Rebeiro Peter F, Bakoyannis Giorgos, Musick Beverly S, Braithwaite Ronald S, Wools-Kaloustian Kara K, Nyandiko Winstone, Some Fatma, Braitstein Paula, Yiannoutsos Constantin T
*Department of Medicine, Division of Infectious Diseases, Vanderbilt University School of Medicine, Nashville, TN; †Department of Biostatistics, Indiana University Fairbanks School of Public Health, Indianapolis, IN; ‡Department of Medicine, Division of Infectious Diseases, Indiana University School of Medicine, Indianapolis, IN; Department of Population Health and Department of Medicine; §New York University School of Medicine, New York City, NY; Departments of ‖Child Health and Paediatrics; ¶Medicine, Moi University School of Medicine, Eldoret, Kenya; and #Epidemiology Division, University of Toronto Dalla Lana School of Public Health, Toronto, Ontario, Canada.
J Acquir Immune Defic Syndr. 2017 Oct 1;76(2):141-148. doi: 10.1097/QAI.0000000000001474.
The burden of HIV remains heaviest in resource-limited settings, where problems of losses to care, silent transfers, gaps in care, and incomplete mortality ascertainment have been recognized.
Patients in care at Academic Model Providing Access to Healthcare (AMPATH) clinics from 2001-2011 were included in this retrospective observational study. Patients missing an appointment were traced by trained staff; those found alive were counseled to return to care (RTC). Relative hazards of RTC were estimated among those having a true gap: missing a clinic appointment and confirmed as neither dead nor receiving care elsewhere. Sample-based multiple imputation accounted for missing vital status.
Among 34,522 patients lost to clinic, 15,331 (44.4%) had a true gap per outreach, 2754 (8.0%) were deceased, and 837 (2.4%) had documented transfers. Of 15,600 (45.2%) remaining without active ascertainment, 8762 (56.2%) with later RTC were assumed to have a true gap. Adjusted cause-specific hazard ratios (aHRs) showed early outreach (a ≤8-day window, defined by grid-search approach) had twice the hazard for RTC vs. those without (aHR = 2.06; P < 0.001). HRs for RTC were lower the later the outreach effort after disengagement (aHR = 0.86 per unit increase in time; P < 0.001). Older age, female sex (vs. male), antiretroviral therapy use (vs. none), and HIV status disclosure (vs. none) were also associated with greater likelihood of RTC, and higher enrollment CD4 count with lower likelihood of RTC.
Patient outreach efforts have a positive impact on patient RTC, regardless of when undertaken, but particularly soon after the patient misses an appointment.
在资源有限的环境中，艾滋病毒负担仍然最为沉重，在这些环境中，失访、隐性转移、护理缺口以及不完全死亡确定等问题已得到认识。
本回顾性观察研究纳入了2001年至2011年在学术模式提供医疗服务（AMPATH）诊所接受治疗的患者。错过预约的患者由经过培训的工作人员进行追踪；那些被发现还活着的患者被劝告返回接受治疗（RTC）。在那些存在真正缺口的患者中估计RTC的相对风险：错过诊所预约且被确认为既未死亡也未在其他地方接受治疗。基于样本的多重插补法考虑了缺失的生命状态。
在34522名失访患者中，每次外展有15331名（44.4%）存在真正缺口，2754名（8.0%）已死亡，837名（2.4%）有记录的转移。在15600名（45.2%）仍未进行有效确定的患者中，8762名（56.2%）后来返回接受治疗的被假定存在真正缺口。调整后的特定病因风险比（aHRs）显示，早期外展（a≤8天窗口，由网格搜索法定义）与未进行早期外展的患者相比，RTC的风险是其两倍（aHR = 2.06；P < 0.001）。脱离接触后外展工作越晚，RTC的风险比越低（每增加一个时间单位aHR = 0.86；P < 0.001）。年龄较大、女性（与男性相比）、使用抗逆转录病毒疗法（与未使用相比）以及披露艾滋病毒状态（与未披露相比）也与RTC的可能性更大相关，而登记时CD4细胞计数较高与RTC的可能性较低相关。
患者外展工作对患者RTC有积极影响，无论何时开展，但特别是在患者错过预约后不久。
