Institut de Recherche pour le Développement, IRD UMI 174, Paris, France.
PLoS One. 2012;7(8):e43375. doi: 10.1371/journal.pone.0043375. Epub 2012 Aug 15.
Data on determinants of long-term disease progression in HIV-infected patients on antiretroviral therapy (ART) are limited in low and middle-income settings.
Effects of current CD4 count, viral load and haemoglobin and diagnosis of AIDS-defining events (ADEs) after start of combination ART (cART) on death and new ADEs were assessed using Poisson regression, in patient aged ≥ 18 years within a multi-centre cohort in Thailand.
Among 1,572 patients, median follow-up from cART initiation was 4.4 (IQR 3.6-6.3) years. The analysis of death was based on 60 events during 6,573 person-years; 30/50 (60%) deaths with underlying cause ascertained were attributable to infections. Analysis of new ADE included 192 events during 5,865 person-years; TB and Pneumocystis jiroveci pneumonia were the most commonly presented first new ADE (35% and 20% of cases, respectively). In multivariable analyses, low current CD4 count after starting cART was the strongest predictor of death and of new ADE. Even at CD4 above 200 cells/mm(3), survival improved steadily with CD4, with mortality rare at ≥ 500 cells/mm(3) (rate 1.1 per 1,000 person-years). Haemoglobin had a strong independent effect, while viral load was weakly predictive with poorer prognosis only observed at ≥ 100,000 copies/ml. Mortality risk increased following diagnosis of ADEs during cART. The decline in mortality rate with duration on cART (from 21.3 per 1,000 person-years within first 6 months to 4.7 per 1,000 person-years at ≥ 36 months) was accounted for by current CD4 count.
Patients with low CD4 count or haemoglobin require more intensive diagnostic and treatment of underlying causes. Maintaining CD4 ≥ 500 cells/mm(3) minimizes mortality. However, patient monitoring could potentially be relaxed at high CD4 count if resources are limited. Optimal ART monitoring strategies in low-income settings remain a research priority. Better understanding of the aetiology of anaemia in patients on ART could guide prevention and treatment.
在接受抗逆转录病毒疗法（ART）的 HIV 感染者中，关于长期疾病进展的决定因素的数据在中低收入国家有限。
使用泊松回归评估当前 CD4 计数、病毒载量和血红蛋白以及组合抗逆转录病毒治疗（cART）开始后 AIDS 定义事件（ADE）的诊断对死亡和新 ADE 的影响，该分析纳入了泰国一个多中心队列中年龄≥18 岁的患者。
在 1572 名患者中，自 cART 开始的中位随访时间为 4.4（IQR 3.6-6.3）年。分析死亡的依据是 60 例事件，共 6573 人年；在确定根本原因的 30/50（60%）死亡中，归因于感染。新 ADE 的分析包括 5865 人年中的 192 例事件；结核病和卡氏肺孢子虫肺炎是最常见的首次新 ADE（分别占 35%和 20%的病例）。在多变量分析中，cART 开始后当前 CD4 计数低是死亡和新 ADE 的最强预测因素。即使 CD4 高于 200 个细胞/mm³，随着 CD4 的增加，生存率也稳步提高，在≥500 个细胞/mm³时死亡率很少（每 1000 人年 1.1 例）。血红蛋白具有很强的独立作用，而病毒载量仅在≥100000 拷贝/ml 时才具有较差的预后。在 cART 期间诊断出 ADE 后，死亡风险增加。随着 cART 持续时间的延长（从最初 6 个月内每 1000 人年 21.3 例降至≥36 个月时每 1000 人年 4.7 例），死亡率下降归因于当前 CD4 计数。
CD4 计数或血红蛋白低的患者需要更积极地治疗潜在病因。维持 CD4≥500 个细胞/mm³可将死亡率降至最低。然而，如果资源有限，在高 CD4 计数时，患者监测可能会得到放松。在低收入国家中，优化 ART 监测策略仍是研究重点。更好地了解接受 ART 治疗的患者贫血的病因有助于指导预防和治疗。
