停止使用、不规范使用和重新开始口服 HIV 暴露前预防：全球系统评价和荟萃分析。
Discontinuation, suboptimal adherence, and reinitiation of oral HIV pre-exposure prophylaxis: a global systematic review and meta-analysis.
机构信息
NHC Key Laboratory of AIDS Immunology and National Clinical Research Center for Laboratory Medicine, First Affiliated Hospital of China Medical University, Shenyang, China; Key Laboratory of AIDS Immunology, Chinese Academy of Medical Sciences, Shenyang, China; Key Laboratory of AIDS Immunology of Liaoning Province, Shenyang, China; Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, Shenyang, China.
Department of Health Behavior, University of North Carolina, Chapel Hill, NC, USA.
出版信息
Lancet HIV. 2022 Apr;9(4):e254-e268. doi: 10.1016/S2352-3018(22)00030-3.
BACKGROUND
Poor adherence to oral HIV pre-exposure prophylaxis (PrEP) diminishes its clinical and public health benefits. This study synthesises evidence regarding discontinuation, adherence, and reinitiation of PrEP among geographically diverse PrEP users.
METHODS
We did a systematic review and meta-analysis evaluating studies published in MEDLINE, Embase, and Cochrane Central Register of Controlled Trials from inception to Dec 18, 2020. We included longitudinal studies that presented data for PrEP discontinuation, defined as investigator-reported loss to follow-up or participant self-reported PrEP stoppage. Data were extracted from published reports and assessed for risk of bias. We used a random-effects meta-analysis to pool estimates of discontinuation and I and τ to evaluate heterogeneity. This study is registered with PROSPERO, CRD42020155675.
FINDINGS
We identified 4129 records, of which 59 articles were included (n=43 917 participants). 41·0% (95% CI 18·8-63·5) of participants discontinued PrEP within 6 months, with the highest rates in observational studies. The discontinuation rate in sub-Saharan Africa (47·5%, 95% CI: 29·4-66·4%) was higher than in other regions (p<0·001). Discontinuation rates were lower in studies with adherence interventions than in those without (24·7% vs 36·7%, p=0·015). Gay or bisexual men who have sex with men and transgender women offered daily or non-daily dosing options had lower discontinuation rates than those offered daily dosing alone (21·6% vs 31·5%; p<0·001). The pooled suboptimal adherence within 6 months was 37·7% (95% CI 8·4-66·9). Among people who discontinued PrEP, 47·3% (95% CI 31·5-63·2) reinitiated PrEP within 1 year of PrEP initiation. The included studies had poor quality in terms of study design, with a moderate risk of bias.
INTERPRETATION
Strategies to encourage reinitiating PrEP for new or persistent risk should be a focus of future PrEP implementation strategies.
FUNDING
National Institutes of Health and Nature Science Foundation of China.
背景
口服 HIV 暴露前预防（PrEP）的依从性差会降低其临床和公共卫生效益。本研究综合了来自不同地理区域的 PrEP 用户中关于 PrEP 停药、依从性和重新开始使用 PrEP 的证据。
方法
我们进行了一项系统评价和荟萃分析，评估了从研究开始到 2020 年 12 月 18 日在 MEDLINE、Embase 和 Cochrane 对照试验中心注册库发表的研究。我们纳入了报告了 PrEP 停药数据的纵向研究，定义为研究者报告的失访或参与者自我报告的 PrEP 停药。从已发表的报告中提取数据，并评估偏倚风险。我们使用随机效应荟萃分析汇总停药和 I 和 τ的估计值，以评估异质性。本研究已在 PROSPERO 注册，CRD42020155675。
结果
我们共确定了 4129 条记录，其中 59 篇文章被纳入（n=43917 名参与者）。在 6 个月内，41.0%（95%CI 18.8-63.5）的参与者停止使用 PrEP，观察性研究中的停药率最高。撒哈拉以南非洲地区（47.5%，95%CI：29.4-66.4%）的停药率高于其他地区（p<0.001）。与没有依从性干预的研究相比，有依从性干预的研究停药率较低（24.7% vs 36.7%，p=0.015）。接受每日或非每日剂量选择的男男性行为者和跨性别女性的停药率低于接受每日剂量的人（21.6% vs 31.5%；p<0.001）。在 6 个月内，亚最佳依从率为 37.7%（95%CI 8.4-66.9）。在停止使用 PrEP 的人群中，有 47.3%（95%CI 31.5-63.2）在 PrEP 开始后 1 年内重新开始使用 PrEP。纳入的研究在研究设计方面质量较差，存在中度偏倚风险。
解释
鼓励新的或持续风险重新开始使用 PrEP 的策略应该是未来 PrEP 实施策略的重点。
资助
美国国立卫生研究院和中国国家自然科学基金会。
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