Sabin Caroline A, Howarth Alison, Jose Sophie, Hill Teresa, Apea Vanessa, Morris Steve, Burns Fiona
aResearch Department of Infection and Population Health, University College London bNational Institute for Health Research Health Protection Research Unit (NIHR HPRU) in Blood Borne and Sexually Transmitted Infections at University College London cBarts Health NHS Trust dDepartment of Applied Health Research, University College London eRoyal Free London NHS Foundation Trust, London, UK.
AIDS. 2017 Mar 13;31(5):653-660. doi: 10.1097/QAD.0000000000001373.
To assess associations between engagement in-care and future mortality.
UK-based observational cohort study.
HIV-positive participants with more than one visit after 1 January 2000 were identified. Each person-month was classified as being in or out-of-care based on the dates of the expected and observed next care visits. Cox models investigated associations between mortality and the cumulative proportion of months spent in-care (% IC, lagged by 1 year), and cumulative %IC prior to antiretroviral therapy (ART) in those attending clinic for more than 1 year, with adjustment for age, CD4/viral load, year, sex, infection mode, ethnicity, and receipt/type of ART.
The 44 432 individuals (27.8% women; 50.5% homosexual, 28.9% black African; median age 36 years) were followed for a median of 5.5 years, over which time 2279 (5.1%) people died. Higher %IC was associated with lower mortality both before [relative hazard 0.91 (95% confidence interval 0.88-0.95)/10% higher, P = 0.0001] and after [0.90 (0.87-0.93), P = 0.0001] adjustment. Adjustment for future CD4 changes revealed that the association was explained by poorer CD4 cell counts in those with lower %IC. In total 8730 participants under follow-up for more than 1 year initiated ART of whom 237 (2.7%) died. Higher values of %IC prior to ART initiation were associated with a reduced risk of mortality before [0.29 (0.17-0.47)/10%, P = 0.0001] and after [0.36 (0.21-0.61)/10%, P = 0.0002] adjustment; the association was again explained by poorer post-ART CD4/ viral load in those with lower pre-ART %IC.
Higher levels of engagement in-care are associated with reduced mortality at all stages of infection, including in those who initiate ART.
评估接受治疗的参与度与未来死亡率之间的关联。
基于英国的观察性队列研究。
确定2000年1月1日后有不止一次就诊的HIV阳性参与者。根据预期和观察到的下次就诊日期，将每个人月分为接受治疗或未接受治疗。Cox模型研究了死亡率与接受治疗的月累计比例（%IC，滞后1年）以及接受抗逆转录病毒治疗（ART）前累计%IC之间的关联，这些研究对象在诊所就诊超过1年，并对年龄、CD4/病毒载量、年份、性别、感染方式、种族以及ART的接受情况/类型进行了调整。
44432名个体（27.8%为女性；50.5%为同性恋者，28.9%为非洲黑人；中位年龄36岁）被随访了中位时间5.5年，在此期间2279人（5.1%）死亡。较高的%IC与调整前[相对风险0.91（95%置信区间0.88 - 0.95）/每高10%，P = 0.0001]和调整后[0.90（0.87 - 0.93），P = 0.0001]的较低死亡率相关。对未来CD4变化进行调整后发现，该关联可由%IC较低者较差的CD4细胞计数来解释。总共有8730名随访超过1年的参与者开始接受ART，其中237人（2.7%）死亡。ART开始前较高的%IC值与调整前[0.29（0.17 - 0.47）/每10%，P = 0.0001]和调整后[0.36（0.21 - 0.61）/每10%，P = 0.0002]的死亡风险降低相关；该关联同样可由ART前%IC较低者ART后较差的CD4/病毒载量来解释。
较高水平的接受治疗参与度与感染各阶段死亡率降低相关，包括开始接受ART的患者。
