Clinical HIV Research Unit, Dept of Medicine, University of the Witwatersrand, Johannesburg, South Africa.
J Int AIDS Soc. 2009 Dec 17;12:38. doi: 10.1186/1758-2652-12-38.
Clinical, immunologic and virologic outcomes at large HIV/AIDS care clinics in resource poor settings are poorly described beyond the first year of highly active antiretroviral treatment (HAART). We aimed to prospectively evaluate long-term treatment outcomes at a large scale HIV/AIDS care clinic in South Africa.
Cohort study of patients initiating HAART between April 1, 2004 and March 13, 2007, and followed up until April 1, 2008 at a public HIV/AIDS care clinic in Johannesburg, South Africa. We performed time to event analysis on key treatment outcomes and program impact parameters including mortality, retention in care, CD4 count gain, virologic success and first line regimen durability.
7583 HIV-infected patients initiated care and contributed to 161,000 person months follow up. Overall mortality rate was low (2.9 deaths per 100 person years, 95% CI 2.6-3.2), but high in the first three months of HAART (8.4 per 100 person years, 95% CI 7.2-9.9). Long-term on-site retention in care was relatively high (74.4% at 4 years, 95%CI 73.2-75.6). CD4 count was above 200 cells/mm(3 )after 6 months of treatment in almost all patients. By the fourth year of HAART, the majority (59.6%, 95%CI 57.8-61.4) of patients had at least one first line drug (mainly stavudine) substituted. Women were twice as likely to experience drug substitution (OR 1.97, 95% CI 1.80-2.16). By 6 months of HAART, 90.8% suppressed virus below 400 copies. Among those with initial viral suppression, 9.4% (95% CI 8.5-10.3%) had viral rebound within one year of viral suppression, 16.8% (95% CI 15.5-18.1) within 2 years, and 20.6% (95% CI 18.9-22.4) within 3 years of initial suppression. Only 10% of women and 13% of men initiated second line HAART.
Despite advanced disease presentation and a very large-scale program, high quality care was achieved as indicated by good long-term clinical, immunologic and virologic outcomes and a low rate of second line HAART initiation. High rates of single drug substitution suggest that the public health approach to HAART could be further improved by the use of a more durable first line regimen.
在资源匮乏的环境中，大型艾滋病护理诊所的临床、免疫和病毒学结果在接受高效抗逆转录病毒治疗（HAART）的第一年之后描述得很差。我们旨在前瞻性地评估南非一家大型艾滋病护理诊所的长期治疗结果。
对 2004 年 4 月 1 日至 2007 年 3 月 13 日期间在约翰内斯堡的一家公共艾滋病护理诊所开始接受 HAART 的患者进行队列研究，并随访至 2008 年 4 月 1 日。我们对关键治疗结果和项目影响参数进行了时间事件分析，包括死亡率、护理保留率、CD4 计数增加、病毒学成功和一线方案耐久性。
7583 名 HIV 感染者开始接受治疗，并为 161000 人年的随访做出了贡献。总的死亡率较低（每 100 人年 2.9 例，95%CI 2.6-3.2），但在 HAART 的前三个月较高（每 100 人年 8.4 例，95%CI 7.2-9.9）。长期现场护理保留率相对较高（4 年内为 74.4%，95%CI 73.2-75.6）。几乎所有患者在治疗 6 个月后 CD4 计数均超过 200 个细胞/mm³。到 HAART 的第四年，大多数（59.6%，95%CI 57.8-61.4）患者至少有一种一线药物（主要是司他夫定）被替代。女性发生药物替代的可能性是男性的两倍（OR 1.97，95%CI 1.80-2.16）。到 HAART 治疗 6 个月时，90.8%的病毒受到抑制，低于 400 拷贝。在最初病毒抑制的患者中，有 9.4%（95%CI 8.5-10.3%）在病毒抑制后的一年内出现病毒反弹，16.8%（95%CI 15.5-18.1%）在 2 年内，20.6%（95%CI 18.9-22.4%）在 3 年内。只有 10%的女性和 13%的男性开始使用二线 HAART。
尽管存在晚期疾病表现和大规模的方案，但良好的长期临床、免疫和病毒学结果以及二线 HAART 启动率低表明实现了高质量的护理。单一药物替代率高表明，通过使用更持久的一线方案，可以进一步改进公共卫生对 HAART 的方法。
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