Duber Herbert C, Dansereau Emily, Masters Samuel H, Achan Jane, Burstein Roy, DeCenso Brendan, Gasasira Anne, Ikilezi Gloria, Kisia Caroline, Masiye Felix, Njuguna Pamela, Odeny Thomas, Okiro Emelda, Roberts D Allen, Gakidou Emmanuela
Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, United States of America.
Infectious Disease Research Collaboration, Makerere University, Kampala, Uganda.
PLoS One. 2015 Mar 25;10(3):e0120350. doi: 10.1371/journal.pone.0120350. eCollection 2015.
Antiretroviral therapy (ART) guidelines were significantly changed by the World Health Organization in 2010. It is largely unknown to what extent these guidelines were adopted into clinical practice.
This was a retrospective observational analysis of first-line ART regimens in a sample of health facilities providing ART in Kenya, Uganda, and Zambia between 2007-2008 and 2011-2012. Data were analyzed for changes in regimen over time and assessed for key patient- and facility-level determinants of tenofovir (TDF) utilization in Kenya and Uganda using a mixed effects model.
Data were obtained from 29,507 patients from 146 facilities. The overall percentage of patients initiated on TDF-based therapy increased between 2007-2008 and 2011-2012 from 3% to 37% in Kenya, 2% to 34% in Uganda, and 64% to 87% in Zambia. A simultaneous decrease in stavudine (d4T) utilization was also noted, but its use was not eliminated, and there remained significant variation in facility prescribing patterns. For patients initiating ART in 2011-2012, we found increased odds of TDF use with more advanced disease at initiation in both Kenya (odds ratio [OR]: 2.78; 95% confidence interval [CI]: 1.73-4.48) and Uganda (OR: 2.15; 95% CI: 1.46-3.17). Having a CD4 test performed at initiation was also a significant predictor in Uganda (OR: 1.43; 95% CI: 1.16-1.76). No facility-level determinants of TDF utilization were seen in Kenya, but private facilities (OR: 2.86; 95% CI: 1.45-5.66) and those employing a doctor (OR: 2.86; 95% CI: 1.48-5.51) were more likely to initiate patients on TDF in Uganda.
d4T-based ART has largely been phased out over the study period. However, significant in-country and cross-country variation exists. Among the most recently initiated patients, those with more advanced disease at initiation were most likely to start TDF-based treatment. No facility-level determinants were consistent across countries to explain the observed facility-level variation.
2010年，世界卫生组织对抗逆转录病毒疗法（ART）指南进行了重大修订。目前尚不清楚这些指南在多大程度上被应用于临床实践。
这是一项回顾性观察分析，研究对象为2007 - 2008年和2011 - 2012年间肯尼亚、乌干达和赞比亚提供抗逆转录病毒疗法的部分医疗机构中的一线抗逆转录病毒治疗方案。分析了治疗方案随时间的变化情况，并使用混合效应模型评估了肯尼亚和乌干达替诺福韦（TDF）使用的关键患者和机构层面决定因素。
数据来自146个医疗机构的29507名患者。在2007 - 2008年至2011 - 2012年间，肯尼亚开始接受基于TDF治疗的患者总体百分比从3%增至37%，乌干达从2%增至34%，赞比亚从64%增至87%。同时，司他夫定（d4T）的使用也有所减少，但其使用并未消除，各机构的处方模式仍存在显著差异。对于2011 - 2012年开始接受抗逆转录病毒治疗的患者，我们发现，在肯尼亚（比值比[OR]：2.78；95%置信区间[CI]：1.73 - 4.48）和乌干达（OR：2.15；95% CI：1.46 - 3.17），疾病进展程度越高的患者开始使用TDF的几率越高。在乌干达，治疗开始时进行CD4检测也是一个显著的预测因素（OR：1.43；95% CI：1.16 - 1.76）。在肯尼亚未发现机构层面TDF使用的决定因素，但在乌干达，私立机构（OR：2.86；95% CI：1.45 - 5.66）和雇佣医生的机构（OR：2.86；95% CI：1.48 - 5.51）让患者开始使用TDF的可能性更大。
在研究期间，基于d4T的抗逆转录病毒疗法已基本淘汰。然而，在国内和国家之间仍存在显著差异。在最近开始治疗的患者中，治疗开始时疾病进展程度越高的患者最有可能开始基于TDF的治疗。各国之间不存在一致的机构层面决定因素来解释观察到的机构层面差异。
