Neilan Anne M, Karalius Brad, Patel Kunjal, Van Dyke Russell B, Abzug Mark J, Agwu Allison L, Williams Paige L, Purswani Murli, Kacanek Deborah, Oleske James M, Burchett Sandra K, Wiznia Andrew, Chernoff Miriam, Seage George R, Ciaranello Andrea L
Division of Infectious Diseases and the Medical Practice Evaluation Center, Massachusetts General Hospital, Boston2Department of Pediatrics, Massachusetts General Hospital, Boston3Harvard Medical School, Harvard University, Boston, Massachusetts.
Department of Epidemiology, Harvard T. H. Chan School of Public Health, Boston, Massachusetts.
JAMA Pediatr. 2017 May 1;171(5):450-460. doi: 10.1001/jamapediatrics.2017.0141.
As perinatally human immunodeficiency virus-infected youth (PHIVY) in the United States grow older and more treatment experienced, clinicians need updated information about the association of age, CD4 cell count, viral load (VL), and antiretroviral (ARV) drug use with risk of opportunistic infections, key clinical events, and mortality to understand patient risks and improve care.
To examine the incidence or first occurrence during follow-up of key clinical events (including Centers for Disease Control and Prevention stage B [CDC-B] and stage C [CDC-C] events) and mortality among PHIVY stratified by age, CD4 cell count, and VL and ARV status.
DESIGN, SETTING, AND PARTICIPANTS: Combining data from the Pediatric HIV/AIDS Cohort Study (PHACS) Adolescent Master Protocol and International Maternal Pediatric Adolescent AIDS Clinical Trials (IMPAACT) P1074 multicenter cohort studies (March 2007 through April 2015), we estimated event rates during person-time spent in key strata of age (7-12, 13-17, and 18-30 years), CD4 cell count (<200, 200-499, and ≥500/μL), and a combined measure of VL and ARV status (VL <400 or ≥400 copies/mL; ARV therapy or no ARV therapy). A total of 1562 participants in the PHACS Adolescent Master Protocol and IMPAACT P1074 were eligible, and 1446 PHIVY from 41 ambulatory sites in the 12 US states, including Puerto Rico were enrolled. The dates of analysis were March 2015 through January 2017.
Clinical event rates stratified by person-time in age, CD4 cell count, and VL and ARV categories.
A total of 1446 PHIVY participated in the study (mean [SD] age, 14.6 [4.6] years; 759 female [52.5%]; 953 black [65.9%]). During a mean (SD) follow-up of 4.9 (1.3) years, higher incidences of CDC-B events, CDC-C events, and mortality were observed as participants aged. Older PHIVY (aged 13-17 and 18-30 years) spent more time with a VL of 400 copies/mL or more and with a CD4 cell count of less than 200/µL compared with 7- to 12-year-old participants (30% and 44% vs 22% of person-time with a VL≥400 copies/mL; 5% and 18% vs 2% of person-time with CD4 cell count <200/µL; P < .001 for each comparison). We observed higher rates of CDC-B events, CDC-C events, bacterial infections, and mortality at lower CD4 cell counts, as expected. The mortality rate among older PHIVY was 6 to 12 times that among the general US population. Higher rates of sexually transmitted infections were also observed at lower CD4 cell counts after adjusting for age.
Older PHIVY were at increased risk of viremia, immunosuppression, CDC-B events, CDC-C events, and mortality. Interventions to improve ARV therapy adherence and optimize models of care for PHIVY as they age are urgently needed to improve long-term outcomes among PHIVY.
在美国，随着感染人类免疫缺陷病毒的围产期青少年（PHIVY）年龄增长且接受治疗的经验增多，临床医生需要有关年龄、CD4细胞计数、病毒载量（VL）以及抗逆转录病毒（ARV）药物使用与机会性感染风险、关键临床事件和死亡率之间关联的最新信息，以了解患者风险并改善护理。
研究按年龄、CD4细胞计数、VL以及ARV状态分层的PHIVY中关键临床事件（包括美国疾病控制与预防中心B期[CDC - B]和C期[CDC - C]事件）在随访期间的发生率或首次发生情况以及死亡率。
设计、背景和参与者：结合来自儿科HIV/艾滋病队列研究（PHACS）青少年主方案和国际母婴儿科青少年艾滋病临床试验（IMPAACT）P1074多中心队列研究（2007年3月至2015年4月）的数据，我们估计了在年龄（7 - 12岁、13 - 17岁和18 - 30岁）、CD4细胞计数（<200、200 - 499和≥500/μL）以及VL和ARV状态综合指标（VL <400或≥400拷贝/mL；接受ARV治疗或未接受ARV治疗）的关键分层中每人随访时间内的事件发生率。PHACS青少年主方案和IMPAACT P1074中共有1562名参与者符合条件，来自美国12个州（包括波多黎各）41个门诊地点的1446名PHIVY被纳入研究。分析日期为2015年3月至
