1. Introduction {#sec1}
===============

Globally, close to 35 million people are believed to live with HIV. Sub-Saharan Africa, worst affected region, in particular accounts for 71% of HIV infections \[[@B1]\]. Life expectancy for patients infected with HIV has improved significantly in the era of highly active antiretroviral therapy (HAART) \[[@B2]\]. The decline in hospitalization due to HAART, however, has been unevenly distributed and inconsistent. Despite the global decrease in AIDS-related death and improvement of access to HAART, eastern and southern Africa remain the most HIV-affected regions \[[@B3]\]. In such low- and middle-income countries, HIV and its associated immunosuppression (AIDS) continue to constitute a significant deal of morbidity and mortality in adults. In some of these countries, the problem is acute \[[@B4]--[@B6]\].

In resource-poor settings, between 20% and 52% of hospital beds in medical wards are occupied by HIV-infected patients at any given time, mostly with opportunistic infections \[[@B7]\] and ended up with longer hospital stays \[[@B8]\]. Furthermore, it is reported that non-HIV-related hospitalizations of HIV-infected patients is increasing, globally \[[@B9]\]. Most reports of hospitalization from HIV infection in the era of HAART are from the developed countries \[[@B10]--[@B13]\]. This is mainly because publications reporting HIV-related hospitalization from developing countries are infrequent.

Data on the spectrum of both HIV- and non-HIV-related illnesses that result in hospital admission are essential for policymakers and stakeholders to plan actions in reducing morbidity, mortality, and further hospitalization \[[@B14]\]. Recently, Negera and Mega \[[@B15]\] reported that body mass index (BMI) of less than 18.5 is a significant predictor of inpatient mortality in Ethiopia. However, with the paucity of published data on HIV/AIDS in Ethiopia, little is known about other reasons for hospitalizations, discharge outcomes, and predictors of inpatient mortality in hospitalized patients with HIV. Thus, this study aimed to assess reasons for hospitalization, discharge outcomes, and predictors of inpatient mortality among people living with HIV in Jimma University Specialized Hospital (JUSH), Jimma, Southwest Ethiopia.

2. Methods {#sec2}
==========

2.1. Study Area and Period {#sec2.1}
--------------------------

This study was conducted from 17^th^ February to 14^th^ August 2017 in medical wards of JUSH, which is the only teaching and referral hospital in Southwest Ethiopia. The hospital provides services for approximately 9000 inpatient and 80,000 outpatient attendants a year from the catchment population of about 15 million people. It has more than 450 beds. In this hospital, the HIV test was performed using the HIV 1/2 STAT-PAK1 RDT (Chembio Diagnostics, Medford, NY, USA) kit. In JUSH, *Mycobacterium tuberculosis* diagnosis was made using the Xpert assay (Cepheid Xpert MTB/RIF®).

2.2. Study Design and Participants {#sec2.2}
----------------------------------

A hospital-based prospective observational study was employed. The study population included 101 patients who met the following criteria: HIV seropositive (either known prior to hospitalization or tested positive following hospitalization), adult patients (≥15 years), admitted to medical wards of JUSH in the study period, willing to participate in the study, and stayed for at least 24 hours in the inpatient wards. To confirm HIV status of patients, every hospitalized patient underwent provider-initiated counseling and testing (PICT).

2.3. Data Collection and Data Quality {#sec2.3}
-------------------------------------

Patient demographics, anthropometric measurements, reason for hospitalization, comorbidities, complications, laboratory profile, and HAART status were collected using a predesigned data collection form. All CD4 cell counts included in study analyses were either done during hospitalization or within the previous 1 month before hospitalization. The clinical staging of patients was carried out using WHO guidelines for the clinical staging of HIV/AIDS for adults.

Adherence to HAART was assessed for 46 patients who were on HAART for at least 6 months prior to their admission. Adherence was estimated from patients\' self-report of missed doses out of 30 doses of their prescribed medication and reported as good (≥95%), fair (85 to 95%), or poor (\<85%) if and only if they missed 2 and less, 3 to 5, or 6 and more doses, respectively \[[@B16]\]. Data were collected by hospital pharmacists, working in medical wards, after being trained on interview techniques, data collection methods, and techniques of measurements. Moreover, to determine the outcomes of hospitalization, they followed the patients prospectively until discharged or died.

2.4. Data Processing and Analysis {#sec2.4}
---------------------------------

Data were coded, entered, cleaned, and analyzed using SPSS version 20 statistical package. Bivariate and multivariate logistic regression analyses with 95% confidence interval were employed in order to infer associations and predictions. In bivariate analysis, all explanatory variables that are associated with the outcome variable (inpatient mortality) with a *P* value of \<0.2 were included in the final logistic model. *P* value \< 0.05 was considered as statistically significant for all the independent variables in the final model.

2.5. Ethical Consideration {#sec2.5}
--------------------------

Letter of ethical clearance was obtained from the Ethical Review Board of College of Public Health and Medical Sciences, Jimma University. Informed, voluntary, written, and signed consent/assent was obtained from each study participants/caregivers. Privacy and confidentiality were strictly maintained throughout the study.

3. Results {#sec3}
==========

3.1. Sociodemographic Characteristics of the Study Population {#sec3.1}
-------------------------------------------------------------

Of 101 hospitalized PLWH enrolled in the study, 62 (61.4%) of them were females and 53 (52.5%) of the patients were between 25 and 34 years of age. Most of the study participants were urban residents (64.4%) and unemployed (62.4%). As it is illustrated in [Table 1](#tab1){ref-type="table"}, the measured mean BMI of patients was 17.63±3.24 kg/m^2^. Slightly more than one-third of the patients (34.8%) had severe malnutrition (BMI \< 16 kg/m^2^).

3.2. Clinical Characteristics of the Participants {#sec3.2}
-------------------------------------------------

Clinical characteristics and laboratory findings of the patients are presented in Tables [2](#tab2){ref-type="table"} and [3](#tab3){ref-type="table"}, respectively. The result showed that 21 (20.8%) of participants were newly diagnosed HIV-positive patients (tested on hospitalization). For known HIV patients (79.2%), the median duration of time since their diagnosis was 24 months (IQR, 6--60). Majority (82.2%) of the patients were in WHO clinical stage 4 and 44.6% of them had complications. The main (46.7%) complication of the hospitalized patient was severe neurologic dysfunctions. More than a quarter (27.7%) of the participants had a history of prior hospitalization in the last 12 months, and opportunistic infections were the leading (53.6%) reasons for their previous hospitalization ([Table 2](#tab2){ref-type="table"}).

In this study, 29 (28.7%) of the patients had CD4 cell counts of ≤100 cells/*μ*L (IQR, 93.5--279.0). The median CD4 cell count for survivors and died was 202 cells/*μ*L (IQR, 121--295) and 70 cells/*μ*L (IQR, 42--100), respectively ([Table 3](#tab3){ref-type="table"}). Anemia was reported in 88 of 96 (85.4%) patients (defined as hemoglobin (Hg) \< 13 gm/dL for males and \<12 gm/dL for females), and it was severe (Hg \< 8gm/dL) in 21 (21.9%) of them.

3.3. Antiretroviral Therapy Regimen of Patient on HAART {#sec3.3}
-------------------------------------------------------

Among 80 known HIV patients, 65 (81.2%) of them were on HAART with the median duration of 19.00 (IQR, 3.25--40.25) months and majority (89.2%) of them were on first-line regimen. About a third (16; 34.8%) of the patients,who were assessed for adherence, had a poor (\<85%) HAART adherence. Among 19 (29.2%) patients who had regimen changes, treatment failure was found to be the leading (36.8%) reason for treatment switch ([Table 4](#tab4){ref-type="table"}).

3.4. Reasons for Hospitalization and Treatment Outcome of Hospitalized Patients {#sec3.4}
-------------------------------------------------------------------------------

Tuberculosis (TB) was the most common diagnosis that accounted for 25 (24.8%) of the reasons for hospitalization ([Figure 1](#fig1){ref-type="fig"}). The median duration of hospital stay for the patients was found to be 13 days (IQR, 8--20 days). As it is revealed in [Figure 2](#fig2){ref-type="fig"}, 82.2% of the admitted patients survived: 69 (68.3%) discharged, 10 (9.9%) of them discharge against medical advice (DAMA), and 4 (4.0%) transferred cases. The remaining 18 (17.8%) were deceased, of whom 12 (66.7%) died within the first 7 days of their hospital stay.

3.5. Factors Associated with Inpatient Mortality {#sec3.5}
------------------------------------------------

Both univariate and multivariate logistic regression analyses ([Table 5](#tab5){ref-type="table"}) showed that presence of neurologic complications, CD4 count ≤ 100 cell/*μ*L, and hospital stay of less than 7 days were predictors of inpatient mortality. PLWH hospitalized with neurologic complications were almost fourteen times more likely to die inpatient compared with those who were not (AOR = 13.97; 95% CI: 2.32--84.17, *P*=0.004). The odds of dying inpatient were significantly (*P*=0.002) higher in PLWH hospitalized with CD4 count ≤ 100 cells/*μ*l compared with CD4 count \> 100 cells/*μ*L (AOR = 16.40; 95% CI: 2.88--93.42).

4. Discussion {#sec4}
=============

In this study, opportunistic and other infectious diseases were dominant attributes of hospitalization. The spectrum of opportunistic infection is in agreement with previous reports on hospitalized HIV/AIDS patients from other parts of Ethiopia \[[@B17]--[@B19]\] and other low- and middle-income countries \[[@B3], [@B5], [@B20]--[@B23]\]. Our study, however, reported a relatively lower proportion of TB. This could be because of the better availability of free HAART, which determines the frequency and severity of opportunistic infections such as active TB disease \[[@B7], [@B18], [@B24]\].

The prevalence of CNS infections observed during our study period was 18.8%. This is in line with a similar study conducted in Kenya \[[@B25]\] and lower than other studies \[[@B26], [@B27]\]. The common CNS infections identified were cryptococcal meningitis (36.8%), bacterial meningitis (31.6%), and cerebral toxoplasmosis (31.6%). This proportion of CNS infections was consistent with other studies \[[@B3], [@B15], [@B20], [@B28]--[@B30]\]. HAART-related toxicity was also among the commonly occurred reasons for hospitalization. Proper counseling about the adverse effects of antiretroviral drugs and aggressive monitoring of patients before and within the first few weeks of commencement of HAART will help to reduce morbidity associated with the use of these drugs.

The overall inpatient mortality in our study population was 17.8%, similar to previous reports \[[@B3], [@B23], [@B31]\]. Our finding, nevertheless, was higher than previous studies in India \[[@B6]\] and France \[[@B30]\]. The high mortality is probably reflective of the advanced nature of the disease during hospitalization \[[@B10], [@B20]\]. Although there were differences in study design, a higher mortality rate was reported in other studies \[[@B16], [@B20], [@B21], [@B32]\].

Logistic regression analysis showed that presentation with neurologic complications, low CD4 count (≤100 cells/*μ*l), and short duration of hospital stay (\<7 days) were predictors of inpatient mortality. Multiple studies reported a statistically significant association of low CD4 cell counts as the predictor of inpatient mortality \[[@B20], [@B33]\]. HIV patients hospitalized with neurologic complications were almost 14 times more likely to die inpatient compared with those without neurologic complications. This is in accordance with findings from other studies from Ethiopia by Berhe et al. \[[@B34]\] and elsewhere by Gill et al. \[[@B35]\].

Our study has some limitations that should be considered while interpreting the findings. They include the following: certain disease conditions might have been overestimated or underestimated due to inadequate diagnostic facilities. Outcome measures for our study depended on the survival status at last contact with our patient in the hospital; we cannot exclude an underrepresentation of mortality rate as some DAMA patients might have died outside our hospital.

5. Conclusion {#sec5}
=============

Tuberculosis, infections of the nervous system, and pneumonia were the top three leading reasons for hospitalization. Furthermore, our study disclosed that presentation with neurologic complication, low CD4 count, and short hospital stay were found to be predictors of inpatient mortality.

The authors would like to express appreciations to Jimma University and the health facility where the research was conducted. The authors would like to extend their appreciation to data collectors and medical ward clinical staffs for their support during data collection.

AIDS:

:   Acquired immunodeficiency syndrome

CNS:

:   Central nervous system

COPD:

:   Chronic obstructive pulmonary disease

DAMA:

:   Discharge against medical advice

DVT:

:   Deep venous thrombosis

HAART:

:   Highly active antiretroviral therapy

HIV:

:   Human immunodeficiency virus

IQR:

:   Interquartile range

JUSH:

:   Jimma University Specialized Hospital

PLWH:

:   People living with HIV

TB:

:   Tuberculosis.

Data Availability
=================

The data used to support the finding of this study are available from the corresponding author upon request.

Disclosure
==========

This study was done for the partial fulfillment Mr. Mishore\'s master\'s degree in clinical pharmacy.

Conflicts of Interest
=====================

The authors declare that they have no conflicts of interest.

![Reasons for hospitalization of PLWH to medical wards of JUSH, Jimma, Southwest Ethiopia, 2017 (*N* = 101). ∗Chronic liver disease, herpes zoster, cellulitis, and disseminated Kaposi sarcoma each accounts for 1.](ART2020-1872358.001){#fig1}

![Discharge outcomes of PLWH admitted to the medical wards of JUSH, Jimma, Southwest Ethiopia, 2017 (*N* = 101).](ART2020-1872358.002){#fig2}

###### 

Sociodemographic characteristics of PLWH hospitalized to the medical wards of JUSH, Jimma, Southwest Ethiopia, 2017 (*N* = 101).

  Characteristics                Frequency   Percent
  ------------------------------ ----------- ---------
  Sex                                         
   Male                          39          38.6
   Female                        62          61.4
                                             
  Age group                                   
   15--24                        8           7.9
   25--34                        53          52.5
   35--44                        25          24.7
   45+                           15          14.9
                                             
  Residence                                   
   Urban                         65          64.4
   Rural                         36          35.6
                                             
  Level of education                          
   No education                  29          28.7
   Primary                       42          41.6
   Secondary+                    30          29.7
                                             
  Marital status                              
   Single                        15          14.8
   Married                       50          49.5
   Divorced                      25          24.8
   Widowed                       11          10.9
                                             
  Occupation                                  
   Government employee           10          9.9
    Self-employed                28          27.7
   Unemployed                    63          62.4
                                             
  Body mass index (in kg/m^2^)                
   \<16                          35          34.7
   16--18.5                      23          22.7
   18.5--24.9                    43          42.6
   ≥25                           0           0.0

###### 

Clinical characteristics of PLWH hospitalized to medical wards of JUSH, Jimma, Southwest Ethiopia, 2017.

  Characteristics                                                                              Category                   Frequency   Percent
  -------------------------------------------------------------------------------------------- -------------------------- ----------- ---------
  HIV status at admission                                                                      Known                      80          79.2
  New                                                                                          21                         20.8        
                                                                                                                                      
  Duration of HIV in month (*N* = 80)                                                          \<6 months                 21          26.3
  ≥6 months                                                                                    59                         73.7        
                                                                                                                                      
  Clinical stage of HIV/AIDS on hospitalization                                                Stage 1                    5           5.0
  Stage 2                                                                                      2                          2.0         
  Stage 3                                                                                      13                         13.0        
  Stage 4                                                                                      81                         80.2        
                                                                                                                                      
  Complication (*N* = 45)                                                                      Neurologic                 21          46.7
  Respiratory                                                                                  14                         31.1        
  Hypovolemic shock                                                                            2                          4.4         
  Hepatic encephalopathy                                                                       2                          4.4         
  Gastric bleeding                                                                             2                          4.4         
  Nephropathy                                                                                  2                          4.4         
                                                                                                                                      
  Comorbidity (*N* = 22)                                                                       Cardiovascular             8           36.4
  Gastrointestinal                                                                             5                          22.7        
  Urologic                                                                                     5                          22.7        
  Respiratory                                                                                  4                          18.2        
                                                                                                                                      
  Reasons for hospitalization (known HIV-positive patients) in the last 12 months (*N* = 28)   Opportunistic infections   15          53.6
  DVT                                                                                          2                          7.1         
  COPD∗                                                                                        2                          7.1         
  Malaria                                                                                      2                          7.1         
  Bacterial meningitis                                                                         2                          7.1         
  Not specified                                                                                5                          17.9        

^*∗*^Chronic obstructive pulmonary disease; DVT = deep venous thrombosis.

###### 

Laboratory profile of PLWH hospitalized to the medical wards of JUSH, Jimma, Southwest Ethiopia, 2017.

  Parameters                                       Median (IQR)            References
  ------------------------------------------------ ----------------------- ------------
  Hemoglobin (gm/dL) (*N* = 96)                    9.75 (8.50--11.50)      12.0--17.0
  Hematocrit (%) (*N* = 96)                        30.24 (26.19--34.70)    40.0--54.0
  Platelet (×10^9^/L) (*N* = 93)                   252.0 (149.50--402.0)   150--500
  Aspartate aminotransferase (unit/L) (*N* = 77)   40.0 (21.40--80.50)     0--38
  Alanine aminotransferase (unit/L) (*N* = 76)     25.25 (16.05--45.83)    0--40
  Serum creatinine (mg/dL) (*N* = 70)              0.85 (0.68--1.29)       0.8--1.2
  Blood urea nitrogen (mg/dL) (*N* = 70)           24.13 (14.38--41.54)    8--20
  CD4 count (cells/*μ*L) (*N* = 101)               193.0 (93.50--279.0)    500--1,500

###### 

Antiretroviral therapy related characteristics of PLWH admitted to medical wards of JUSH, Jimma, Southwest Ethiopia, 2017.

  Characteristics                                                     Category            Frequency   Percent
  ------------------------------------------------------------------- ------------------- ----------- ---------
  Prior HAART use (*N* = 80)                                          Yes                 65          81.2
  No                                                                  15                  18.8        
                                                                                                      
  Type of HAART regimen (*N* = 65)                                    First line          58          89.2
  Second line                                                         7                   10.8        
                                                                                                      
  First-line regimen (*N* = 58)                                       TDF + 3TC + EFV     37          63.8
  AZT + 3TC + NVP                                                     11                  19.0        
  TDF + 3TC + NVP                                                     5                   8.6         
  Others                                                              5                   8.6         
                                                                                                      
  Second-line regimen (*N* = 7)                                       ABC + ddi + LPV/r   6           85.7
  ABC + 3TC + LPV/r                                                   1                   14.3        
                                                                                                      
  Adherence status among HAART users for ≥6 months (*N* = 46)         Good                28          60.9
  Fair                                                                2                   4.3         
  Poor                                                                16                  34.8        
  History of regimen change (*N* = 65)                                Yes                 19          29.2
  No                                                                  46                  70.8        
                                                                                                      
  Reason for regimen change(*N* = 19)                                 Treatment failure   7           36.8
  Toxicity/side effects                                               6                   31.6        
  Due to new TB                                                       3                   15.8        
  Others                                                              3                   15.8        
                                                                                                      
  Prior co-trimoxazole prophylaxis in known HIV patients (*N* = 80)   Yes                 51          63.8
  No                                                                  29                  36.2        

###### 

Univariate and multivariate analyses of factors associated with inpatient mortality among PLWH admitted to the medical wards of JUSH, Jimma, Southwest Ethiopia, 2017 (*N* = 101).

  Variables                 Category    Died (*N* = 18)   Survived (*N* = 83)   COR (95% CI)          *P* value∗   AOR (95% CI)          *P* value^*∗*^
  ------------------------- ----------- ----------------- --------------------- --------------------- ------------ --------------------- ----------------
  Sex                       Male        10 (25.6%)        29 (74.4%)            2.33 (0.83--6.54)     0.109        0.57 (0.09--3.43)     0.539
  Female                    8 (12.9%)   54 (87.1%)        1.000                                       1.000                              
                                                                                                                                         
  Neurologic complication   Yes         13 (61.9%)        8 (38.1%)             24.38 (6.89--86.19)   0.000        13.97 (2.32--84.17)   0.004
  No                        5 (6.2%)    75 (93.8%)        1.000                 0.000                 1.000                              
                                                                                                                                         
  CD4 count                 ≤100        14 (48.3%)        15 (51.7%)            15.9 (4.57--6)        0.001        16.40 (2.88--93.42)   0.002
  \>100                     4 (5.6%)    68 (94.4%)        1.000                                       1.000                              
                                                                                                                                         
  Hospital stay in days     \<7         12 (46.2%)        14 (53.8%)            9.86 (3.17--30.69)    0.000        12.98 (2.13--78.97)   0.005
  ≥7                        6 (8.0%)    69 (92.0%)        1.000                                       1.000                              

COR = crude odds ratio; AOR : adjusted odds ratio; CI: confidence interval; ^*∗*^*P* value \<0.05 indicates a statistically significant association.

[^1]: Academic Editor: Bhaskaran Unnikrishnan
