Carolina Population Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina.
Meta-Research Innovation Center at Stanford University, Stanford, California.
AIDS. 2020 Jun 1;34(7):1047-1055. doi: 10.1097/QAD.0000000000002502.
The Joint United Nations Programme on HIV/AIDS (UNAIDS) 90-90-90 and other cross-sectional metrics can lead to potentially counterintuitive conclusions when used to evaluate health systems' performance. This study demonstrates how time and population dynamics impact UNAIDS 90-90-90 metrics in comparison with a longitudinal analogue.
A simplified simulation representing a hypothetical population was used to estimate and compare inference from UNAIDS 90-90-90 metrics and longitudinal metrics based on Kaplan-Meier-estimated 2-year probability of transition between stages.
We simulated a large cohort over 15 years. Everyone started out at risk for HIV, and then transitioned through the HIV care continuum based on fixed daily probabilities of acquiring HIV, learning status, entering care, initiating antiretroviral therapy (ART), and becoming virally suppressed, or dying. We varied the probability of ART initiation over three five-year periods (low, high, and low). We repeated the simulation with an increased probability of death.
The cross-sectional probability of being on ART among persons who were diagnosed responded relatively slowly to changes in the rate of ART initiation. Increases in ART initiation rates caused apparent declines in the cross-sectional probability of being virally suppressed among persons who had initiated ART, despite no changes in the rate of viral suppression. In some cases, higher mortality resulted in the cross-sectional metrics implying improved healthcare system performance. The longitudinal continuum was robust to these issues.
The UNAIDS 90-90-90 care continuum may lead to incorrect inference when used to evaluate health systems performance. We recommend that evaluation of HIV care delivery include longitudinal care continuum metrics wherever possible.
联合国艾滋病规划署（UNAIDS）90-90-90 联合目标和其他横断面指标在用于评估卫生系统绩效时，可能会得出有悖常理的结论。本研究通过与纵向模拟比较，展示了时间和人口动态如何影响 UNAIDS 90-90-90 指标。
使用简化的模拟代表一个假设的人群，以估计和比较 UNAIDS 90-90-90 指标和基于 Kaplan-Meier 估计的 2 年阶段间转移概率的纵向指标的推断。
我们在 15 年内模拟了一个大型队列。每个人都从感染 HIV 的风险开始，然后根据获得 HIV 的固定每日概率、学习状况、进入护理、开始抗逆转录病毒治疗 (ART) 和实现病毒抑制或死亡，在 HIV 护理连续体中过渡。我们在三个五年期内改变了开始 ART 的概率（低、高和低）。我们增加了死亡概率重复了模拟。
诊断为 HIV 的人群中接受 ART 的横断面概率对 ART 起始率的变化反应相对较慢。ART 起始率的增加导致开始 ART 的人群中病毒抑制的横断面概率明显下降，尽管病毒抑制率没有变化。在某些情况下，更高的死亡率导致横断面指标暗示医疗保健系统的表现有所改善。纵向连续体对这些问题具有稳健性。
当用于评估卫生系统绩效时，UNAIDS 90-90-90 护理连续体可能导致不正确的推断。我们建议，在可能的情况下，评估 HIV 护理提供应包括纵向护理连续体指标。
