抗反转录病毒治疗（ART）起始时的青少年妊娠：维持抗反转录病毒治疗的关键障碍。

Adolescent pregnancy at antiretroviral therapy (ART) initiation: a critical barrier to retention on ART.

机构信息

Mailman School of Public Health, ICAP at Columbia University, New York, NY.

Department of Epidemiology, Columbia University Mailman School of Public Health, New York, NY.

出版信息

J Int AIDS Soc. 2018 Sep;21(9):e25178. doi: 10.1002/jia2.25178.

DOI:10.1002/jia2.25178

PMID:30225908

原文链接:https://pmc.ncbi.nlm.nih.gov/articles/PMC6141900/

Abstract

INTRODUCTION

Adolescence and pregnancy are potential risk factors for loss to follow-up (LTFU) while on antiretroviral therapy (ART). We compared adolescent and adult LTFU after ART initiation to quantify the impact of age, pregnancy, and site-level factors on LTFU.

METHODS

We used routine clinical data for patients initiating ART as young adolescents (YA; 10 to 14 years), older adolescents (OA; 15 to 19 years) and adults (≥20 years) from 2000 to 2014 at 52 health facilities affiliated with the International epidemiology Databases to Evaluate AIDS (IeDEA) East Africa collaboration. We estimated cumulative incidence (95% confidence interval, CI) of LTFU (no clinic visit for ≥6 months after ART initiation) and identified patient and site-level correlates of LTFU, using multivariable Cox proportional hazards models for all patients as well as individual age groups.

RESULTS

A total of 138,387 patients initiated ART, including 2496 YA, 2955 OA and 132,936 adults. Of these, 55%, 78% and 66%, respectively, were female and 0.7% of YA, 22.3% of OA and 8.3% of adults were pregnant at ART initiation. Cumulative incidence of LTFU at five years was 26.6% (24.6 to 28.6) among YA, 44.1% (41.8 to 46.3) among OA and 29.3% (29.1 to 29.6) among adults. Overall, compared to adults, the adjusted hazard ratio, aHR, (95% CI) of LTFU for OA was 1.54 (1.41 to 1.68) and 0.77 (0.69 to 0.86) for YA. Compared to males, pregnant females had higher hazard of LTFU, aHR 1.20 (1.14 to 1.27), and nonpregnant women had lower hazard aHR 0.90 (0.88 to 0.93). LTFU hazard among the OA was primarily driven by both pregnant and nonpregnant females, aHR 2.42 (1.98 to 2.95) and 1.51 (1.27 to 1.80), respectively, compared to men. The LTFU hazard ratio varied by IeDEA program. Site-level factors associated with overall lower LTFU hazard included receiving care in tertiary versus primary-care clinics aHR 0.61 (0.56 to 0.67), integrated adult and adolescent services and food ration provision aHR 0.93 (0.89 to 0.97) versus nonintegrated clinics with food ration provision, having patient support groups aHR 0.77 (0.66 to 0.90) and group adherence counselling aHR 0.61 (0.57 to 0.67).

CONCLUSIONS

Older adolescents experienced higher risk of LTFU compared to YA and adults. Interventions to prevent LTFU among older adolescents are critically needed, particularly for female and/or pregnant adolescents.

摘要

引言

青少年和妊娠是抗逆转录病毒治疗（ART）期间失访（LTFU）的潜在风险因素。我们比较了青少年和成年患者在开始 ART 后的 LTFU，以量化年龄、妊娠和地点因素对 LTFU 的影响。

方法

我们使用了 2000 年至 2014 年期间来自与国际艾滋病流行病学数据库评估合作组织（IeDEA）东非合作的 52 个卫生机构的接受 ART 的年轻青少年（YA；10 至 14 岁）、大龄青少年（OA；15 至 19 岁）和成年患者（≥20 岁）的常规临床数据。我们使用多变量 Cox 比例风险模型估计了 LTFU（ART 开始后≥6 个月未进行门诊就诊）的累积发生率（95%置信区间，CI），并确定了患者和地点相关的 LTFU 因素，该模型适用于所有患者以及各个年龄组。

结果

共有 138387 名患者开始接受 ART，其中 2496 名 YA、2955 名 OA 和 132936 名成年人。其中，分别有 55%、78%和 66%为女性，0.7%的 YA、22.3%的 OA 和 8.3%的成年人在开始 ART 时怀孕。YA、OA 和成年人的五年 LTFU 累积发生率分别为 26.6%（24.6 至 28.6）、44.1%（41.8 至 46.3）和 29.3%（29.1 至 29.6）。总体而言，与成年人相比，OA 的调整后的 LTFU 风险比（aHR）（95%CI）为 1.54（1.41 至 1.68），YA 为 0.77（0.69 至 0.86）。与男性相比，妊娠女性的 LTFU 风险更高，aHR 为 1.20（1.14 至 1.27），非妊娠女性的 LTFU 风险较低，aHR 为 0.90（0.88 至 0.93）。OA 的 LTFU 风险主要是由妊娠和非妊娠女性驱动的，与男性相比，aHR 分别为 2.42（1.98 至 2.95）和 1.51（1.27 至 1.80）。LTFU 风险比因 IeDEA 项目而异。与整体较低的 LTFU 风险相关的地点因素包括在三级而非初级保健诊所接受护理 aHR 0.61（0.56 至 0.67）、提供综合成人和青少年服务和粮食配给 aHR 0.93（0.89 至 0.97）与提供粮食配给但非综合诊所相比，有患者支持小组 aHR 0.77（0.66 至 0.90）和小组坚持咨询 aHR 0.61（0.57 至 0.67）。