Division of HIV/AIDs, Rwanda Biomedical Center, STIs and Viral Hepatitis, City of Kigali, Rwanda.
Partners in Heath, Inshuti Mu Buzima, Infectious Disease Program, City of Kigali, Rwanda.
BMC Infect Dis. 2022 Aug 25;22(1):706. doi: 10.1186/s12879-022-07692-w.
In 2016 Rwanda adopted "treat all" where all patients with HIV are immediately eligible for ART regardless of disease progression. Despite widespread availability of treatment, it is unknown whether presentation with advanced HIV persists.
We conducted a retrospective cohort among patients aged ≥ 15 who enrolled in care between July 2016 and July 2018 in three rural Rwandan districts. We estimated the prevalence of advanced HIV, defined as presenting with CD4 count < 200 cells/mm or WHO stage 3 or 4, and compared baseline characteristics of patients with and without advanced HIV. We compared cumulative incidences and time to events using Chi squared tests and Cox proportional hazards models, respectively, for (a) viral load tests; (b) viral suppression; (c) death; and (d) treatment failure (a composite of death, lost to follow up, or virologic failure).
Among 957 patients, 105 (11.0%) presented with advanced HIV. These patients were significantly more likely to have low body mass index, come from Burera district, be older, and be identified through inpatient settings rather than through voluntary or prenatal testing. Patients with advanced HIV had significantly higher risks of death at 12-months (9.5% vs 1.5%, p < 0.001) and 18-months (10.5% vs 1.9%, p < 0.001) and significantly higher risk of treatment failure at 12-months (21.9% vs. 14.2%, p = 0.037). After adjusting for confounders, patients with advanced HIV had still higher rates of death (adjusted Hazard ratio [aHR] = 4.4, 95% CI: 1.9, 10.2, p < 0.001) and treatment failure (aHR = 1.7, 95% CI: 1.1, 2.5, p = 0.017), but no difference in viral load testing (aHR = 1.1, 95% CI: 0.8, 1.5, p = 0.442) or viral suppression (aHR = 1.0, 95% CI: 0.8, 1.4, p = 0.949). When allowing for the hazard ratio to vary over time, patients with advanced HIV experienced elevated rates of treatment failure in the first six of enrollment, but not after nine months.
Presenting with advanced HIV remains common and is still associated with poor patient outcomes. Sensitization of the community to the benefits of early ART initiation, identification of patients with advanced HIV, and holistic support programs for the first 6 months of treatment may be needed to improve outcomes.
2016 年，卢旺达开始推行“即治即服”方案，所有 HIV 患者无论疾病进展如何，均立即有资格接受 ART 治疗。尽管治疗广泛普及，但尚不清楚是否仍存在晚期 HIV 患者就诊的情况。
我们对 2016 年 7 月至 2018 年 7 月期间在卢旺达三个农村地区入组治疗的年龄≥15 岁的患者进行了回顾性队列研究。我们评估了晚期 HIV 的患病率，定义为 CD4 计数<200 个细胞/mm 或 WHO 分期 3 或 4，并比较了有和无晚期 HIV 的患者的基线特征。我们使用卡方检验和 Cox 比例风险模型分别比较了（a）病毒载量检测；（b）病毒抑制；（c）死亡；和（d）治疗失败（包括死亡、失访或病毒学失败）的累积发生率和时间到事件。
在 957 名患者中，有 105 名（11.0%）患者表现为晚期 HIV。这些患者更有可能体重指数较低、来自布瑞拉区、年龄更大、以及通过住院环境而不是自愿或产前检测发现。晚期 HIV 患者在 12 个月时（9.5% vs. 1.5%，p<0.001）和 18 个月时（10.5% vs. 1.9%，p<0.001）死亡风险显著更高，并且在 12 个月时治疗失败的风险也显著更高（21.9% vs. 14.2%，p=0.037）。在调整混杂因素后，晚期 HIV 患者的死亡率（调整后的危险比[aHR] = 4.4，95%CI：1.9，10.2，p<0.001）和治疗失败率（aHR = 1.7，95%CI：1.1，2.5，p=0.017）仍然更高，但病毒载量检测（aHR = 1.1，95%CI：0.8，1.5，p=0.442）或病毒抑制（aHR = 1.0，95%CI：0.8，1.4，p=0.949）无差异。当允许危险比随时间变化时，晚期 HIV 患者在入组的前 6 个月内治疗失败的风险增加，但在 9 个月后没有增加。
晚期 HIV 患者就诊仍然很常见，且仍然与较差的患者结局相关。需要提高社区对早期 ART 启动益处的认识，识别晚期 HIV 患者，并在治疗的前 6 个月内提供全面的支持计划，以改善结局。
