Advanced HIV disease and 30-day mortality among hospitalized adults with virally suppressed HIV in South Africa

Objectives: An increasing proportion of hospitalized persons living with HIV (PWH) in South Africa are virally suppressed. This study aimed to characterize causes of hospitalization, the burden of advanced HIV disease (AHD), and 30-day post-discharge mortality among this patient population. Methods: We conducted a prospective observational study of adult PWH with a viral load <1,000 copies/mL admitted to a public tertiary hospital in Klerksdorp, South Africa from October 2023 to September 2024. Demographic, clinical, and laboratory data were collected, and 30-day follow-up was conducted to assess mortality. AHD was defined as a CD4 count < 200 cells / mm 3 or WHO Stage 3 or 4 disease based on presence of an AIDS-defining illness. Comparisons between participants hospitalized with AIDS-defining conditions versus other causes, as well as between decedents and survivors, were conducted using Wilcoxon rank sum and Fisher's exact tests. Results: Of 1245 hospitalized patients screened, 99 virally suppressed PWH were enrolled. Median age was 45 years; 56% were female. AIDS-defining illnesses, primarily tuberculosis (TB), accounted for 27.3% of hospitalizations. Forty-four participants (44%) met criteria for AHD. Thirty-day mortality was 12.1% (6 in-hospital, 6 post-discharge). Most decedents were <50 years of age and had undetectable viral loads. Factors significantly associated with 30-day mortality included >10 years since HIV diagnosis and initial hemoglobin <12 g /dL. Conclusions: Despite virologic suppression, PWH who are hospitalized remain at high risk for death—particularly from TB and other AIDS-related illnesses. Strengthening early TB detection, expanding preventive therapy, and improving post-discharge care are critical to improving outcomes in this population.