High mortality in adults with community-acquired pneumonia admitted to hospitals in South Africa before and during the COVID-19 pandemic, stratified by HIV-serostatus and viral load: data from a prospective cohort study (2019-2021)

Abstract Background Community-acquired pneumonia (CAP) is a leading cause of death (CoD) in adults, but recent data in people with HIV (PWH) are lacking. We studied South African adults hospitalized with CAP to describe mortality and risk factors. Methods We prospectively enrolled consenting adults aged ≥18 years, hospitalized with CAP, defined by symptoms, signs, and chest x-ray, from March 2019-October 2021 in three South African hospitals. Blood, sputum, nasopharyngeal/oropharyngeal swabs, and urine were tested for HIV, TB, SARS-CoV-2, influenza, RSV and Streptococcus pneumoniae. Participants were followed for one year. CoDs were defined following record review. Timing and risk factors for death were evaluated using Kaplan-Meier and Cox analyses. Results Of 2000 adults (median age 46 years), 1079 (54·0%) were PWH, of which 289/994 (29·1%) with HIV viral load results were virally-suppressed; 700/1556 (45·0%) tested for SARS-CoV-2 were positive. There were 569 (28.5%) deaths; the majority died early: 47·7% during hospitalization and 10·6% ≤30 days post-discharge. Leading underlying CoDs were COVID-19 (23·0%), TB (16·9%), and advanced HIV (13·2%). Age ≥45 years (Hazard Ratio [HR]: 2·7, 1·5-4·6), active tuberculosis (1·6, 1·2-2·0), unsuppressed HIV viral load (1·4, 1·0-1·9), anaemia (1·3, 1·0-1·6), underweight (1·3, 1·0-1·7) and low admission oxygen saturation (<94% on room air; 1·3, 1·0-1·6) were associated with mortality. Mortality was higher in PWH (18·2 versus 11·7 per 100 person-years), but similar between virally-suppressed and -unsuppressed PWH (21·3 versus 24·7 per 100 person-years). Interpretation In-hospital and post-discharge CAP mortality remains high, particularly among PWH, regardless of virological status, warranting urgent investigation of mitigation strategies.