Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK.
Karonga Prevention Study, Chilumba, Malawi.
J Acquir Immune Defic Syndr. 2014 Sep 1;67(1):e27-e33. doi: 10.1097/QAI.0000000000000252.
Patient retention in antiretroviral therapy (ART) programs remains a major challenge in sub-Saharan Africa. We examined whether and why retention in ART care has changed with increasing access.
Retrospective cohort study combining individual data from ART registers and interview data, enabling us to link patients across different ART clinics in Karonga District, Malawi. We recorded information on all adults (≥15 years) starting ART between July 2005 and August 2012, including those initiating due to pregnancy and breastfeeding (Option B+). Retention in care was defined as being alive and receiving ART at the end of study. Predictors of attrition were assessed using a multivariable Cox proportional hazards model.
The number of clinics providing ART increased from 1 in 2005 to 16 in 2012. Six-month retention increased from 73% [95% confidence interval (CI): 71 to 76] to 93% (95% CI: 92 to 94) when comparing the 2005-2006 and 2011-2012 cohorts, and 12-month retention increased from 70% (95% CI: 67 to 73) to 92% (95% CI: 90 to 93). Over the study period, the proportion of patients starting ART at World Health Organization stage 4 declined from 62% to 10%. Being a man, younger than 35 years, having a more advanced World Health Organization stage and being part of an earlier cohort were all independently associated with attrition. Women starting ART for Option B+ experienced higher attrition than women of childbearing age starting for other reasons.
In this area, retention in care has increased dramatically. Improved health in patients starting ART and decentralization of ART care to peripheral health centers seem to be the major drivers for this change.
在撒哈拉以南非洲，患者在抗逆转录病毒疗法（ART）方案中的保留仍然是一个主要挑战。我们研究了随着获得途径的增加，保留在 ART 护理中的情况是否发生了变化以及为什么会发生这种变化。
这是一项回顾性队列研究，结合了来自 ART 登记处的个人数据和访谈数据，使我们能够将马拉维卡拉翁加区不同 ART 诊所的患者联系起来。我们记录了所有 2005 年 7 月至 2012 年 8 月期间开始接受 ART 的成年人（≥15 岁）的信息，包括因怀孕和哺乳期而开始接受治疗的患者（B+方案）。保留护理的定义是在研究结束时仍然活着并接受 ART。使用多变量 Cox 比例风险模型评估了流失的预测因素。
提供 ART 的诊所数量从 2005 年的 1 个增加到 2012 年的 16 个。与 2005-2006 年和 2011-2012 年的队列相比，6 个月保留率从 73%[95%置信区间（CI）：71 至 76]增加到 93%（95% CI：92 至 94），12 个月保留率从 70%（95% CI：67 至 73）增加到 92%（95% CI：90 至 93）。在研究期间，开始接受世卫组织第 4 阶段治疗的患者比例从 62%下降到 10%。男性、年龄小于 35 岁、更严重的世卫组织阶段和属于较早的队列都是与流失独立相关的因素。因 B+方案开始接受 ART 的女性比因其他原因开始接受 ART 的育龄女性的流失率更高。
在这一地区，护理保留率显著提高。开始接受 ART 的患者健康状况的改善以及 ART 护理向周边保健中心的分散似乎是这一变化的主要驱动因素。
