Makerere University, Kampala, Uganda.
Infectious Diseases Research Collaboration, Kampala, Uganda.
Clin Infect Dis. 2021 Oct 5;73(7):e1938-e1945. doi: 10.1093/cid/ciaa1782.
We tested the hypothesis that patient-centered, streamlined human immunodeficiency virus (HIV) care would achieve lower mortality than the standard treatment model for persons with HIV and CD4 ≤ 350/uL in the setting of population-wide HIV testing.
In the SEARCH (Sustainable East Africa Research in Community Health) Study (NCT01864603), 32 communities in rural Uganda and Kenya were randomized to country-guided antiretroviral therapy (ART) versus streamlined ART care that included rapid ART start, visit spacing, flexible clinic hours, and welcoming environment. We assessed persons with HIV and CD4 ≤ 350/uL, ART eligible in both arms, and estimated the effect of streamlined care on ART initiation and mortality at 3 years. Comparisons between study arms used a cluster-level analysis with survival estimates from Kaplan-Meier; estimates of ART start among ART-naive persons treated death as a competing risk.
Among 13 266 adults with HIV, 2973 (22.4%) had CD4 ≤ 350/uL. Of these, 33% were new diagnoses, and 10% were diagnosed but ART-naive. Men with HIV were almost twice as likely as women with HIV to have CD4 ≤ 350/uL and be untreated (15% vs 8%, respectively). Streamlined care reduced mortality by 28% versus control (risk ratio [RR] = 0.72; 95% confidence interval [CI]: .56, .93; P = .02). Despite eligibility in both arms, persons with CD4 ≤ 350/uL started ART faster under streamlined care versus control (76% vs 43% by 12 months, respectively; P < .001). Mortality was reduced substantially more among men (RR = 0.61; 95% CI: .43, .86; P = .01) than among women (RR = 0.90; 95% CI: .62, 1.32; P = .58).
After population-based HIV testing, streamlined care reduced population-level mortality among persons with HIV and CD4 ≤ 350/uL, particularly among men. Streamlined HIV care models may play a key role in global efforts to reduce AIDS deaths.
我们检验了这样一个假设，即在进行全民 HIV 检测的背景下，以患者为中心、流程简化的 HIV 护理模式比针对 CD4≤350/uL 的 HIV 感染者的标准治疗模式能实现更低的死亡率。
在东非可持续社区健康研究（SEARCH）中（NCT01864603），乌干达和肯尼亚的 32 个社区被随机分配到国家指导的抗逆转录病毒治疗（ART）与简化的 ART 护理中，包括快速开始 ART、就诊间隔、灵活的就诊时间和欢迎的环境。我们评估了 CD4≤350/uL 的 HIV 感染者、在两个治疗组中都符合 ART 治疗条件的患者，并估计了 3 年内简化护理对 ART 启动和死亡率的影响。研究组之间的比较采用了基于群组的分析，Kaplan-Meier 生存估计；对接受治疗的未接受 ART 治疗的新诊断患者的 ART 启动进行了估计，将死亡视为竞争风险。
在 13266 名 HIV 感染者中，有 2973 人（22.4%）CD4≤350/uL。其中，33%为新诊断病例，10%为诊断但未接受 ART 治疗的患者。男性 HIV 感染者的 CD4≤350/uL 且未接受治疗的可能性几乎是女性 HIV 感染者的两倍（分别为 15%和 8%）。与对照组相比，简化护理使死亡率降低了 28%（风险比 [RR]＝0.72；95%置信区间 [CI]：0.56，0.93；P＝0.02）。尽管在两个治疗组中都符合条件，但与对照组相比，简化护理组的 CD4≤350/uL 患者更快地开始接受 ART（分别在 12 个月时为 76%和 43%；P＜0.001）。死亡率的降低在男性中更为显著（RR＝0.61；95%CI：0.43，0.86；P＝0.01），而在女性中则不显著（RR＝0.90；95%CI：0.62，1.32；P＝0.58）。
在进行全民 HIV 检测后，简化护理降低了 CD4≤350/uL 的 HIV 感染者的人群死亡率，特别是在男性中。简化的 HIV 护理模式可能在全球减少艾滋病死亡的努力中发挥关键作用。
