撒哈拉以南非洲地区 HIV 感染儿童和青少年开始抗逆转录病毒治疗后 1 年内死亡率预测：一项回顾性观察队列研究。

Predicting mortality within 1 year of ART initiation in children and adolescents living with HIV in sub-Saharan Africa: a retrospective observational cohort study.

机构信息

Baylor College of Medicine, Houston, TX, USA; Baylor College of Medicine Children's Foundation-Eswatini, Mbabane, Eswatini.

Department of Health Policy and Organization, University of Alabama at Birmingham, Birmingham, AL, USA.

出版信息

Lancet Glob Health. 2024 Jun;12(6):e929-e937. doi: 10.1016/S2214-109X(24)00091-3.

DOI:10.1016/S2214-109X(24)00091-3

PMID:38762295

原文链接:https://pmc.ncbi.nlm.nih.gov/articles/PMC11149103/

Abstract

BACKGROUND

Differentiated service delivery (DSD) for children and adolescents living with HIV can improve targeted resource use. We derived a mortality prediction score to guide clinical decision making for children and adolescents living with HIV.

METHODS

Data for this retrospective observational cohort study were evaluated for all children and adolescents living with HIV and initiating antiretroviral therapy (ART); aged 0-19 years; and enrolled at Baylor clinics in Eswatini, Malawi, Lesotho, Tanzania, and Uganda between 2005 and 2020. Data for clinical prediction, including anthropometric values, physical examination, ART, WHO stage, and laboratory tests were captured at ART initiation. Backward stepwise variable selection and logistic regression were performed to develop predictive models for mortality within 1 year of ART initiation. Probabilities of mortality were generated, compared with true outcomes, internally validated, and evaluated against WHO advanced HIV criteria.

FINDINGS

The study population included 16 958 children and adolescents living with HIV and initiated on ART between May 18, 2005, and Dec 18, 2020. Predictive variables for the most accurate model included: age, CD4 percentage, white blood cell count, haemoglobin concentration, platelet count, and BMI Z score as continuous variables, and WHO clinical stage and oedema, abnormal muscle tone and respiratory distress on examination as categorical variables. The area under the curve (AUC) of the predictive model was 0·851 (95% CI 0·839-0·863) in the training set and 0·822 (0·800-0·845) in the test set, compared with 0·606 (0·595-0·617) for the WHO advanced HIV criteria (p<0·0001).

INTERPRETATION

This study evaluated a large, multinational population to derive a mortality prediction tool for children and adolescents living with HIV. The model more accurately predicted clinical outcomes than the WHO advanced HIV criteria and has the potential to improve DSD for children and adolescents living with HIV in high-burden settings.

FUNDING

National Institute of Health Fogarty International Center.

摘要

背景

为艾滋病毒感染者儿童和青少年提供差异化服务（DSD）可以改善有针对性的资源利用。我们得出了一个死亡率预测评分，以指导艾滋病毒感染者儿童和青少年的临床决策。

方法

本回顾性观察队列研究的数据评估了所有在 2005 年至 2020 年间在斯威士兰、马拉维、莱索托、坦桑尼亚和乌干达的贝勒诊所登记、年龄在 0-19 岁、开始接受抗逆转录病毒治疗（ART）的艾滋病毒感染者儿童和青少年。在开始接受 ART 时，收集了临床预测数据，包括人体测量值、体格检查、ART、世界卫生组织（WHO）分期和实验室检查。使用向后逐步变量选择和逻辑回归建立了 ART 开始后 1 年内死亡的预测模型。生成死亡率概率，并与真实结果进行比较，进行内部验证，并与 WHO 先进的 HIV 标准进行比较。

结果

该研究人群包括 16958 名艾滋病毒感染者儿童和青少年，他们于 2005 年 5 月 18 日至 2020 年 12 月 18 日开始接受 ART。最准确模型的预测变量包括：年龄、CD4 百分比、白细胞计数、血红蛋白浓度、血小板计数和 BMI Z 评分（连续变量），以及 WHO 临床分期和水肿、检查时异常肌肉张力和呼吸困难（分类变量）。预测模型在训练集中的曲线下面积（AUC）为 0.851（95%CI 0.839-0.863），在测试集中为 0.822（0.800-0.845），而 WHO 先进的 HIV 标准为 0.606（0.595-0.617）（p<0.0001）。