Department of Medicine, University of California, San Diego, California, USA.
Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA.
Clin Infect Dis. 2020 Dec 3;71(9):e384-e391. doi: 10.1093/cid/ciaa114.
Public health action combating human immunodeficiency virus (HIV) includes facilitating navigation through the HIV continuum of care: timely diagnosis followed by linkage to care and initiation of antiretroviral therapy to suppress viral replication. Molecular epidemiology can identify rapidly growing HIV genetic transmission clusters. How progression through the care continuum relates to transmission clusters has not been previously characterized.
We performed a retrospective study on HIV surveillance data from 5226 adult cases in Los Angeles County diagnosed from 2010 through 2014. Genetic transmission clusters were constructed using HIV-TRACE. Cox proportional hazard models were used to estimate the impact of transmission cluster growth on the time intervals between care continuum events. Gamma frailty models incorporated the effect of heterogeneity associated with genetic transmission clusters.
In contrast to our expectations, there were no differences in time to the care continuum events among individuals in clusters with different growth dynamics. However, upon achieving viral suppression, individuals in high growth clusters were slower to experience viral rebound (hazard ratio 0.83, P = .011) compared with individuals in low growth clusters. Heterogeneity associated with cluster membership in the timing to each event in the care continuum was highly significant (P < .001), with and without adjustment for transmission risk and demographics.
Individuals within the same transmission cluster have more similar trajectories through the HIV care continuum than those across transmission clusters. These findings suggest molecular epidemiology can assist public health officials in identifying clusters of individuals who may benefit from assistance in navigating the HIV care continuum.
公共卫生行动旨在抗击人类免疫缺陷病毒（HIV），包括为 HIV 连续护理提供便利：及时诊断，随后进行护理衔接，并开始抗逆转录病毒治疗以抑制病毒复制。分子流行病学可以识别出快速增长的 HIV 基因传播集群。然而，目前尚未对连续护理过程与传播集群之间的关系进行描述。
我们对洛杉矶县 5226 名成年 HIV 监测数据进行了回顾性研究，这些病例于 2010 年至 2014 年期间确诊。使用 HIV-TRACE 构建遗传传播集群。使用 Cox 比例风险模型估计传播集群增长对连续护理事件之间时间间隔的影响。伽马脆弱性模型纳入了与遗传传播集群相关的异质性效应。
与我们的预期相反，在具有不同增长动态的集群中，个体之间在连续护理事件之间的时间上没有差异。然而，在达到病毒抑制后，与低增长集群相比，高增长集群中的个体经历病毒反弹的速度较慢（危险比 0.83，P=0.011）。与连续护理中每个事件的时间相关的集群成员身份的异质性非常显著（P<0.001），无论是否调整传播风险和人口统计学因素。
同一传播集群中的个体在 HIV 护理连续体中的轨迹比跨传播集群的个体更相似。这些发现表明，分子流行病学可以帮助公共卫生官员识别可能受益于帮助导航 HIV 护理连续体的个体集群。
