Epidemiology, Management, and Care of Hospitalised People Living with HIV at MRC Unit The Gambia at LSHTM: A Retrospective Study

The Medical Research Council Unit The Gambia (MRCG) at the London School of Hygiene and Tropical Medicine (LSHTM) is a leading centre for biomedical research in West Africa. Within MRCG, the Clinical Services Department (CSD) delivers healthcare to local populations while supporting clinical research, it operates in a context of constrained resources, with limited diagnostic tools and therapeutic options. People living with HIV (PLHIV) represent a clinically vulnerable subgroup of CSD admissions. These patients are frequently hospitalised with complications of advanced HIV infection, most commonly pneumonia, bacteraemia, opportunistic infections such as tuberculosis, cryptococcal meningitis, or Pneumocystis pneumonia. In The Gambia — an economically constrained lower-middle-income country with a population of about 2.4 million and a predominantly young demographic — the burden of HIV remains modest compared to other sub-Saharan African nations. According to 2024 UNAIDS estimates, the adult HIV prevalence is 1.3% [1.0-1.6], with approximately 25,000 PLHIV. Yet, significant challenges persist across the HIV care cascade: stigma remains deeply rooted, awareness of HIV status among PLHIV is estimated at 64%, antiretroviral therapy (ART) coverage reaches just 44%, and viral suppression rates remain far below global targets, at 35%. At the continental level, sub-Saharan Africa continues to bear the greatest global burden of HIV and despite significant advances in ART that have transformed HIV into a manageable chronic condition, a substantial number of people still progress to advanced HIV disease. As highlighted in recent literature, current global targets have shifted their focus toward the number of people tested, initiated on treatment, and achieving viral suppression. Consequently, reducing mortality is no longer a central metric. Advanced HIV can therefore be regarded as a neglected disease, with limited attention given to the consistent use of existing tools or the development of new interventions to prevent AIDS-related deaths. This underscores the importance of ensuring that MRCG CSD is adequately equipped to support patients with advanced disease who require hospital-based care, thereby avoiding preventable morbidity and mortality. This thesis provides a comprehensive analysis of the clinical and social background of HIV-positive patients admitted to the CSD. It characterises symptoms and indicators of HIV disease among patients accessing the clinic, the range of opportunistic infections, evaluates baseline laboratory markers including CD4 count and organ function, and examines social determinants such as age, sex, socioeconomic background, and access to social support. Outcomes assessed include in-hospital mortality, duration of admission, recovery trajectories, and post-discharge follow-up where available. By combining epidemiological data with clinical and social variables, the study offers an integrated perspective on the factors shaping HIV morbidity and mortality in a resource-limited setting. The overarching aim is to evaluate the quality of care provided to PLHIV at MRCG, benchmarking observed practices and outcomes against MRCG internal guidelines as well as national and international standards. By analysing patterns of admission, identifying predictors of poor prognosis, and assessing adherence to recommended standards of HIV management, this work contributes valuable insights into the realities of HIV care in The Gambia. Ultimately, the findings are intended to inform improvements in clinical practice, guide resource allocation, and support evidence-based policy, not only locally but also across comparable health systems in sub-Saharan Africa that continue to face the dual challenges of constrained resources and rising demand for high-quality HIV care.