Grimsrud Anna, Balkan Suna, Casas Esther C, Lujan Johnny, Van Cutsem Gilles, Poulet Elisabeth, Myer Landon, Pujades-Rodriguez Mar
*Division of Epidemiology & Biostatistics, School of Public Health & Family Medicine, University of Cape Town, Cape Town, South Africa; †Médecins Sans Frontières, Paris, France; ‡Médecins Sans Frontières, Amsterdam, Netherlands; §Médecins Sans Frontières, Geneva, Switzerland; ‖Médecins Sans Frontières, Cape Town, South Africa; ¶Epicentre, Paris, France; #Epicentre-Médecins Sans Frontières, Paris, France; and **University College London, London, United Kingdom.
J Acquir Immune Defic Syndr. 2014 Oct 1;67(2):e55-66. doi: 10.1097/QAI.0000000000000268.
Little is known about the evolution of program outcomes associated with rapid expansion of antiretroviral therapy (ART) in resource-limited settings. We describe temporal trends and assess associations with mortality and loss to follow-up (LTFU) in HIV cohorts from 8 countries.
Multicohort study using electronic health records.
Analysis included adults in 25 Médecins Sans Frontières-supported programs initiating ART between 2001 and 2011. Kaplan-Meier methods were used to describe time to death or LTFU and proportional hazards models to assess associations with individual and program factors.
ART programs (n = 132,334, median age 35 years, 61% female) expanded rapidly. Whereas 36-month mortality decreased from 22% to 9% over 5 years (≤2003-2008), LTFU increased from 11% to 21%. Hazard ratios (HR) of early (0-12 months) and late (12-72 months) LTFU increased over time, from 1.09 [95% confidence interval (CI): 0.83 to 1.43] and 1.04 (95% CI: 0.84 to 1.28) in 2004 to 3.29 (95% CI: 2.42 to 4.46) and 6.86 (95% CI: 4.94 to 9.53) in 2011, compared with 2001-2003. Rate of program expansion was strongly associated with increased early and late LTFU, adjusted HR (aHR) = 2.31 (95% CI: 1.78 to 3.01) and HR = 2.29 (95% CI: 1.76 to 2.99), respectively, for ≥125 vs. 0-24 patients per month. Larger program size was associated with decreased early mortality (aHR = 0.49, 95% CI: 0.31 to 0.77 for ≥20,000 vs. <500 patients) and increased early LTFU (aHR = 1.77, 95% CI: 1.04 to 3.04 for ≥20,000 vs. <500 patients).
As ART expands in resource-limited settings, challenges remain in improving access to ART and preventing program attrition. There is an urgent need for novel and sustainable models of care to increase long-term retention of patients.
在资源有限的环境中，与抗逆转录病毒疗法（ART）迅速推广相关的项目成果演变情况鲜为人知。我们描述了来自8个国家的HIV队列的时间趋势，并评估了与死亡率和失访（LTFU）的关联。
使用电子健康记录的多队列研究。
分析纳入了2001年至2011年间在无国界医生组织支持的25个项目中开始接受ART的成年人。采用Kaplan-Meier方法描述死亡或失访时间，并使用比例风险模型评估与个体和项目因素的关联。
ART项目（n = 132,334，中位年龄35岁，61%为女性）迅速扩张。在5年期间（≤2003 - 2008年），36个月死亡率从22%降至9%，而失访率从11%升至21%。早期（0 - 12个月）和晚期（12 - 72个月）失访的风险比（HR）随时间增加，与2001 - 2003年相比，2004年时分别为1.09 [95%置信区间（CI）：0.83至1.43]和1.04（95%CI：0.84至1.28），到2011年时分别为3.29（95%CI：2.42至4.46）和6.86（95%CI：4.94至9.53）。项目扩张率与早期和晚期失访增加密切相关，每月≥125名患者与0 - 24名患者相比，调整后风险比（aHR）分别为2.31（95%CI：1.78至3.01）和HR = 2.29（95%CI：1.76至2.99）。项目规模较大与早期死亡率降低相关（≥20,000名患者与<500名患者相比，aHR = 0.49，95%CI：0.31至0.77），但与早期失访增加相关（≥20,000名患者与<500名患者相比，aHR = 1.77，95%CI：1.04至3.04）。
随着ART在资源有限的环境中推广，在改善ART可及性和防止项目减员方面仍存在挑战。迫切需要新颖且可持续的护理模式以提高患者的长期留存率。
