Division of HIV/AIDS, San Francisco General Hospital, Department of Medicine, University of California, San Francisco, CA 94110, USA.
J Acquir Immune Defic Syndr. 2013 Jun 1;63(2):e64-71. doi: 10.1097/QAI.0b013e31828af5a6.
Delays and failures in initiation of antiretroviral therapy (ART) among treatment eligible patients may compromise the effectiveness of HIV care in Africa. An accurate understanding, however, of the pace and completeness of ART initiation and mortality during the waiting period is obscured by frequent losses to follow-up.
We evaluated newly ART-eligible HIV-infected adults from 2007 to 2011 in a prototypical clinic in Mbarara, Uganda. A random sample of patients lost to follow-up was tracked in the community to determine vital status and ART initiation after leaving the original clinic. Outcomes among the tracked patients were incorporated using probability weights, and a competing risks approach was used in analyses.
Among 2633 ART-eligible patients, 490 were lost to follow-up, of whom a random sample of 132 was tracked and 111 (84.0%) had outcomes ascertained. After incorporating the outcomes among the lost, the cumulative incidence of ART initiation at 30, 90, and 365 days after eligibility was 16.0% [95% confidence interval (CI): 14.2 to 17.7], 64.5% (95% CI: 60.9 to 68.1), and 81.7% (95% CI: 77.7 to 85.6). Death before ART was 7.7% at 1 year. Male sex, higher CD4 count, and no education were associated with delayed ART initiation. Lower CD4 level, malnourishment, and travel time to clinic were associated with mortality.
Using a sampling-based approach to account for losses to follow-up revealed that both the speed and the completeness of ART initiation were suboptimal in a prototypical large clinic in Uganda. Improving the kinetics of ART initiation in Africa is needed to make ART more in real-world populations.
在符合治疗条件的患者中，抗逆转录病毒疗法（ART）的启动延迟和失败可能会影响非洲的 HIV 护理效果。然而，由于经常失去随访，人们对启动 ART 和等待期间的死亡率的速度和完整性的准确了解受到了干扰。
我们评估了 2007 年至 2011 年期间乌干达姆巴拉拉一个典型诊所中符合新 ART 条件的 HIV 感染成年患者。对随访中失访的患者进行随机抽样，并在社区中进行追踪，以确定离开原始诊所后的生死和 ART 启动情况。通过概率权重纳入跟踪患者的结果，并在分析中使用竞争风险方法。
在 2633 名符合 ART 条件的患者中，有 490 名失访，其中对随机抽取的 132 名进行了跟踪，有 111 名（84.0%）确定了结果。纳入失访患者的结果后，符合条件后 30、90 和 365 天的 ART 启动累积发生率分别为 16.0%（95%置信区间：14.2 至 17.7）、64.5%（95%置信区间：60.9 至 68.1）和 81.7%（95%置信区间：77.7 至 85.6）。1 年内死亡前 ART 为 7.7%。男性、较高的 CD4 计数和无教育与 ART 启动延迟有关。较低的 CD4 水平、营养不良和前往诊所的时间与死亡率有关。
使用基于抽样的方法来解释随访中的失访情况，发现乌干达一个典型大型诊所中 ART 的启动速度和完整性都不理想。需要改善非洲 ART 的启动动力学，以使 ART 在实际人群中更加有效。
