莫桑比克农村地区接受抗逆转录病毒治疗的HIV感染儿童临床结局不佳：需要提高项目质量并促进社区参与。
Poor clinical outcomes for HIV infected children on antiretroviral therapy in rural Mozambique: need for program quality improvement and community engagement.
作者信息
Vermund Sten H, Blevins Meridith, Moon Troy D, José Eurico, Moiane Linda, Tique José A, Sidat Mohsin, Ciampa Philip J, Shepherd Bryan E, Vaz Lara M E
机构信息
Vanderbilt Institute for Global Health, Vanderbilt University School of Medicine, Nashville, Tennessee, United States of America; Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, Tennessee, United States of America; Friends in Global Health, Quelimane and Maputo, Mozambique.
Vanderbilt Institute for Global Health, Vanderbilt University School of Medicine, Nashville, Tennessee, United States of America; Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, Tennessee, United States of America.
出版信息
PLoS One. 2014 Oct 20;9(10):e110116. doi: 10.1371/journal.pone.0110116. eCollection 2014.
INTRODUCTION
Residents of Zambézia Province, Mozambique live from rural subsistence farming and fishing. The 2009 provincial HIV prevalence for adults 15-49 years was 12.6%, higher among women (15.3%) than men (8.9%). We reviewed clinical data to assess outcomes for HIV-infected children on combination antiretroviral therapy (cART) in a highly resource-limited setting.
METHODS
We studied rates of 2-year mortality and loss to follow-up (LTFU) for children <15 years of age initiating cART between June 2006-July 2011 in 10 rural districts. National guidelines define LTFU as >60 days following last-scheduled medication pickup. Kaplan-Meier estimates to compute mortality assumed non-informative censoring. Cumulative LTFU incidence calculations treated death as a competing risk.
RESULTS
Of 753 children, 29.0% (95% CI: 24.5, 33.2) were confirmed dead by 2 years and 39.0% (95% CI: 34.8, 42.9) were LTFU with unknown clinical outcomes. The cohort mortality rate was 8.4% (95% CI: 6.3, 10.4) after 90 days on cART and 19.2% (95% CI: 16.0, 22.3) after 365 days. Higher hemoglobin at cART initiation was associated with being alive and on cART at 2 years (alive: 9.3 g/dL vs. dead or LTFU: 8.3-8.4 g/dL, p<0.01). Cotrimoxazole use within 90 days of ART initiation was associated with improved 2-year outcomes Treatment was initiated late (WHO stage III/IV) among 48% of the children with WHO stage recorded in their records. Marked heterogeneity in outcomes by district was noted (p<0.001).
CONCLUSIONS
We found poor clinical and programmatic outcomes among children taking cART in rural Mozambique. Expanded testing, early infant diagnosis, counseling/support services, case finding, and outreach are insufficiently implemented. Our quality improvement efforts seek to better link pregnancy and HIV services, expand coverage and timeliness of infant diagnosis and treatment, and increase follow-up and adherence.
引言
莫桑比克赞比西亚省的居民以农村自给农业和渔业为生。2009年该省15 - 49岁成年人的艾滋病毒流行率为12.6%，女性（15.3%）高于男性（8.9%）。我们回顾了临床数据，以评估在资源极度有限的环境中接受联合抗逆转录病毒疗法（cART）的艾滋病毒感染儿童的治疗结果。
方法
我们研究了2006年6月至2011年7月期间在10个农村地区开始接受cART治疗的15岁以下儿童的2年死亡率和失访率。国家指南将失访定义为自上次预定取药后超过60天。采用Kaplan - Meier估计法计算死亡率，假定为非信息性删失。累积失访率计算将死亡视为竞争风险。
结果
在753名儿童中，到2年时29.0%（95%置信区间：24.5，33.2）被确认死亡，39.0%（95%置信区间：34.8，42.9）失访，临床结局未知。队列在接受cART治疗90天后的死亡率为8.4%（95%置信区间：6.3，10.4），365天后为19.2%（95%置信区间：16.0，22.3）。开始接受cART治疗时血红蛋白水平较高与2年时存活且仍在接受cART治疗相关（存活：9.3 g/dL，死亡或失访：8.3 - 8.4 g/dL，p<0.01）。在开始抗逆转录病毒治疗后90天内使用复方新诺明与2年结局改善相关。在有记录的世界卫生组织分期的儿童中，48%的儿童开始治疗较晚（世界卫生组织III/IV期）。各地区的结局存在显著异质性（p<0.001）。
结论
我们发现莫桑比克农村地区接受cART治疗的儿童临床和项目结局较差。扩大检测、早期婴儿诊断、咨询/支持服务、病例发现和外展工作的实施力度不足。我们的质量改进工作旨在更好地衔接妊娠和艾滋病毒服务，扩大婴儿诊断和治疗的覆盖范围和及时性，并加强随访和依从性。
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