Nasasira Benson, Banturaki Grace, Kalema Nelson, Musaazi Joseph, Nanvuma Aidah, Okoboi Stephen, Kiarie Nancy Gathoni, Moitui Joash Ntenga, Kadengye Damazo, Izudi Jonathan, Castelnuovo Barbara
Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda.
Faculty of Medicine and Health Science, University of Antwerp, Antwerp, Belgium.
AIDS Res Ther. 2025 Jun 2;22(1):56. doi: 10.1186/s12981-025-00741-9.
Differentiated service delivery (DSD) models in resource-limited settings reduce strain on health services and improve clinical outcomes such as retention and viral suppression, but little is known about the impact of HIV DSD models on quality of life (QoL), which is essential for optimizing person-centered care. This study assessed the impact of DSD models on Quality of life, loss to follow-up (LTFU), and mortality among persons living with HIV (PLHIV) on Antiretroviral therapy (ART) over time at a large urban HIV clinic in Uganda.
Records of 1,000 PLHIV enrolled in a 10-year cohort at the Infectious Diseases Institute (IDI) clinic in Kampala, Uganda were retrospectively analyzed. QoL was assessed using an adapted Medical Outcomes Study (MOS-HIV) tool. QoL scores, sustained annual viral suppression (< 200 copies/mL), all-cause mortality and LTFU (≥ 3 months of missed visits) were compared for PLHIV in three DSD models for ≥ 6 consecutive months-fast-track drug refill (FTDR), facility-based groups (FBG), and composite model combining these two-versus facility-based individual management (FBIM) or the standard of care (SOC). Inverse probability treatment weighting was applied for covariate comparability while robustness of results was checked using G-computation. Sustained viral suppression was compared using odds ratios; all-cause mortality and LTFU were compared using hazard ratios from the Cox proportional hazard regression model.
Of the 1,000 PLHIV, 980 had ≥ 1 follow-up and were included in the analysis. Median age was 45 years (IQR: 40-51), 62% were female, and 95% had a suppressed viral load at baseline. Baseline QoL was 90.1% in any DSD model vs. 89.2% in SOC. After eight years of follow-up, weighted mean QoL was higher in participants enrolled in DSD models than the SOC (90.4% vs. 89.1%; weighted mean ratio 3.66, 95% CI 2.10-6.37, p-value < 0.001); there were no statistical differences across DSD models. Participants in DSD models were more likely to have sustained viral suppression (weighted odds ratio 1.69, 95% CI 1.24-2.31), lower mortality (weighted hazard ratio 0.08, 95% CI 0.03-0.20) and lower LTFU rates (weighted hazard ratio 0.08, 95% CI 0.02-0.31).
DSD models were associated with modestly higher quality of life, better viral suppression, and lower mortality and LTFU compared to the standard of care. These findings support the broader adoption of DSD models in delivering ART across HIV programs to enhance the QoL and clinical outcomes among PLHIV.
资源有限环境下的差异化服务提供（DSD）模式减轻了卫生服务的压力，并改善了诸如留存率和病毒抑制等临床结果，但对于HIV DSD模式对生活质量（QoL）的影响知之甚少，而生活质量对于优化以患者为中心的护理至关重要。本研究评估了在乌干达一家大型城市HIV诊所中，随着时间推移，DSD模式对接受抗逆转录病毒治疗（ART）的HIV感染者（PLHIV）的生活质量、失访（LTFU）和死亡率的影响。
对乌干达坎帕拉传染病研究所（IDI）诊所10年队列中登记的1000名PLHIV的记录进行回顾性分析。使用改编后的医学结局研究（MOS-HIV）工具评估生活质量。比较了连续≥6个月处于三种DSD模式——快速药物 refill（FTDR）、基于机构的群组（FBG）以及将这两者结合的综合模式——与基于机构的个体管理（FBIM）或标准护理（SOC）的PLHIV的生活质量得分、持续年度病毒抑制（<200拷贝/mL）、全因死亡率和失访（≥3个月未就诊）情况。应用逆概率处理加权以实现协变量可比性，同时使用G计算检查结果的稳健性。使用优势比比较持续病毒抑制情况；使用Cox比例风险回归模型的风险比比较全因死亡率和失访情况。
在1000名PLHIV中，980名有≥1次随访并纳入分析。中位年龄为45岁（四分位间距：40 - 51岁），62%为女性，95%在基线时病毒载量得到抑制。任何DSD模式下的基线生活质量为90.1%，而SOC为89.2%。随访8年后，参与DSD模式的参与者的加权平均生活质量高于SOC（90.4%对89.1%；加权平均比3.66，95%置信区间2.10 - 6.37，p值<0.001）；各DSD模式之间无统计学差异。参与DSD模式的参与者更有可能实现持续病毒抑制（加权优势比1.69，95%置信区间1.24 - 2.31）、死亡率更低（加权风险比0.08，95%置信区间0.03 - 0.20）以及失访率更低（加权风险比0.08，95%置信区间0.02 - 0.31）。
与标准护理相比，DSD模式与略高的生活质量、更好的数据抑制、更低的死亡率和失访率相关。这些发现支持在HIV项目中更广泛地采用DSD模式来提供ART，以提高PLHIV的生活质量和临床结果。
