Incidence of HIV-Related Hospital Admission and Inpatient Mortality in Malawi (2012-2019): A Population Cohort Study

Background: Hospital admission and discharge data from Southern and Eastern Africa are sparse but suggest that, despite impressive progress in population coverage of HIV testing and antiretroviral therapy (ART) programmes, many hospital admissions remain attributable to HIV.  Methods: An inpatient electronic health information system (‘SPINE’) in Queen Elizabeth Central Hospital (QECH), Blantyre, Malawi recorded data from all adult medical admissions. We combined these with Malawi census data to investigate trends in admission rates for Blantyre residents between 2012 and 2019. Multiple imputation and negative binomial regression was used to estimate population age- and sex-specific admission rates over time. A log-binomial model was used to investigate trends in risk of in-hospital death.  Results: Of 32,814 medical admissions during Q4.2012-Q3.2019, HIV status was recorded for 75.6%. ART coverage among hospitalised people living with HIV (PLHIV) increased from 66.0% in Q4.2012 to 92.5% in Q3.2019. After imputation for missing data, HIV-positive admissions per 100,000 Blantyre residents decreased substantially from peak Q3.2014 rates of 110 to 43 per 100,000 residents per quarter-year in Q3.2019. An estimated 10,818 fewer than expected PLHIV (95%CI 10,068-11,568) were admitted after 2012-2019 compared to the counterfactual situation where admission rates stayed the same throughout this period. Absolute reductions were greatest for women aged 25-34 years (2,264 fewer HIV-positive admissions, 95%CI 2,002-2,526). In-hospital mortality for PLHIV was 23.5%, with no significant change over time in any age-sex group, and no association with ART at admission.  Discussion: Rates of admission for PLHIV decreased substantially, likely due to large increases in community provision of HIV diagnosis, treatment and care. However, HIV-positive in-hospital deaths remain unacceptably high, despite improvements in ART coverage. A concerted research and implementation agenda is urgently needed to reduce inpatient deaths among PLHIV. Funding Statement: SPINE received funding from Wellcome Core Grant to the Malawi-Liverpool-Wellcome Trust (reference 206545). RMB and PM are funded by Wellcome (203905/Z/16/Z and 206575/Z/17/Z, respectively). Declaration of Interests: MISSING Ethics Approval Statement: Use of anonymous electronic data (from SPINE project) was approved by QECH hospital research committee. Individual patient consent for anonymised secondary analysis was not sought.