Cause of Death and Risk of Death for People Living With HIV Admitted to Hospital: A Systematic Review and Meta‐Analysis

INTRODUCTION: Despite increasing access to HIV treatment and care, HIV-associated deaths remain high. We aimed to summarize global and regional trends in risk and causes of death among people living with HIV (PLHIV) admitted to hospital. METHODS: We conducted a systematic search across eight databases on 23 April 2023, identifying studies that reported cause of hospital admission or death among hospitalized PLHIV from first January 2014 onwards. We extracted data on age, geographical region, type of ward, antiretroviral treatment use, CD4 cell count, risk of death, cause of death and method of ascertainment of cause of death. We grouped studies into mutually exclusive groups: adults in medical wards by world region; adults in intensive care; and children. We used a Bayesian multilevel meta-regression model to pool data on causes of death. We additionally estimated temporal trends in risk of death among hospitalized PLHIV between 2000 and 2023. RESULTS: We identified 67 studies (59,013 participants) reporting risk of death among hospitalized PLHIV between 2014 and 2023. The overall risk of in-hospital death was 16% (95% credible interval CrI: 8%-27%). Mortality risk was highest among adults in Africa (19%, 95% CI: 15%-24%) and adults in intensive care units (44%, 95% CI: 34%-55%). Among 40 studies reporting cause of death in 6,838 participants, AIDS-related conditions predominated (72% of deaths, 95% CrI: 57%-85%), including tuberculosis deaths (27% of deaths, 95% CrI: 15%-40%). Bacterial infections were the second leading cause of death (25% of deaths, 95% CrI: 9%-47%). There was no strong evidence of risk of death changing between 2000 and 2023 (-2.2 percentage point decrease, 95% CrI -16.1 to +17.0 percentage points). CONCLUSIONS: Despite advances in HIV treatment, AIDS-related illnesses and bacterial infections remain the leading causes of in-hospital death among PLHIV. Our analysis reveals that in most regions, the risk of death for hospitalized PLHIV has remained largely unchanged in the past 23 years. These findings underscore the critical need to prioritize high-quality hospital care for opportunistic infections to reduce AIDS-related deaths.