Agolory Simon G, Auld Andrew F, Odafe Solomon, Shiraishi Ray W, Dokubo E Kainne, Swaminathan Mahesh, Dalhatu Ibrahim, Onotu Dennis, Abiri Oseni, Debem Henry, Bashorun Adebobola, Ellerbrock Tedd V
Division of Global HIV & TB, U.S. Centers for Disease Control & Prevention, Atlanta, United States of America.
Division of Global HIV & TB, U.S. Centers for Disease Control & Prevention, Abuja, Nigeria.
PLoS One. 2017 Sep 1;12(9):e0183823. doi: 10.1371/journal.pone.0183823. eCollection 2017.
With about 3.4 million HIV-infected persons, Nigeria has the second highest number of people living with HIV (PLHIV) in the world. However, antiretroviral treatment (ART) coverage in Nigeria remains low with only 748,846 (22%) of PLHIV on ART by the end of 2014. Retention of HIV-infected patients in pre-ART care is essential to ensure timely ART initiation. We assessed outcomes of patients enrolled in Nigeria's pre-ART program during 2004-2012.
We conducted a nationally representative retrospective cohort study among adults (≥15 years old), enrolling in pre-ART programs supported by the U.S. President's Emergency Plan for AIDS Relief in Nigeria. A total of 35 sites enrolling ≥50 patients in pre-ART were selected using probability proportional-to-size sampling; 2,415 eligible medical records at these sites were randomly selected for abstraction. Determinants of loss to follow-up (LTFU) and mortality during pre-ART care were estimated using Cox proportional hazards regression models.
The median age at enrollment was 32 years (interquartile range (IQR) 27-40). A total of 1,216 (51.4%) initiated ART by the time of data abstraction. Among the remaining 1,199 patients, 898 (74.9%) had been LTFU, 180 (15.0%) were alive and in pre-ART care, 71 (5.9%) had died, 50 (4.2%) had transferred out or stopped care. Baseline markers of advanced disease, including weight <45 kg (adjusted hazard ration (AHR) = 4.23; 95% confidence interval (CI): 1.51-15.58) and more advanced WHO disease stage, were predictive of pre-ART mortality. Compared with patients aged 15-24, patients aged 35-44 (AHR = 0.67; 95% CI: 1.0.47-0.95) and age 45-54 (AHR = 0.66; 95% CI: 0.48-0.91) had lower LTFU rates. Compared with attending facilities in North Central geopolitical zone, attending facility locations in South East (AHR = 0.44; 95% CI: 0.24-0.83) was protective against LTFU.
About half of patients enrolling in HIV program during 2004-2012 in Nigeria had not initiated ART by 2013. Key strategies to improve early ART initiation among pre-ART enrollees include implementation of the WHO test and treat guidelines, earlier HIV testing, and better monitoring to improve ART initiation rates. Further research to understand regional variations in pre-ART outcomes is warranted.
尼日利亚约有340万艾滋病毒感染者，是全球艾滋病毒感染者人数第二多的国家。然而，尼日利亚的抗逆转录病毒治疗（ART）覆盖率仍然很低，截至2014年底，只有748,846名（22%）艾滋病毒感染者接受了ART治疗。让艾滋病毒感染者留在ART前护理阶段对于确保及时开始ART治疗至关重要。我们评估了2004年至2012年期间参加尼日利亚ART前项目的患者的结局。
我们在成年人（≥15岁）中开展了一项具有全国代表性的回顾性队列研究，这些成年人参加了由美国总统艾滋病紧急救援计划在尼日利亚支持的ART前项目。使用按规模大小成比例的概率抽样方法，总共选择了35个在ART前登记≥50名患者的地点；从这些地点随机抽取了2415份符合条件的医疗记录进行摘要分析。使用Cox比例风险回归模型估计ART前护理期间失访（LTFU）和死亡率的决定因素。
入组时的中位年龄为32岁（四分位间距（IQR）27 - 40）。到数据摘要分析时，共有1216名（51.4%）患者开始接受ART治疗。在其余1199名患者中，898名（74.9%）失访，180名（15.0%）存活且仍在接受ART前护理，71名（5.9%）死亡，50名（4.2%）转出或停止护理。疾病进展的基线指标，包括体重<45千克（调整后风险比（AHR）= 4.23；95%置信区间（CI）：1.51 - 15.58）以及更严重的世界卫生组织疾病阶段，可预测ART前死亡率。与15 - 24岁的患者相比，35 - 44岁（AHR = 0.67；95% CI：0.47 - 0.95）和45 - 54岁（AHR = 0.66；95% CI：0.48 - 0.91）的患者失访率较低。与在中北部地缘政治区的就诊机构相比，东南部的就诊机构地点（AHR = 0.44；95% CI：0.24 - 0.83）可预防失访。
2004年至2012年期间在尼日利亚参加艾滋病毒项目的患者中，约有一半到2013年时尚未开始接受ART治疗。提高ART前入组者早期ART治疗启动率的关键策略包括实施世界卫生组织的检测与治疗指南、更早进行艾滋病毒检测以及更好地监测以提高ART治疗启动率。有必要进一步开展研究以了解ART前结局的区域差异。
