Fairfield K M, Libman H, Davis R B, Eisenberg D M
Division of General Medicine and Primary Care, Department of Medicine, Beth Israel Deaconess Medical Center, and Harvard Medical School, Boston, Mass. 02215, USA.
J Gen Intern Med. 1999 Jul;14(7):395-401. doi: 10.1046/j.1525-1497.1999.08198.x.
To determine the clinical factors associated with delayed protease inhibitor initiation.
Chart review and telephone survey.
General medicine practice at an academic medical center in Boston, Mass.
One hundred ninety patients living with HIV and a viral load of more than 10,000 copies/ml.
The main outcome measurement was time to first protease inhibitor prescription after first elevated HIV viral load (>10,000 copies/ml). In this cohort, 190 patients had an elevated viral load (median age 39; 87% male; 12% history of injection drug use; 63% AIDS; 53% with depression; 17% history of pneumocystis pneumonia; 54% CD4 <200). In Cox proportional hazards modeling, significant univariate correlates for delayed protease inhibitor initiation were higher CD4 cell count (hazard ratio [HR] 2. 38 for CD4 200-500 compared with <200, 95% confidence interval [CI] 1.59, 3.57; and HR 8.33 for CD4> 500; 95% CI 2.63, 25.0), higher viral load (HR 0.43 for each 10-fold increase; 95% CI 0.31, 0.59), injection drug use (HR 2.08; 95% CI 1.05, 4.17), AIDS (HR 0.24; 95% CI 0.15, 0.36), and history of pneumocystis pneumonia (HR 0.32; 95% CI 0.21, 0.49). In multivariate models adjusted for secular trends in protease inhibitor use, factors significantly associated with delay of protease inhibitor initiation (p <.05) were higher CD4 cell count (for CD4 200-500, HR 2.63; 95% CI 1.61, 4.17; for CD4> 500, HR 11.11; 95% CI 3.57, 33.33), higher viral load (HR 0.66 for each 10-fold increase; 95% CI 0.45, 0.98), history of pneumocystis pneumonia (HR 0.57; 95% CI 0.37, 0.90), history of depression (HR 1. 49; 95% CI 1.03, 2.13), and history of injection drug use (HR 2.70; 95% CI 1.35, 5.56).
HIV-infected patients with higher CD4 cell counts or a history of depression or history of injection drug use have significant and lengthy delays of protease inhibitor therapy. Although some delays may be clinically appropriate, enhancement of provider and patient education might prove beneficial. Further research should examine reasons for delays in protease inhibitor initiation and their appropriateness.
确定与蛋白酶抑制剂起始延迟相关的临床因素。
病历回顾和电话调查。
马萨诸塞州波士顿一所学术医疗中心的普通内科诊所。
190例HIV感染者，病毒载量超过10,000拷贝/毫升。
主要结局指标为首次HIV病毒载量升高（>10,000拷贝/毫升）后至首次开具蛋白酶抑制剂处方的时间。在该队列中，190例患者病毒载量升高（中位年龄39岁；87%为男性；12%有注射吸毒史；63%患有艾滋病；53%患有抑郁症；17%有肺孢子菌肺炎病史；54%的CD4细胞计数<200）。在Cox比例风险模型中，蛋白酶抑制剂起始延迟的显著单因素相关因素为较高的CD4细胞计数（CD4 200 - 500时的风险比[HR]为2.38，而CD4<200时为1.59, 3.57；CD4>500时HR为8.33；95%置信区间[CI]为2.63, 25.0）、较高的病毒载量（每增加10倍HR为0.43；95% CI为0.31, 0.59）、注射吸毒史（HR为2.08；95% CI为1.05, 4.17）、艾滋病（HR为0.24；95% CI为0.15, 0.36）以及肺孢子菌肺炎病史（HR为0.32；95% CI为0.21, 0.49）。在针对蛋白酶抑制剂使用的长期趋势进行调整的多变量模型中，与蛋白酶抑制剂起始延迟显著相关（p<.05）的因素为较高的CD4细胞计数（CD4 200 - 500时，HR为2.63；95% CI为1.61, 4.17；CD4>500时，HR为11.11；95% CI为3.57, 33.33）、较高的病毒载量（每增加10倍HR为0.66；95% CI为0.45, 0.98）、肺孢子菌肺炎病史（HR为0.57；95% CI为0.37, 0.90）、抑郁症病史（HR为1.49；95% CI为1.03, 2.13）以及注射吸毒史（HR为2.70；95% CI为1.35, 5.56）。
CD4细胞计数较高、有抑郁症病史或注射吸毒史的HIV感染患者在蛋白酶抑制剂治疗方面存在显著且长时间的延迟。尽管某些延迟在临床上可能是合适的，但加强医护人员和患者教育可能会有帮助。进一步的研究应探讨蛋白酶抑制剂起始延迟的原因及其合理性。
