Matsena Zingoni Zvifadzo, Chirwa Tobias, Todd Jim, Musenge Eustasius
Division of Epidemiology and Biostatistics, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
National Institute of Health Research, Ministry of Health and Child Care, Harare, Zimbabwe.
BMJ Open. 2020 Oct 6;10(10):e036136. doi: 10.1136/bmjopen-2019-036136.
To determine the loss to follow-up (LTFU) rates at different healthcare levels after antiretroviral therapy (ART) services decentralisation among ART patients who initiated ART between 2004 and 2017 using the competing risk model in addition to the Kaplan-Meier and Cox regressions analysis.
A retrospective cohort study.
The study was done in Zimbabwe using a nationwide routinely collected HIV patient-level data from various health levels of care facilities compiled through the electronic patient management system (ePMS).
We analysed 390 771 participants aged 15 years and above from 538 health facilities.
The primary endpoint was LTFU defined as a failure of a patient to report for drug refill for at least 90 days from last appointment date or if the patient missed the next scheduled visit date and never showed up again. Mortality was considered a secondary outcome if a patient was reported to have died.
The total exposure time contributed was 1 544 468 person-years. LTFU rate was 5.75 (95% CI 5.71 to 5.78) per 100 person-years. Adjustment for the competing event independently increased LTFU rate ratio in provincial and referral (adjusted sub-HRs (AsHR) 1.22; 95% CI 1.18 to 1.26) and district and mission (AsHR 1.47; 95% CI 1.45 to 1.50) hospitals (reference: primary healthcare); in urban sites (AsHR 1.61; 95% CI 1.59 to 1.63) (reference: rural); and among adolescence and young adults (15-24 years) group (AsHR 1.19; 95% CI 1.16 to 1.21) (reference: 35-44 years). We also detected overwhelming association between LTFU and tuberculosis-infected patients (AsHR 1.53; 95% CI 1.45 to 1.62) (reference: no tuberculosis).
We have observed considerable findings that 'leakages' (LTFU) within the ART treatment cascade persist even after the decentralisation of health services. Risk factors for LTFU reflect those found in sub-Saharan African studies. Interventions that retain patients in care by minimising any 'leakages' along the treatment cascade are essential in attaining the 90-90-90 UNAIDS fast-track targets.
运用竞争风险模型以及Kaplan-Meier和Cox回归分析，确定2004年至2017年开始接受抗逆转录病毒治疗（ART）的患者在ART服务下放后，不同医疗保健级别上的失访（LTFU）率。
一项回顾性队列研究。
该研究在津巴布韦开展，使用了通过电子患者管理系统（ePMS）收集的全国范围内不同医疗保健级别设施的HIV患者层面的常规数据。
我们分析了来自538个医疗机构的390771名15岁及以上的参与者。
主要终点是LTFU，定义为患者自上次预约日期起至少90天未报告药物 refill，或者患者错过下次预定就诊日期且再也未出现。如果报告患者死亡，则将死亡率视为次要结果。
总的暴露时间为1544468人年。LTFU率为每100人年5.75（95%CI 5.71至5.78）。对竞争事件进行调整后，省级和转诊医院（调整后的子风险比（AsHR）1.22；95%CI 1.18至1.26）以及地区和教会医院（AsHR 1.47；95%CI 1.45至1.50）的LTFU率比值独立增加（参考：初级医疗保健）；在城市地区（AsHR 1.61；95%CI 1.59至1.63）（参考：农村）；以及在青少年和青年（15 - 24岁）组中（AsHR 1.19；95%CI 1.16至1.21）（参考：35 - 44岁）。我们还检测到LTFU与结核病感染患者之间存在显著关联（AsHR 1.53；95%CI 1.45至1.62）（参考：无结核病）。
我们观察到了相当多的结果，即即使在卫生服务下放之后，ART治疗级联中的“漏出”（LTFU）现象仍然存在。LTFU的风险因素反映了撒哈拉以南非洲研究中的发现。通过尽量减少治疗级联中的任何“漏出”来使患者持续接受治疗的干预措施对于实现联合国艾滋病规划署的90 - 90 - 90快速通道目标至关重要。
