Advanced HIV disease management and patient outcomes in rural setting - Malawi: a retrospective cohort study.

Introduction: Advanced HIV disease (AHD) is increasingly becoming a threat to the survival of people living with HIV. Many countries, including Malawi, have adopted and adapted World Health Organization AHD management guidelines to manage the country's HIV cohort better. However, literature regarding adherence to these guidelines and the treatment outcomes remains limited. Therefore, we describe AHD management and patient outcomes at two rural hospitals in Southern Malawi.

Methods: We conducted a retrospective cohort study at Neno District and Lisungwi Community Hospitals in Neno District, Malawi. We extracted data from inpatient files, patients' manual charts referred to as "Mastercards" for outpatients attending Integrated Chronic Care Clinic (IC3) and from Electronic Medical Records (EMR) between January 2022 and December 2022. IC3 is a specialized clinic for people with chronic diseases including HIV, AHD and Non-communicable diseases. We used counts and percentages for all categorical variables and median and Interquartile range (IQR) for all continuous variables.

Results: During the study period, 343 HIV patients were hospitalized, of which 9.8% (n = 34) were new HIV infections. Of these, 50.4% (n = 173) had AHD, and 64.2% (n = 111) were admitted primarily due to infectious diseases. Tuberculosis (58.6%, n = 65) was the leading cause of admission. Of 173 hospitalized and classified as AHD, 75% had CD4 ordered, but only 43% (n = 74) were done. The viral load test was ordered for 34% (n = 59),) and only 28.8% (n = 17) were done. TB LAM and CrAg tests were ordered for 64.2% (n = 111) and 59.5% (n = 103) of which 69.4% and 72.8% were done, respectively. Among 146 IC3 AHD clients, 46%, 47%, 42% and 40% had CD4, viral load, TB LAM and CrAg tests done, respectively. Overall, 17.9% (n = 31) of inpatients with AHD died compared to 2.4%(n = 4) among HIV patients without AHD.

Conclusions: We found sub-optimal adherence to management guidelines for patients with AHD, with higher deaths reported compared to those without AHD. Therefore, strengthening adherence to AHD management guidelines through quality improvement initiatives and increased availability of diagnostic resources could potentially improve health outcomes for people living with HIV. Further studies should explore patients' perspectives on the quality of AHD clinics.