Graham N M, Jacobson L P, Kuo V, Chmiel J S, Morgenstern H, Zucconi S L
Department of Epidemiology, Johns Hopkins University, School of Hygiene and Public Health, Baltimore, MD 21205, USA.
J Clin Epidemiol. 1994 Sep;47(9):1003-12. doi: 10.1016/0895-4356(94)90115-5.
The study aims were (i) to describe secular trends in the utilization of antiretrovirals, antivirals, Pneumocystis carinii pneumonia (PCP) prophylaxis, and antifungal prophylaxis and (ii) to determine whether factors such as clinical status, health services utilization, insurance status, income, education and race were associated with access to therapy. Data on utilization of therapy, health services utilization, income and insurance status were collected semiannually from October 1990 through March 1992 from 1415 homosexual/bisexual HIV-1 seropositive men in the Multicenter AIDS Cohort Study (MACS). Prevalence of therapy use according to level of immunosuppression was determined at each study visit. Clinical AIDS was defined using the 1987 CDC definition. Factors associated with use of antiretroviral therapy and PCP prophylaxis were assessed using multiple logistic regression with robust variance techniques to adjust variance estimates and significance levels for within-person correlations of drug use over time. Prevalence of zidovudine use remained relatively constant throughout the study period. In contrast, use of didanosine (21-34%), acyclovir (23-34%) and dideoxycytidine (zalcitabine) (8-25%) increased in participants with clinical AIDS. Similar trends were seen for combination antiretroviral therapy, trimethoprim-sulfamethoxazole, dapsone, ketoconazole and fluconazole. However, reported use of aerosolized pentamidine fell. After adjusting for CD4+ lymphocyte count and HIV-1 symptoms, previous HIV-related hospitalization (OR = 1.52; 95% CI = 1.22-1.91), outpatient visit (OR = 2.83; 95% CI = 2.12-3.78), having insurance (OR = 1.32; 95% CI = 1.01-1.75), college education (OR = 1.42; 95% CI = 1.13-1.80) and white race (OR = 1.58; 95% CI = 1.21-2.07) were all associated with being on antiretroviral therapy in persons without clinical AIDS. In persons with clinical AIDS, having insurance (OR = 2.89; 95% CI = 1.04-8.02) and a previous outpatient visit (OR = 11.69; 95% CI = 1.77-77.30) were the significant variables. Factors significantly associated with being on PCP prophylaxis in multivariate models were previous hospitalization, previous outpatient visit, and college education (for subjects without clinical AIDS.
（i）描述抗逆转录病毒药物、抗病毒药物、卡氏肺孢子虫肺炎（PCP）预防用药及抗真菌预防用药的使用情况的长期趋势；（ii）确定诸如临床状况、医疗服务利用情况、保险状况、收入、教育程度和种族等因素是否与获得治疗的机会相关。从1990年10月至1992年3月，每半年从多中心艾滋病队列研究（MACS）中的1415名同性恋/双性恋HIV-1血清阳性男性中收集治疗使用情况、医疗服务利用情况、收入和保险状况的数据。在每次研究访视时，根据免疫抑制水平确定治疗使用的患病率。临床艾滋病根据1987年美国疾病控制与预防中心（CDC）的定义来界定。使用多因素逻辑回归和稳健方差技术评估与抗逆转录病毒治疗及PCP预防用药使用相关的因素，以调整方差估计值及药物使用随时间的个体内相关性的显著性水平。在整个研究期间，齐多夫定的使用患病率保持相对稳定。相比之下，患临床艾滋病的参与者中，去羟肌苷（21%-34%）、阿昔洛韦（23%-34%）和双脱氧胞苷（扎西他滨）（8%-25%）的使用有所增加。联合抗逆转录病毒治疗、甲氧苄啶-磺胺甲恶唑、氨苯砜、酮康唑和氟康唑也出现了类似趋势。然而，雾化戊烷脒的报告使用量有所下降。在调整了CD4 +淋巴细胞计数和HIV-1症状后，既往HIV相关住院（比值比[OR]=1.52；95%置信区间[CI]=1.22-1.91）、门诊就诊（OR = 2.83；95% CI = 2.12-3.78）、拥有保险（OR = 1.32；95% CI = 1.01-1.75）、大学教育程度（OR = 1.42；95% CI = 1.13-1.80）和白人种族（OR = 1.58；95% CI = 1.21-2.07）均与未患临床艾滋病者接受抗逆转录病毒治疗相关。在患临床艾滋病者中，拥有保险（OR = 2.89；95% CI = 1.04-8.02）和既往门诊就诊（OR = 11.69；95% CI = 1.77-77.30）是显著变量。在多变量模型中，与接受PCP预防用药显著相关因素是既往住院、既往门诊就诊和大学教育程度（针对未患临床艾滋病的受试者）。
