The Spectrum of HIV‐Associated Kidney Pathology at a Tertiary Centre in South Africa

Aim South Africa has one of the highest prevalences of human immunodeficiency virus (HIV) infection worldwide. Kidney disease is a common and important complication of HIV. This study describes biopsy‐proven kidney pathology in people living with HIV (PLHIV) over 29 years at a South African centre, comparing patterns before and after antiretroviral therapy (ART) rollout. Methods This retrospective descriptive study included PLHIV who underwent native kidney biopsy at Tygerberg Hospital during the period of 1 January 1992 to 31 December 2020. Patients were categorised by biopsy year into a pre‐ART rollout period (before 2004) and a post‐ART rollout period (2004 or later). Results The cohort included 554 PLHIV, mostly biopsied post‐ART rollout (90.1%). Mean age was 36.5 years, with a balanced sex distribution. During the post‐ART period, 54.8% were on ART at biopsy. HIVAN was diagnosed in 45.7%, of which one‐third had an additional histopathological pattern of injury. In the pre‐ART rollout period, HIVAN was the most prevalent diagnosis (60.0%), whereas a lower prevalence was observed post‐ART rollout (44.1%). During the post‐ART rollout period, more than half of patients (55.9%) exhibited only non‐HIVAN kidney pathology, with immune‐complex‐mediated glomerulonephritis (52.7%) and tubulointerstitial disease (39.7%) the most common. Conclusion This study describes the spectrum of kidney pathology in PLHIV at a South African tertiary centre over nearly three decades, highlighting a significant HIVAN burden overall. We observed a lower proportion of patients with HIVAN following ART rollout, coinciding with an increase in non‐HIVAN pathologies like immune complex glomerulonephritis and tubulointerstitial disease.