2004-2018 年美国按年龄划分的进入 HIV 护理和抗逆转录病毒治疗处方时的观察 CD4 计数：一项队列研究。

Observed CD4 counts at entry into HIV care and at antiretroviral therapy prescription by age in the USA, 2004-18: a cohort study.

机构信息

Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA.

出版信息

Lancet HIV. 2022 Mar;9 Suppl 1:S2. doi: 10.1016/S2352-3018(22)00067-4.

Abstract

BACKGROUND: Adults aged 50 years or older comprise a majority of people with HIV in the USA. Our objective was to describe observed differences by age in CD4 count at entry into HIV care, timing of antiretroviral therapy (ART) prescription, and CD4 count at time of ART prescription before (2004-11) and during (2012-18) the current era of universal treatment. METHODS: For this descriptive study, we calculated median (IQR) CD4 count at entry into care, days from entry into care to ART prescription, and CD4 count at time of ART prescription among patients enrolled in US-based clinical cohorts of the North American AIDS Cohort Collaboration on Research and Design (NA-ACCORD; see appendix). We excluded participants with no CD4 count recorded at entry into care, medical records that suggested previous ART use, or previous AIDS diagnosis. All calculations were stratified by age (≥50 and 18-50 years) and calendar year. FINDINGS: Of 35 293 ART-naive adult participants entering care between Jan 1, 2004 and Dec 31, 2018, 5794 (16%) were women and 29 499 (84%) were men; 15817 (45%) were Black, 11566 (33%) were White, 5538 (16%) were Hispanic (any race), 737 (2%) were Asian or Pacific Islander, 152 (0.4%) were Indigenous, and 98 (0.3%) were multiracial. Median age at entry into care was 39 years (IQR 29-49); 8004 (23%) were aged 50 years or older. Of 29 141 participants initially prescribed ART, 7274 (25%) were aged 50 years or older. From 2004 to 2018, median CD4 count at entry into care increased from 228 cells per µL (IQR 80-422) to 295 cells per µL (134-489) among adults aged 50 years and older, and from 297 cells per µL (119-480) to 378 cells per µL (202-564) among adults younger than 50 years. Median days from entry into care to ART prescription declined from 56 (IQR 17-658) to 6 (0-15) among adults older than 50 years, and from 61 (17-509) to 6 (0-16) among adults younger than 50 years. Median CD4 count at time of ART prescription increased from 139 cells per µL (IQR 59-257) to 311 cells per µL (137-504) among adults aged 50 years or older, and from 166 cells per µL (49-287) to 377 cells per µL (198-564) among adults younger than 50 years. INTERPRETATION: Before the release of universal treatment guidelines by the US Department of Health and Human Services in 2012, median time to ART prescription was already falling, leading to increases in median CD4 count at ART prescription for both age groups; both measures continued to improve in the treat-all era. However, median CD4 counts, both at entry into care and at ART prescription, among adults aged 50 years and older were lower than those of adults younger than 50 years throughout the study period. Furthermore, even into the treat-all era, over half of adults aged 50 years and older entered care with CD4 counts of less than 350 cells per µL, potentially because of factors including immunosenescence, delayed HIV diagnosis, and late presentation to care. Given that age-related immunological changes might not be fully avoidable, targeted strategies for increasing HIV risk awareness, routine testing, and immediate linkage to HIV care at diagnosis are particularly essential for this population. FUNDING: US National Institutes of Health grant U01AI069918.

摘要

背景：50 岁及以上成年人在美国的 HIV 患者中占大多数。我们的目的是描述在当前普遍治疗时代之前（2004-11 年）和期间（2012-18 年），按年龄观察 CD4 计数进入 HIV 护理、开始抗逆转录病毒治疗（ART）处方的时间以及开始 ART 处方时的 CD4 计数的差异。

方法：在这项描述性研究中，我们计算了入组美国基于临床队列的北美艾滋病队列合作研究与设计（NA-ACCORD）的患者的 CD4 计数（IQR）中位数（入组时）、从入组到开始 ART 处方的天数，以及开始 ART 处方时的 CD4 计数（见附录）。我们排除了没有入组时 CD4 计数记录、有之前 ART 使用记录或之前 AIDS 诊断的参与者。所有计算均按年龄（≥50 岁和 18-50 岁）和日历年份分层。

结果：在 2004 年 1 月 1 日至 2018 年 12 月 31 日期间，有 35293 名接受抗逆转录病毒治疗的成年患者，其中 5794 名（16%）为女性，29499 名（84%）为男性；15817 名（45%）为黑人，11566 名（33%）为白人，5538 名（16%）为西班牙裔（任何种族），737 名（2%）为亚洲人或太平洋岛民，152 名（0.4%）为土着，98 名（0.3%）为多种族，中位年龄为 39 岁（IQR 29-49）；8004 名（23%）年龄在 50 岁或以上。在 29141 名最初接受 ART 处方的患者中，7274 名（25%）年龄在 50 岁或以上。从 2004 年到 2018 年，50 岁及以上成年人的 CD4 计数中位数从入组时的 228 个细胞/µL（IQR 80-422）增加到 295 个细胞/µL（134-489），而年龄小于 50 岁的成年人的 CD4 计数中位数从 297 个细胞/µL（119-480）增加到 378 个细胞/µL（202-564）。从入组到开始 ART 处方的天数从 56 天（IQR 17-658）减少到 6 天（0-15），在 50 岁以上的成年人中，从 61 天（17-509）减少到 6 天（0-16），在年龄小于 50 岁的成年人中。50 岁及以上成年人开始 ART 处方时的 CD4 计数中位数从 139 个细胞/µL（IQR 59-257）增加到 311 个细胞/µL（137-504），而年龄小于 50 岁的成年人的 CD4 计数中位数从 166 个细胞/µL（49-287）增加到 377 个细胞/µL（198-564）。

解释：在美国卫生与公众服务部发布普遍治疗指南之前（2012 年），开始 ART 处方的时间已经在下降，导致两个年龄组的开始 ART 处方时的 CD4 计数中位数增加；在所有治疗组中，这两个指标都在继续改善。然而，在整个研究期间，50 岁及以上成年人的 CD4 计数，无论是在入组时还是在开始 ART 处方时，都低于年龄小于 50 岁的成年人。此外，即使在普遍治疗时代，仍有一半以上的 50 岁及以上成年人的 CD4 计数低于 350 个细胞/µL，这可能是由于免疫衰老、延迟的 HIV 诊断和晚期到护理机构就诊等因素所致。鉴于与年龄相关的免疫变化可能无法完全避免，针对增加 HIV 风险意识、常规检测以及在诊断时立即将 HIV 感染者与 HIV 护理机构联系起来的有针对性的策略，对于这一人群尤为重要。

资助：美国国立卫生研究院授予 U01AI069918 号基金。