Kesselring S, Cescon A, Colley G, Osborne C, Zhang W, Raboud J M, Hosein S R, Burchell A N, Cooper C, Klein M B, Loutfy M, Machouf N, Montaner Jsg, Rachlis A, Tsoukas C, Hogg R S, Lima V D
British Columbia Centre for Excellence in HIV/AIDS, Vancouver, BC, Canada.
Northern Ontario School of Medicine, Sudbury, ON, Canada.
HIV Med. 2017 Mar;18(3):151-160. doi: 10.1111/hiv.12409. Epub 2016 Jul 6.
To document the quality of initial HIV care in Canada using the Programmatic Compliance Score (PCS), to explore the association of the PCS with mortality, and to identify factors associated with higher quality of care.
We analysed data from the Canadian Observational Cohort Collaboration (CANOC), a multisite Canadian cohort of HIV-positive adults initiating combination antiretroviral therapy (ART) from 2000 to 2011. PCS indicators of noncompliance with HIV treatment guidelines include: fewer than three CD4 count tests in the first year of ART; fewer than three viral load tests in the first year of ART; no drug resistance testing before initiation; baseline CD4 count < 200 cells/mm ; starting a nonrecommended ART regimen; and not achieving viral suppression within 6 months of initiation. Indicators are summed for a score from 0 to 6; higher scores indicate poorer care. Cox regression was used to assess the association between PCS and mortality and ordinal logistic regression was used to explore factors associated with higher quality of care.
Of the 7460 participants (18% female), the median score was 1.0 (Q1-Q3 1.0-2.0); 21% scored 0 and 8% scored ≥ 4. In multivariable analysis, compared with a score of 0, poorer PCS was associated with mortality for scores > 1 [score = 2: adjusted hazard ratio (AHR) 1.64; 95% confidence interval (CI) 1.13-2.36; score = 3: AHR 2.02; 95% CI 1.38-2.97; score ≥ 4: AHR 2.14; 95% CI 1.43-3.21], after adjustments for age, sex, province, ART start year, hepatitis C virus (HCV) coinfection, and baseline viral load. Women, individuals with HCV coinfection, younger people, and individuals starting ART earlier (2000-2003) had poorer scores.
Our findings further validate the PCS as a predictor of all-cause mortality. Disparities identified suggest that further efforts are needed to ensure that care is equitably accessible.
使用项目合规评分（PCS）记录加拿大初始HIV护理的质量，探讨PCS与死亡率之间的关联，并确定与更高护理质量相关的因素。
我们分析了加拿大观察性队列合作研究（CANOC）的数据，这是一个加拿大多中心队列，研究对象为2000年至2011年开始接受联合抗逆转录病毒治疗（ART）的HIV阳性成年人。不符合HIV治疗指南的PCS指标包括：ART第一年CD4细胞计数检测少于3次；ART第一年病毒载量检测少于3次；开始治疗前未进行耐药性检测；基线CD4细胞计数<200个/立方毫米；开始使用不推荐的ART方案；以及开始治疗后6个月内未实现病毒抑制。各项指标相加得到0至6分的评分；分数越高表明护理质量越差。使用Cox回归评估PCS与死亡率之间的关联，并使用有序逻辑回归探讨与更高护理质量相关的因素。
在7460名参与者中（18%为女性），中位数评分为1.0（第一四分位数至第三四分位数为 1.0 - 2.0）；21%的人得分为0，8%的人得分≥4。在多变量分析中，与得分为0相比，PCS较差与得分>1时的死亡率相关[得分=2：调整后风险比（AHR）1.64；95%置信区间（CI）1.13 - 2.36；得分=3：AHR 2.02；95%CI 1.38 - 2.97；得分≥4：AHR 2.14；95%CI 1.43 - 3.21]，在对年龄、性别、省份、ART开始年份、丙型肝炎病毒（HCV）合并感染和基线病毒载量进行调整后。女性、HCV合并感染个体、年轻人以及更早开始ART（2000 - 2003年）的个体得分较差。
我们的研究结果进一步验证了PCS作为全因死亡率预测指标的有效性。发现的差异表明需要进一步努力以确保公平获得护理。
