Risk Factors for Coronavirus Disease 2019 (COVID-19) Death in a Population Cohort Study from the Western Cape Province, South Africa
Andrew Boulle, Mary‐Ann Davies, Hannah Hussey, Muzzammil Ismail, Erna Morden, Ziyanda Vundle, Virginia Zweigenthal, Hassan Mahomed, Masudah Paleker, David Pienaar, Yamanya Tembo, Charlene Lawrence, Washiefa Isaacs, Hlengani Mathema, Derick Allen, Taryn Allie, Jamy‐Lee Bam, Kasturi Buddiga, Pierre Dane, Alexa Heekes, Boitumelo Matlapeng, Themba Mutemaringa, Luckmore Muzarabani, Florence Phelanyane, R. Pienaar, Catherine Rode, Mariette Smith, Nicki Tiffin, Nesbert Zinyakatira, Carol Cragg, Frederick Marais, Vanessa Mudaly, Jacqueline Voget, Jody Davids, F Roodt, Nellis van Zyl Smit, Alda Vermeulen, Kevin Adams, Gordon Audley, Kathleen Bateman, Peter Beckwith, M. Bernon, Dirk Blom, Linda Boloko, Jean Botha, Adam Boutall, S. Burmeister, Lydia Cairncross, Greg Calligaro, Cecilia Coccia, Chadwin Corin, Remy Daroowala, Joel A. Dave, Elsa Du Bruyn, Martin De Villiers, Mimi Deetlefs, Sipho Dlamini, Thomas Du Toit, Wilhelm Endres, Tarin A. Europa, Graham Fieggan, Anthony Figaji, Petro Frankenfeld, Elizabeth Gatley, Phindile Gina, Evashan Govender, Rochelle Grobler, M. V. Gule, Christoff Hanekom, Michael Held, Alana Heynes, Sabelo Hlatswayo, Bridget Hodkinson, J. A. Holtzhausen, Shakeel Hoosain, Ashely Jacobs, Miriam Kahn, Thania Kahn, Arvin Khamajeet, Joubin Khan, Riaasat Khan, Alicia Khululwa Khwitshana, Lauren Knight, Sharita Kooverjee, Rene Krogscheepers, Jean Jacque Kruger, Suzanne Kuhn, Kim Laubscher, J. Michael Lazarus, Jacque Le Roux, Scott Lee Jones, Dion Levin, Gary Maartens, Thina Majola, Rodgers Manganyi, David Marais, Suzaan Marais, F J Maritz, Deborah Maughan, Simthandile Mazondwa
Abstract
BACKGROUND: Risk factors for coronavirus disease 2019 (COVID-19) death in sub-Saharan Africa and the effects of human immunodeficiency virus (HIV) and tuberculosis on COVID-19 outcomes are unknown. METHODS: We conducted a population cohort study using linked data from adults attending public-sector health facilities in the Western Cape, South Africa. We used Cox proportional hazards models, adjusted for age, sex, location, and comorbidities, to examine the associations between HIV, tuberculosis, and COVID-19 death from 1 March to 9 June 2020 among (1) public-sector "active patients" (≥1 visit in the 3 years before March 2020); (2) laboratory-diagnosed COVID-19 cases; and (3) hospitalized COVID-19 cases. We calculated the standardized mortality ratio (SMR) for COVID-19, comparing adults living with and without HIV using modeled population estimates. RESULTS: Among 3 460 932 patients (16% living with HIV), 22 308 were diagnosed with COVID-19, of whom 625 died. COVID-19 death was associated with male sex, increasing age, diabetes, hypertension, and chronic kidney disease. HIV was associated with COVID-19 mortality (adjusted hazard ratio [aHR], 2.14; 95% confidence interval [CI], 1.70-2.70), with similar risks across strata of viral loads and immunosuppression. Current and previous diagnoses of tuberculosis were associated with COVID-19 death (aHR, 2.70 [95% CI, 1.81-4.04] and 1.51 [95% CI, 1.18-1.93], respectively). The SMR for COVID-19 death associated with HIV was 2.39 (95% CI, 1.96-2.86); population attributable fraction 8.5% (95% CI, 6.1-11.1). CONCLUSIONS: While our findings may overestimate HIV- and tuberculosis-associated COVID-19 mortality risks due to residual confounding, both living with HIV and having current tuberculosis were independently associated with increased COVID-19 mortality. The associations between age, sex, and other comorbidities and COVID-19 mortality were similar to those in other settings.