Ssebunya Rogers, Wanyenze Rhoda K, Lukolyo Heather, Mutto Milton, Kisitu Grace, Amuge Pauline, Maganda Albert, Kekitiinwa Adeodata
Baylor College of Medicine Children's Foundation, Mulago Hospital Complex, P.O. Box 72052, Kampala, Uganda.
School of Public Health, Makerere University College of Health Sciences, P.O. Box 7072, Kampala, Uganda.
BMC Infect Dis. 2017 Jun 19;17(1):439. doi: 10.1186/s12879-017-2550-2.
Viral suppression is a critical indicator of HIV treatment success. In the era of test-and-start, little is known about treatment outcomes and time to undetectable viral loads. This study compares treatment outcomes, median times to achieve undetectable viral loads and its predictors under different antiretroviral (ART) treatment initiation schedules (i.e. within seven days of enrolment or later).
A retrospective cohort of 367 patients <18 years who enrolled in care between January 2010 and December 2015 with a baseline viral load of >5000 copies/ml were followed up for 60 months. Undetectable viral load measurements were based on both Roche (<20copies/ml) and Abbot (<75copies/ml). Clinical treatment outcomes were compared using chi-squared test. Survival experiences between the two cohorts were assessed through incidence rates and Kaplan Meier curves. A cox model with competing risks was used to assess predictors for time to undetectable viral load.
Of the 367 patients, 180 (49.1%) initiated ART within seven days from enrolment, 192 (52.3%) attained undetectable viral load of which 133 (69.3%) were children below six years and 101 (52.6%) were females. Among those who initiated ART within seven days 15 (8.3%) died and 6 (3.3%) were lost to follow-up compared to 27 (14.4%) and 16 (8.6%) respectively in the later initiators. The median time to undetectable viral load was 24.9 months (95% CI: 19.7, 28.5) among early ART initiators and 38.5 months (95% CI: 31.1, 44.5) among those initiating beyond seven days. There was a significant difference in failure estimates between those initiating within seven and those that deferred (log rank, p = 0.001). Significant predictors for time to undetectable viral load were; starting ART within seven days (SHR = 2.02, 95% CI: 1.24, 3.28), baseline WHO stage I or II (SHR = 1.59, 95% CI: 1.06, 2.28), inconsistent adherence on three consecutive clinic visits (SHR = 0.44, 95% CI: 0.28, 0.67), and baseline weight (SRH = 1.04, 95% CI: 1.01, 1.07).
Prompt initiation of ART within the first week of enrolment is associated with better treatment outcomes. Early timing, baseline WHO clinical stage and adherence rates should be major considerations while managing HIV among children.
病毒抑制是评估HIV治疗效果的关键指标。在检测即治疗时代，对于治疗结果以及实现病毒载量不可检测所需时间了解甚少。本研究比较了在不同抗逆转录病毒（ART）治疗启动方案下（即在入组后7天内或之后）的治疗结果、实现病毒载量不可检测的中位时间及其预测因素。
对2010年1月至2015年12月期间入组接受治疗、基线病毒载量>5000拷贝/ml的367例18岁以下患者进行回顾性队列研究，随访60个月。病毒载量不可检测的测量基于罗氏（<20拷贝/ml）和雅培（<75拷贝/ml）检测。使用卡方检验比较临床治疗结果。通过发病率和Kaplan Meier曲线评估两组队列的生存情况。采用具有竞争风险的Cox模型评估病毒载量不可检测时间的预测因素。
在367例患者中，180例（49.1%）在入组后7天内开始接受ART治疗，192例（52.3%）实现了病毒载量不可检测，其中133例（69.3%）为6岁以下儿童，101例（52.6%）为女性。在入组后7天内开始接受ART治疗的患者中，15例（8.3%）死亡，6例（3.3%）失访，而在较晚开始治疗的患者中，分别为27例（14.4%）和16例（8.6%）。早期开始ART治疗的患者实现病毒载量不可检测的中位时间为24.9个月（95%CI：19.7，28.5），而在7天后开始治疗的患者中为38.5个月（95%CI：31.1，44.5）。在7天内开始治疗和推迟治疗的患者之间，失败估计存在显著差异（对数秩检验，p = 0.001）。病毒载量不可检测时间的显著预测因素为：在7天内开始ART治疗（SHR = 2.02，95%CI：1.24，3.28）、基线WHO I期或II期（SHR = 1.59，95%CI：1.06，2.28）、连续三次门诊就诊依从性差（SHR = 0.44，95%CI：0.28，0.67）以及基线体重（SRH = 1.04，95%CI：1.01，1.07）。
在入组第一周内迅速开始ART治疗与更好的治疗结果相关。在管理儿童HIV感染时，早期治疗时机、基线WHO临床分期和依从率应作为主要考虑因素。
