HIV and CKD in the Tenofovir Era: A Prospective Parallel-Group Cohort Study From Tanzania

Abstract

Rationale & Objective

Longitudinal research on chronic kidney disease (CKD) in sub-Saharan Africa is sparse, especially among people living with HIV (PLWH). We evaluated the incidence of CKD among PLWH compared with HIV-uninfected controls in Tanzania.

Study Design

Prospective cohort study.

Setting & Participants

A total of 495 newly diagnosed PLWH who initiated antiretroviral therapy (ART) and 505 HIV-uninfected adults enrolled from public HIV clinics and followed from 2016-2021. The control group was recruited from HIV treatment partners from the same HIV clinics.

Exposures

Untreated HIV (at baseline), ART, sociodemographic information, health behaviors, hypertension, and diabetes.

Outcomes

Incident CKD, defined as a follow-up estimated glomerular filtration rate (eGFR) of <60 mL/min/1.73 m² with ≥25% reduction from baseline; annual eGFR change; incident albuminuria; 3-year all-cause mortality.

Analytical Approach

Multivariable Poisson and linear regression determined the association between HIV and other factors with a baseline prevalent reduced eGFR and albuminuria, incident CKD and albuminuria, and annual eGFR change. Cox hazard regression assessed the association between baseline CKD and mortality.

Results

Median age was 35 years and 67.5% were women. There were 101 incident CKD cases, 71 among PLWH and 30 among HIV-uninfected participants, equivalent to a CKD incidence of 57.9 per 1,000 person-years (95% CI, 44.4-71.4) and 26.2 per 1,000 person-years (95% CI, 16.8-35.5), respectively. PLWH had a more rapid eGFR decline (−6.65 vs −2.61 mL/min/1.73 m² per year). Female sex and older age were positively associated with incident CKD. Albuminuria incidence did not differ by HIV status. PLWH with albuminuria at baseline had higher mortality (HR, 2.13; 95% CI, 1.08-4.21).

Limitations

As an observational cohort study, there was no comparison group of HIV-positive participants on a nontenofovir disoproxil fumarate–based ART regimen.

Conclusions

PLWH receiving tenofovir disoproxil fumarate–based ART had a very high incidence of CKD and rapid eGFR decline. Conversely, albuminuria stabilized with ART use. Expanding access to less-nephrotoxic ART, such as tenofovir alafenamide, is urgently needed throughout sub-Saharan Africa.

Plain-Language Summary

Managing chronic kidney disease (CKD) among people living with HIV (PLWH) in sub-Saharan Africa is complex owing to resource constraints and sparse longitudinal data. Using a prospective cohort of 495 newly diagnosed PLWH who initiated tenofovir disoproxil fumarate–based antiretroviral therapy (ART) and 505 HIV-uninfected controls in Tanzania, we analyzed CKD incidence based on HIV status. The mean age of participants was 35 years and 67.5% were women. The incidence of CKD was over 2-fold greater among PLWH than among HIV-uninfected participants. PLWH also had a more rapid annual decline in kidney function. The high incidence of CKD among PLWH on tenofovir disoproxil fumarate–based ART indicates that expanding access to less-nephrotoxic ART regimens is warranted throughout sub-Saharan Africa.