AIDS admitted in the late stages of the disease. 0Nords 423)
Title: Case Management and Clinical Outcomes of People Living with HIV and Admitted to
a State-aided District Hospital in Durban, South Africa in 2007.
Introduction: A proportion of the many patients who have advanced AIDS in South Africa
present for the first time requiring admission to hospital, the number of which are limited by
the availability of beds. Novel ways were developed to offer subacute inpatient care at
Siyaphila, a facility linked to McCord Hospital in Durban to provide expedited or immediate
antiretroviral therapy (ART) (exposed) for patients with advanced disease before their
discharge (ART group) . Different components of palliative care were offered for those who
did not enter the inpatient ART programme or who were terminally ill (non-ART group)
(non-exposed).
Aim: The aim of the study is to describe the clinical condition, inpatient case
management and outcomes before discharge of people living with HIV admitted to
Siyaphila in order to assist in developing appropriate protocols for inpatient care.
Methods: This was an observational, analytic, cohort study using a convenience sample
of all patients consecutively admitted to Siyaphila during nine months in 2006/2007.
Prevalence of AIDS defining conditions at Siyaphila, time taken to progress from one
stage of care to another and outcomes for the two groups before discharge were
determined. Univariate and mUltivariate logistic regression analysis was performed on the
ART group to identify risk factors for mortality before discharge. A comparison between
the ART and non-ART group was also undertaken.
Results: Among the cohort of 405 PLHIV enrolled at Siyaphila during the study period
only 171 (42%) were initiated on ART immediately. In all patients, tuberculosis (251;
62%) was the most common opportunistic infection followed by cryptococcal meningitis
(68; 17%) and Pneumocystis pneumonia (28; 7%). The mean baseline CD4 cell count
was 84 celis/uL for the non-ART group and 55 celis/uL for the ART group. (p <0.01) The
median time from initial admission until discharge was 13 days in the non-ART group and
18 days in the ART group. The mortality before discharge among the non-ART group was
24% compared to 6% among the ART group. (p =0.001). The median number of days
before ART was initiated was 14 days. Immune reconstitution inflammatory syndrome
was diagnosed in seven patients (4%) among the admissions but caused no deaths. In
the mUltivariate analysis, the odds ratio for mortality for patients under 40 years was 0.1
(95% Confidence Interval: 0.01 - 0.9).
Conclusions: Subacute care offered at Siyaphila provides an entry point into the ART
programme for non-ambulatory patients who in the KwaZulu-Natal context have low ART
uptake after discharge. The findings of this study should be adopted as the best clinical
practice for PLHIV and AIDS admitted in the late stages of the disease. (Words 423)
Description
Thesis (M.Med.)-University of KwaZulu-Natal, Durban, 2011.
Keywords
HIV-positive persons--Medical care--KwaZulu-Natal--Durban., Theses--Public health medicine.