从医生管理的抗逆转录病毒治疗诊所下调至护士管理的基层医疗诊所进行监测和治疗的稳定 HIV 阳性患者的结局。
Outcomes of stable HIV-positive patients down-referred from a doctor-managed antiretroviral therapy clinic to a nurse-managed primary health clinic for monitoring and treatment.
机构信息
Health Economics and Epidemiology Research Office, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.
出版信息
AIDS. 2011 Oct 23;25(16):2027-36. doi: 10.1097/QAD.0b013e32834b6480.
OBJECTIVE
To compare clinical, immunologic and virologic outcomes among stable HIV-positive patients down-referred to a nurse-managed primary healthcare clinic (PHC) for treatment maintenance to those who remained at a doctor-managed treatment-initiation site.
DESIGN
We conducted a matched cohort analysis among stable HIV patients at the Themba Lethu Clinic in Johannesburg, South Africa. Eligible patients met the criteria for down-referral [undetectable viral load <10 months, antiretroviral therapy (ART) >11 months, CD4 cell count ≥200 cells/μl, stable weight and no opportunistic infections], regardless of whether they were down-referred to a PHC for treatment maintenance between February 2008 and January 2009. Patients were matched 1 : 3 (down-referred : treatment-initiation) using propensity scores.
METHODS
We calculated rates and hazard ratios (HRs) for the effect of down-referral on loss to follow-up (LTFU) and mortality and the relative risk of down-referral on viral rebound by 12 months of follow-up.
RESULTS
Six hundred and ninety-three down-referred patients were matched to 2079 treatment-initiation patients. Two (0.3%) down-referred and 32 (1.5%) treatment-initiation patients died, 10 (1.4%) down-referred and 87 (4.2%) treatment-initiation patients were lost, and 22 (3.3%) down-referred and 100 (5.6%) treatment-initiation patients experienced viral rebound by 12 months of follow-up. After adjustment, patients down-referred were less likely to die [hazard ratio (HR) 0.2, 95% confidence interval (CI) 0.04-0.8], become LTFU (HR 0.3, 95% CI 0.2-0.6) or experience viral rebound (relative risk 0.6, 95% CI 0.4-0.9) than treatment-initiation patients during follow-up.
CONCLUSION
The utilization of nurse-managed PHCs for treatment maintenance of stable patients could decrease the burden on specialized doctor-managed ART clinics. Patient outcomes for down-referred patients at PHCs appear equal, if not better, than those achieved at ART clinics among stable patients.
目的
比较稳定的 HIV 阳性患者下调至护士管理的基层医疗诊所（PHC）进行治疗维持与留在医生管理的治疗启动点的患者在临床、免疫和病毒学结局方面的差异。
设计
我们在南非约翰内斯堡的 Themba Lethu 诊所进行了一项稳定的 HIV 患者匹配队列分析。符合下调标准的合格患者[病毒载量不可检测<10 个月，抗逆转录病毒治疗（ART）>11 个月，CD4 细胞计数≥200 个/μl，稳定体重且无机会性感染]，无论他们是否在 2008 年 2 月至 2009 年 1 月期间下调至 PHC 进行治疗维持。使用倾向评分对患者进行 1:3（下调：治疗启动）匹配。
方法
我们计算了下调对失访（LTFU）和死亡率的影响以及 12 个月随访时病毒反弹的下调相对风险的发生率和风险比（HRs）。
结果
693 名下调患者与 2079 名治疗启动患者匹配。两名（0.3%）下调和 32 名（1.5%）治疗启动患者死亡，10 名（1.4%）下调和 87 名（4.2%）治疗启动患者失访，22 名（3.3%）下调和 100 名（5.6%）治疗启动患者在 12 个月的随访中病毒反弹。调整后，下调患者死亡的可能性较低[风险比（HR）0.2，95%置信区间（CI）0.04-0.8]，失访的可能性较低（HR 0.3，95% CI 0.2-0.6）或经历病毒反弹（相对风险 0.6，95% CI 0.4-0.9）比治疗启动患者在随访期间。
结论
利用护士管理的 PHC 进行稳定患者的治疗维持可以减轻专门的医生管理的 ART 诊所的负担。PHC 下调患者的治疗效果似乎与稳定患者的 ART 诊所相当，甚至更好。
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