The Spectrum of HIV‐Associated Kidney Pathology at a Tertiary Centre in South Africa

Aim: South Africa has one of the highest prevalences of human immunodeficiency virus (HIV) infection worldwide. Kidney disease is a common and important complication of HIV. This study describes biopsy-proven kidney pathology in people living with HIV (PLHIV) over 29 years at a South African centre, comparing patterns before and after antiretroviral therapy (ART) rollout. Methods: This retrospective descriptive study included PLHIV who underwent native kidney biopsy at Tygerberg Hospital during the period of 1 January 1992 to 31 December 2020. Patients were categorised by biopsy year into a pre-ART rollout period (before 2004) and a post-ART rollout period (2004 or later). Results: The cohort included 554 PLHIV, mostly biopsied post-ART rollout (90.1%). Mean age was 36.5 years, with a balanced sex distribution. During the post-ART period, 54.8% were on ART at biopsy. HIVAN was diagnosed in 45.7%, of which one-third had an additional histopathological pattern of injury. In the pre-ART rollout period, HIVAN was the most prevalent diagnosis (60.0%), whereas a lower prevalence was observed post-ART rollout (44.1%). During the post-ART rollout period, more than half of patients (55.9%) exhibited only non-HIVAN kidney pathology, with immune-complex-mediated glomerulonephritis (52.7%) and tubulointerstitial disease (39.7%) the most common. Conclusion: This study describes the spectrum of kidney pathology in PLHIV at a South African tertiary centre over nearly three decades, highlighting a significant HIVAN burden overall. We observed a lower proportion of patients with HIVAN following ART rollout, coinciding with an increase in non-HIVAN pathologies like immune complex glomerulonephritis and tubulointerstitial disease.