Crellen Thomas, Ssonko Charles, Piening Turid, Simaleko Marcel Mbeko, Geiger Karen, Siddiqui M Ruby
Médecins Sans Frontières Hollande, Avenue Barthelemy Boganda, PK4, Bangui, BP 1793 Central African Republic.
2Mahidol-Oxford Tropical Medicine Research Unit, 420/6 Rajvithi Road, Tungphyathai, Bangkok, 10400 Thailand.
Confl Health. 2019 Nov 14;13:52. doi: 10.1186/s13031-019-0236-7. eCollection 2019.
Provision of antiretroviral therapy (ART) during conflict settings is rarely attempted and little is known about the expected patterns of mortality. The Central African Republic (CAR) continues to have a low coverage of ART despite an estimated 110,000 people living with HIV and 5000 AIDS-related deaths in 2018. We present results from a cohort in Zemio, Haut-Mboumou prefecture. This region had the highest prevalence of HIV nationally (14.8% in a 2010 survey), and was subject to repeated attacks by armed groups on civilians during the observed period.
Conflict from armed groups can impact cohort mortality rates i) directly if HIV patients are victims of armed conflict, or ii) indirectly if population displacement or fear of movement reduces access to ART. Using monthly counts of civilian deaths, injuries and abductions, we estimated the impact of the conflict on patient mortality. We also determined patient-level risk factors for mortality and how the risk of mortality varies with time spent in the cohort. Model-fitting was performed in a Bayesian framework, using logistic regression with terms accounting for temporal autocorrelation.
Patients were recruited and observed in the HIV treatment program from October 2011 to May 2017. Overall 1631 patients were enrolled and 1628 were included in the analysis giving 48,430 person-months at risk and 145 deaths. The crude mortality rate after 12 months was 0.92 (95% CI 0.90, 0.93). Our model showed that patient mortality did not increase during periods of heightened conflict; the odds ratios (OR) 95% credible interval (CrI) for i) civilian fatalities and injuries, and ii) civilian abductions on patient mortality both spanned unity. The risk of mortality for individual patients was highest in the second month after entering the cohort, and declined seven-fold over the first 12 months. Male sex was associated with a higher mortality (odds ratio 1.70 [95% CrI 1.20, 2.33]) along with the severity of opportunistic infections (OIs) at baseline (OR 2.52; 95% CrI 2.01, 3.23 for stage 2 OIs compared with stage 1).
Our results show that chronic conflict did not appear to adversely affect rates of mortality in this cohort, and that mortality was driven predominantly by patient-specific risk factors. The risk of mortality and recovery of CD4 T-cell counts observed in this conflict setting are comparable to those in stable resource poor settings, suggesting that conflict should not be a barrier in access to ART.
在冲突环境中提供抗逆转录病毒疗法（ART）的尝试很少，对预期的死亡率模式了解甚少。尽管2018年估计有11万人感染艾滋病毒，5000人死于艾滋病相关疾病，但中非共和国的ART覆盖率仍然很低。我们展示了上姆博穆省泽米奥一个队列的研究结果。该地区是全国艾滋病毒感染率最高的地区（2010年调查中为14.8%），在观察期内，平民多次遭到武装组织的袭击。
武装组织的冲突可能会影响队列死亡率，一是如果艾滋病毒患者是武装冲突的受害者，则直接影响；二是如果人口流离失所或对行动的恐惧减少了获得抗逆转录病毒疗法的机会，则间接影响。我们使用每月平民死亡、受伤和绑架的计数，估计冲突对患者死亡率的影响。我们还确定了患者层面的死亡风险因素，以及死亡率风险如何随在队列中的时间而变化。模型拟合在贝叶斯框架下进行，使用逻辑回归并考虑时间自相关项。
2011年10月至2017年5月，患者被纳入艾滋病毒治疗项目并接受观察。共有1631名患者入组，1628名患者纳入分析，共48430人月的风险期，145例死亡。12个月后的粗死亡率为0.92（95%CI 0.90，0.93）。我们的模型显示，在冲突加剧期间，患者死亡率没有增加；i）平民伤亡和ii）平民被绑架对患者死亡率的比值比（OR）95%可信区间（CrI）均包含1。个体患者的死亡风险在进入队列后的第二个月最高，在最初的12个月内下降了7倍。男性与较高的死亡率相关（比值比1.70[95%CrI 1.20，2.33]），同时基线时机会性感染（OIs）的严重程度也相关（与1期相比，2期OIs的OR为2.52；95%CrI 2.01，3.23）。
我们的结果表明，长期冲突似乎并未对该队列的死亡率产生不利影响，死亡率主要由患者特定的风险因素驱动。在这种冲突环境中观察到的死亡风险和CD4 T细胞计数的恢复与资源匮乏的稳定环境中的情况相当，这表明冲突不应成为获得抗逆转录病毒疗法的障碍。
