坦桑尼亚、乌干达和赞比亚抗逆转录病毒治疗项目中成年人的留存率及治疗中断的风险因素。
Retention and risk factors for attrition among adults in antiretroviral treatment programmes in Tanzania, Uganda and Zambia.
作者信息
Koole Olivier, Tsui Sharon, Wabwire-Mangen Fred, Kwesigabo Gideon, Menten Joris, Mulenga Modest, Auld Andrew, Agolory Simon, Mukadi Ya Diul, Colebunders Robert, Bangsberg David R, van Praag Eric, Torpey Kwasi, Williams Seymour, Kaplan Jonathan, Zee Aaron, Denison Julie
机构信息
Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK; Clinical Sciences Department, Institute of Tropical Medicine, Antwerp, Belgium.
出版信息
Trop Med Int Health. 2014 Dec;19(12):1397-410. doi: 10.1111/tmi.12386. Epub 2014 Sep 17.
OBJECTIVES
We assessed retention and predictors of attrition (recorded death or loss to follow-up) in antiretroviral treatment (ART) clinics in Tanzania, Uganda and Zambia.
METHODS
We conducted a retrospective cohort study among adults (≥18 years) starting ART during 2003-2010. We purposefully selected six health facilities per country and randomly selected 250 patients from each facility. Patients who visited clinics at least once during the 90 days before data abstraction were defined as retained. Data on individual and programme level risk factors for attrition were obtained through chart review and clinic manager interviews. Kaplan-Meier curves for retention across sites were created. Predictors of attrition were assessed using a multivariable Cox-proportional hazards model, adjusted for site-level clustering.
RESULTS
From 17 facilities, 4147 patients were included. Retention ranged from 52.0% to 96.2% at 1 year to 25.8%-90.4% at 4 years. Multivariable analysis of ART initiation characteristics found the following independent risk factors for attrition: younger age [adjusted hazard ratio (aHR) and 95% confidence interval (95%CI) = 1.30 (1.14-1.47)], WHO stage 4 ([aHR (95% CI): 1.56 (1.29-1.88)], >10% bodyweight loss [aHR (95%CI) = 1.17 (1.00-1.38)], poor functional status [ambulatory aHR (95%CI) = 1.29 (1.09-1.54); bedridden aHR1.54 (1.15-2.07)], and increasing years of clinic operation prior to ART initiation in government facilities [aHR (95%CI) = 1.17 (1.10-1.23)]. Patients with higher CD4 cell count were less likely to experience attrition [aHR (95%CI) = 0.88 (0.78-1.00)] for every log (tenfold) increase. Sites offering community ART dispensing [aHR (95%CI) = 0.55 (0.30-1.01) for women; 0.40 (0.21-0.75) for men] had significantly less attrition.
CONCLUSIONS
Patient retention to an individual programme worsened over time especially among males, younger persons and those with poor clinical indicators. Community ART drug dispensing programmes could improve retention.
目的
我们评估了坦桑尼亚、乌干达和赞比亚抗逆转录病毒治疗（ART）诊所的留存率及失访（记录的死亡或随访失访）预测因素。
方法
我们对2003年至2010年开始接受ART治疗的成年人（≥18岁）进行了一项回顾性队列研究。我们每个国家特意选择了6家医疗机构，并从每家机构中随机选取250名患者。在数据提取前90天内至少就诊一次诊所的患者被定义为留存患者。通过病历审查和与诊所经理访谈获取了关于失访的个体和项目层面风险因素的数据。创建了各研究点留存率的Kaplan-Meier曲线。使用多变量Cox比例风险模型评估失访的预测因素，并对研究点层面的聚类进行了调整。
结果
来自17家机构的4147名患者被纳入研究。1年时的留存率在52.0%至96.2%之间，4年时在25.8%至90.4%之间。对ART起始特征的多变量分析发现以下失访的独立风险因素：年龄较小[调整后风险比（aHR）及95%置信区间（95%CI）=1.30（1.14 - 1.47）]、世界卫生组织4期[aHR（95%CI）：1.56（1.29 - 1.88）]、体重减轻>10%[aHR（95%CI）=1.17（1.00 - 1.38）]、功能状态较差[能走动者aHR（95%CI）=1.29（1.09 - 1.54）；卧床者aHR=1.54（1.15 - 2.07）]，以及在政府机构中开始接受ART治疗前诊所运营年限增加[aHR（95%CI）=1.17（1.10 - 1.23）]。CD4细胞计数每增加一个对数（十倍），患者失访的可能性就越小[aHR（95%CI）=0.88（0.78 - 1.00）]。提供社区ART药物分发的研究点失访率显著更低[女性aHR（95%CI）=0.55（0.30 - 1.01）；男性aHR（95%CI）=0.40（0.21 - 0.75）]。
结论
随着时间推移，个体项目的患者留存情况恶化，尤其是男性、年轻人和临床指标较差的患者。社区ART药物分发项目可提高留存率。
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