Johns Hopkins University, Baltimore, Maryland, USA.
Clin Infect Dis. 2013 Apr;56(8):1174-82. doi: 10.1093/cid/cit003. Epub 2013 Jan 11.
Since the mid-1990s, effective antiretroviral therapy (ART) regimens have improved in potency, tolerability, ease of use, and class diversity. We sought to examine trends in treatment initiation and resulting human immunodeficiency virus (HIV) virologic suppression in North America between 2001 and 2009, and demographic and geographic disparities in these outcomes.
We analyzed data on HIV-infected individuals newly clinically eligible for ART (ie, first reported CD4+ count<350 cells/µL or AIDS-defining illness, based on treatment guidelines during the study period) from 17 North American AIDS Cohort Collaboration on Research and Design cohorts. Outcomes included timely ART initiation (within 6 months of eligibility) and virologic suppression (≤500 copies/mL, within 1 year). We examined time trends and considered differences by geographic location, age, sex, transmission risk, race/ethnicity, CD4+ count, and viral load, and documented psychosocial barriers to ART initiation, including non-injection drug abuse, alcohol abuse, and mental illness.
Among 10,692 HIV-infected individuals, the cumulative incidence of 6-month ART initiation increased from 51% in 2001 to 72% in 2009 (Ptrend<.001). The cumulative incidence of 1-year virologic suppression increased from 55% to 81%, and among ART initiators, from 84% to 93% (both Ptrend<.001). A greater number of psychosocial barriers were associated with decreased ART initiation, but not virologic suppression once ART was initiated. We found significant heterogeneity by state or province of residence (P<.001).
In the last decade, timely ART initiation and virologic suppression have greatly improved in North America concurrent with the development of better-tolerated and more potent regimens, but significant barriers to treatment uptake remain, both at the individual level and systemwide.
自 20 世纪 90 年代中期以来，有效的抗逆转录病毒疗法（ART）在疗效、耐受性、易用性和药物种类多样性方面均有所改善。我们旨在研究 2001 年至 2009 年期间北美地区治疗启动的趋势以及由此产生的人类免疫缺陷病毒（HIV）病毒学抑制情况，并分析这些结果的人群和地理差异。
我们分析了来自北美 17 个艾滋病队列协作研究设计队列中临床新符合接受抗逆转录病毒治疗（ART）条件（即根据研究期间的治疗指南，首次报告 CD4+计数<350 个/µL 或出现艾滋病定义性疾病）的 HIV 感染者的数据。结果包括及时开始 ART（在符合条件后 6 个月内）和病毒学抑制（≤500 拷贝/mL，在 1 年内）。我们考察了时间趋势，并考虑了地理位置、年龄、性别、传播风险、种族/民族、CD4+计数和病毒载量的差异，并记录了影响开始 ART 的心理社会障碍，包括非注射吸毒、酗酒和精神疾病。
在 10692 名 HIV 感染者中，6 个月内开始 ART 的累积发生率从 2001 年的 51%增加到 2009 年的 72%（Ptrend<.001）。1 年内病毒学抑制的累积发生率从 55%增加到 81%，而在开始接受 ART 的人群中，从 84%增加到 93%（两者 Ptrend<.001）。更多的心理社会障碍与 ART 开始率降低相关，但与开始 ART 后病毒学抑制无关。我们发现居住地州或省之间存在显著差异（P<.001）。
在过去十年中，随着更耐受和更有效的方案的发展，及时开始 ART 和病毒学抑制在北美地区有了很大改善，但在个人层面和整个系统中，治疗的接受仍然存在重大障碍。
