# Advances in Chronic Kidney Disease in Africa
## 9 What Is New in HIV and CKD in SSA  
In 2020, human immunodeficiency virus (HIV) affected 37.7 million people globally, with 1.5 million new cases during that year. Eastern and SSA had the highest disease burden, with SSA accounting for almost 60% of new infections [89; 90]. In a systematic review and meta-analysis of CKD in an adult cohort with HIV, the overall global prevalence was 6.4%, with the highest prevalence in SSA (7.9%) [21]. The improved longevity on ART has extended the causes of ESKD by increasing the prevalence of traditional CKD risk factors such as diabetes and hypertension [91]. With improved HIV viral suppression, the survival of people with HIV (PWH) receiving kidney replacement therapy (KRT) has been described as being comparable to HIV-negative cohorts, although there have been some conflicting data [92; 93]. In Cameroon, the one-year survival of PWH on maintenance haemodialysis was reported to be lower compared to their HIV negative counterparts, with a two-fold increased risk of death [94]. Registry data throughout SSA are scarce; however, South Africa reported that 13.5% of patients on chronic KRT were PWH in 2019 [95]. This is an underestimate of the true prevalence, as unsuppressed HIV is often an exclusion criterion for maintenance dialysis in the state sector, due to imposed resource constraints. There have now been several studies reporting on a change in the spectrum of kidney disease in PWH since the ART era [96; 97; 98]. As early as 1998, HIVAN was reported to decline in regions with early ART initiatives [99]. South Africa lagged woefully behind, with large-scale roll-out only occurring from 2004. Since then, published biopsy data from South Africa reported a decline in HIVAN, which corresponds with an increase in the proportion of PWH receiving ART at the time of biopsy and an increase in median CD4 cell count [96; 97; 100]. Two recent biopsy series from South Africa also reported an increase in the proportion of biopsies with tubulointerstitial disease [97; 101]. This increase was likely influenced by HIV/TB coinfection, sepsis, and tenofovir exposure, as well as other insults. TB is the most common opportunistic infection seen in PWH. It can affect the kidney in two major ways: firstly, by causing genitourinary TB, and, secondly, in the form of granulomatous interstitial nephritis (GIN). Unfortunately, the COVID-19 pandemic displaced TB improvement targets globally, with an increase in TB deaths [102]. In SSA, the overall estimate of HIV prevalence in TB patients was 31.8% [103]. Autopsy series describing TB involvement in the kidney of PWH in the pre-ART from India, Mexico, and the Cote d'Ivoire reported a frequency of 59%, 23%, and 60%, respectively [104; 105; 106]. ART has also seen the additional challenge of TB immune reconstitution inflammatory syndrome (IRIS) in the kidney in the form of TB-GIN and acute interstitial nephritis [107]. ART re-establishes the host's ability to form granulomatous, often resulting in an intense \"paradoxical\" reaction [108]. The role of the kidney biopsy is particularly important in this cohort due to the multiple pathologies that often coexist providing a role in assisting management decisions. TAF is the next generation tenofovir (TDF) prodrug whose composition has improved stability and allows superior penetrance into cells. Tenofovir diphosphate (TFV-DP) is the active intracellular metabolite for TDF and TAF [109]. Compared with 300 mg TDF, TAF 25 mg showed more potent antiviral activity, higher peripheral blood mononuclear cell (PBMC) intracellular TFV-DP concentrations, and lower plasma tenofovir exposures. This study also demonstrated less proximal tubular injury and a smaller decrease in eGFR compared with TDF [110]. Dolutgeravir (DTG) is a pivotal ART that has become the backbone of several HIV programmes, especially in SSA.