Hospitalization Patterns Among People Living with HIV During India’s Transition to Universal Antiretroviral Therapy Access, 2013–2017

India has 2.6 million people living with human immunodeficiency virus (HIV) (PLWHIV) yet remains underrepresented in global hospitalization analyses. This study characterizes hospitalization patterns during India's transition toward universal antiretroviral therapy (ART) access (2013-2017) and quantifies the protective effect of sustained ART against acquired immunodeficiency syndrome (AIDS)-defining hospitalizations. A retrospective cohort study of HIV-positive patients aged ≥18 years admitted to a tertiary care center in Manipal, India was performed. Primary hospitalization reasons were categorized as AIDS-defining illness, HIV-associated non-AIDS (HANA), or non-HANA conditions. Multivariable logistic regression estimated associations between ART duration (≥9 vs. <9 months) and AIDS-defining hospitalization. Among 1,280 patients (2,157 admissions), median age was 44 years, 68% were male, and 46% were newly diagnosed at admission. AIDS-defining illnesses accounted for 45% of admissions, with tuberculosis being most prevalent (18%). Patients receiving ART ≥9 months had significantly lower odds of AIDS-defining hospitalization (adjusted odds ratio 0.78, 95% confidence interval 0.61-0.99). AIDS-defining illnesses, particularly tuberculosis, remain the predominant cause of HIV-related hospitalization in India. The high proportion of new diagnoses at admission and protective effect of sustained ART underscore the need for earlier HIV testing, rapid ART initiation, and adherence support.