Epidemiology and aetiology of moderate to severe diarrhoea in hospitalised patients ≥5 years old living with HIV in South Africa, 2018-2021: A case-control analysis

Siobhan L Johnstone; Linda Erasmus; Juno Thomas; Michelle J Groome; Nicolette M du Plessis; Theunis Avenant; Maryke de Villiers; Nicola A Page

doi:10.1371/journal.pgph.0001718

Epidemiology and aetiology of moderate to severe diarrhoea in hospitalised patients ≥5 years old living with HIV in South Africa, 2018-2021: A case-control analysis

PLOS Glob Public Health. 2023 Sep 8;3(9):e0001718. doi: 10.1371/journal.pgph.0001718. eCollection 2023.

Authors

Siobhan L Johnstone^{1

2}, Linda Erasmus¹, Juno Thomas¹, Michelle J Groome^{3

4}, Nicolette M du Plessis⁵, Theunis Avenant⁵, Maryke de Villiers⁶, Nicola A Page^{1

7}

Affiliations

¹ Center for Enteric Diseases, National Institute for Communicable Diseases, A Division of the National Health Laboratory Service (NHLS), Johannesburg, South Africa.
² School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.
³ Division of Public Health Surveillance and Response, National Institute for Communicable Diseases, A Division of the National Health Laboratory Service (NHLS), Johannesburg, South Africa.
⁴ School of Pathology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.
⁵ Department of Paediatrics, Kalafong Provincial Tertiary Hospital, Faculty of Health Sciences, University of Pretoria, Pretoria, South Africa.
⁶ Department of Internal Medicine, Kalafong Provincial Tertiary Hospital, Faculty of Health Sciences, University of Pretoria, Pretoria, South Africa.
⁷ Department of Medical Virology, Faculty of Health Sciences, University of Pretoria, Pretoria, Arcadia, South Africa.

Abstract

Diarrhoea is a recognised complication of HIV-infection, yet there are limited local aetiological data in this high-risk group. These data are important for informing public health interventions and updating diagnostic and treatment guidelines. This study aimed to determine the pathogenic causes of diarrhoeal admissions in people living with HIV (PLHIV) compared to hospital controls between July 2018 and November 2021. Admitted diarrhoeal cases (n = 243) and non-diarrhoeal hospital controls (n = 101) ≥5 years of age were enrolled at Kalafong, Mapulaneng and Matikwana hospitals. Stool specimens/rectal swabs were collected and pathogen screening was performed on multiple platforms. Differences in pathogen detections between cases and controls, stratified by HIV status, were investigated. The majority (n = 164, 67.5%) of enrolled diarrhoeal cases with known HIV status were HIV-infected. Pathogens could be detected in 66.3% (n = 228) of specimens, with significantly higher detection in cases compared to controls (72.8% versus 50.5%, p<0.001). Amongst PLHIV, prevalence of Cystoisospora spp. was significantly higher in cases than controls (17.7% versus 0.0%, p = 0.028), while Schistosoma was detected more often in controls than cases (17.4% versus 2.4%, p = 0.009). Amongst the HIV-uninfected participants, prevalence of Shigella spp., Salmonella spp. and Helicobacter pylori was significantly higher in cases compared to controls (36.7% versus 12.0%, p = 0.002; 11.4% versus 0.0%, p = 0.012; 10.1% versus 0.0%, p = 0.023). Diarrhoeal aetiology differed by HIV status, with Shigella spp. (36.7%) and Salmonella spp. (11.4%) having the highest prevalence amongst HIV-uninfected cases and Shigella spp. (18.3%), Cystoisospora (17.7%), and Cryptosporidium spp. (15.9%) having the highest prevalence in cases amongst PLHIV. These differences should be considered for the development of diagnostic and treatment guidelines.

Copyright: © 2023 Johnstone et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Grants and funding

The ANDEMIA study was supported by the German Federal Ministry of Education and Research (https://www.bmbf.de/bmbf/en/home/home_node.html) [Grant number 81203616] to N.A.P and S.L.J. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.