High Mortality in Adults With Community-Acquired Pneumonia Admitted to Hospitals in South Africa Before and During the COVID-19 Pandemic, Stratified by HIV Serostatus and Viral Load: Data From a Prospective Cohort Study (2019–2021)

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Background Community-acquired pneumonia (CAP) is a leading cause of death in adults, but recent data in people with HIV (PWH) are lacking. We studied South African adults hospitalized with CAP to describe mortality and risk factors. Methods We prospectively enrolled consenting adults aged ≥18 years hospitalized with CAP, as defined by symptoms, signs, and chest x-ray, from March 2019 to October 2021 in 3 South African hospitals. Blood, sputum, nasopharyngeal/oropharyngeal swabs, and urine were tested for HIV, tuberculosis, SARS-CoV-2, influenza, respiratory syncytial virus, and Streptococcus pneumoniae. Participants were followed for 1 year. Causes of death were defined following record review. Timing and risk factors for death were evaluated by Kaplan-Meier and Cox analyses. Results Of 2000 adults (median age, 46 years), 1079 (54.0%) were PWH. Among 994 with HIV viral load results, 289 (29.1%) were virally suppressed, and among 1556 tested for SARS-CoV-2, 700 (45.0%) were positive. There were 569 (28.5%) deaths, and the majority died early: 47.7% during hospitalization and 10.6% ≤30 days postdischarge. Leading underlying causes of death were COVID-19 (23.0%), tuberculosis (16.9%), and advanced HIV (13.2%). Age ≥45 years (hazard ratio, 2.7; 95% CI, 1.5–4.6), active tuberculosis (1.6, 1.2–2.0), unsuppressed HIV viral load (1.4, 1.0–1.9), anemia (1.3, 1.0–1.6), underweight (1.3, 1.0–1.7), and low admission oxygen saturation (<94% on room air; 1.3, 1.0–1.6) were associated with mortality. Mortality was higher in PWH (18.2 vs 11.7 per 100 person-years) but similar between PWH who were virally suppressed and unsuppressed (21.3 vs 24.7 per 100 person-years). Conclusions In-hospital and postdischarge CAP mortality remains high, particularly among PWH, regardless of virologic status, warranting urgent investigation of mitigation strategies.