Inserm, U897, Epidemiologie-Biostatistiques-Bordeaux, France.
J Acquir Immune Defic Syndr. 2013 Feb 1;62(2):208-19. doi: 10.1097/QAI.0b013e31827b70bf.
We investigated 18-month incidence and determinants of death and loss to follow-up of children after antiretroviral therapy (ART) initiation in a multiregional collaboration in lower-income countries.
HIV-infected children (positive polymerase chain reaction <18 months or positive serology ≥18 months) from International Epidemiologic Databases to Evaluate AIDS cohorts, <16 years, initiating ART were eligible. A competing risk regression model was used to analyze the independent risk of 2 failure types: death and loss to follow-up (>6 months).
Data on 13,611 children, from Asia (N = 1454), East Africa (N = 3114), Southern Africa (N = 6212), and West Africa (N = 2881) contributed 20,417 person-years of follow-up. At 18 months, the adjusted risk of death was 4.3% in East Africa, 5.4% in Asia, 5.7% in Southern Africa, and 7.4% in West Africa (P = 0.01). Age < 24 months, World Health Organization stage 4, CD4 < 10%, attending a private sector clinic, larger cohort size, and living in West Africa were independently associated with poorer survival. The adjusted risk of loss to follow-up was 4.1% in Asia, 9.0% in Southern Africa, 14.0% in East Africa, and 21.8% in West Africa (P < 0.01). Age < 12 months, nonnucleoside reverse transcriptase inhibitor I-based ART regimen, World Health Organization stage 4 at ART start, ART initiation after 2005, attending a public sector or a nonurban clinic, having to pay for laboratory tests or antiretroviral drugs, larger cohort size, and living in East Africa or West Africa were significantly associated with higher loss to follow-up.
Findings differed substantially across regions but raise overall concerns about delayed ART start, low access to free HIV services for children, and increased workload on program retention in lower-income countries. Universal free access to ART services and innovative approaches are urgently needed to improve pediatric outcomes at the program level.
我们在低收入国家的多区域合作中研究了接受抗逆转录病毒治疗（ART）后 18 个月儿童的死亡率和失访率及其决定因素。
本研究纳入了国际艾滋病流行病学数据库评估队列中接受 ART 的年龄<16 岁、感染 HIV 的儿童（18 个月时聚合酶链反应阳性<18 个月或血清学阳性≥18 个月）。使用竞争风险回归模型分析 2 种失败类型（死亡和失访>6 个月）的独立风险。
来自亚洲（N=1454）、东非（N=3114）、南部非洲（N=6212）和西非（N=2881）的 13611 名儿童的数据共提供了 20417 人年的随访。18 个月时，东非、亚洲、南部非洲和西非的死亡调整风险分别为 4.3%、5.4%、5.7%和 7.4%（P=0.01）。年龄<24 个月、世界卫生组织（WHO）分期 4 期、CD4<10%、在私营部门诊所就诊、较大的队列规模以及生活在西非与生存率降低相关。亚洲、南部非洲、东非和西非的失访调整风险分别为 4.1%、9.0%、14.0%和 21.8%（P<0.01）。年龄<12 个月、非核苷类逆转录酶抑制剂为基础的 ART 方案、ART 开始时处于 WHO 分期 4 期、2005 年后开始 ART、在公立部门或非城市诊所就诊、需要支付实验室检测或抗逆转录病毒药物费用、较大的队列规模以及生活在东非或西非与失访风险增加显著相关。
研究结果在不同地区存在很大差异，但总体上对延迟开始 ART、儿童获得免费 HIV 服务的机会有限以及低收入国家方案保留工作负担增加提出了担忧。迫切需要普及免费的 ART 服务和创新方法，以改善儿科结局。
