HIV确诊后尽早启动治疗可能减少患者脱失

安靓; 楼金成; 杨根; 劳云飞

doi:10.16462/j.cnki.zhjbkz.2020.12.010

HIV确诊后尽早启动治疗可能减少患者脱失

doi: 10.16462/j.cnki.zhjbkz.2020.12.010

安靓^{1, 2},
楼金成¹,
杨根¹,
劳云飞^1, ,

1.
650301 昆明，云南省传染病医院/艾滋病关爱中心艾滋病临床管理办公室
2.
650500 昆明，昆明医科大学公共卫生学院

基金项目:

云南省科学技术厅昆明医科大学应用基础研究联合专项资金项目 202001AY070001-105

详细信息

通讯作者:
劳云飞，E-mail：laoyunfei@hotmail.com

中图分类号: R181;R512.91
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出版历程
- 收稿日期: 2020-01-15
- 修回日期: 2020-07-23
- 刊出日期: 2020-12-10

Early treatment initiation post- HIV diagnosis may reduce care dropout

AN Jing^{1, 2},
LOU Jin-cheng¹,
YANG Gen¹,
LAO Yun-fei^{1
, ,}

1.
Yunnan Provincial Infectious Disease Hospital, Yunnan AIDS Care Center, AIDS Clinical Management Office, Kunming 650301, China
2.
Kunming Medical University, School of Public Health, Kunming 650500, China

Funds:

Applied Basic Research Joint Special Fund Project of Kunming Medical University and Yunnan Provincial Department of Science and Technology 202001AY070001-105

More Information

Corresponding author: LAO Yun-fei, E-mail:laoyunfei@hotmail.com

摘要

摘要: 目的分析从人类免疫缺陷病毒(human immunodeficiency virus, HIV)确诊到启动治疗时间间隔对艾滋病抗病毒治疗中患者脱失的影响，为指导动员治疗咨询提供参考。方法对云南省15年艾滋病抗病毒治疗(antiretroviral therapy, ART)数据回顾性分析，用COX回归评估不同时间间隔组患者首次发生脱失的风险。结果 2004年-2018年在云南省接受ART的110 373例HIV感染者纳入分析，从HIV确诊到启动ART时间中位数47(11，550) d，中位随访2.63(0.88，5.28)年。其中47 974例(43.5%)患者在确诊HIV后30 d内启动ART，15 811例(14.3%)间隔时间在31~90 d，14 253(12.9%)例间隔时间在91~365 d，32 335例(29.3%)间隔时间超过365 d。总脱失率为6.77/100人年(95% CI：6.69~6.85)。以 < 30 d组为参照，30~ d组、91~ d组、>365 d组发生脱失的风险分别提高了10%、22%和14%。 < 30 d组、30~ d组、91~ d组、>365 d组患者治疗1年累计脱失率分别为11.4%、12.7%、15.0%和15.7%。结论通过真实世界数据证实：缩短从HIV确诊到启动ART时间间隔(30 d内)可以减少治疗中脱失。研究结果支持“艾滋病检测与治疗一站式服务”作为防治措施实施，并为云南省指导动员治疗咨询提供建议。
- HIV/AIDS /
- 抗病毒治疗 /
- 脱失
Abstract: Objective To analyze the effect of time interval from diagnosis of human immunodeficiency virus (HIV) to initiation of antiretroviral therapy (ART) on the dropout during treatment, and to provide reference for counseling on mobilization of ART. Methods COX regression was used to assess the risk of first dropout in patients with different time intervals. The data of 15- years ART in Yunnan Province were analyzed retrospectively. Results 110 373 cases of ART among people living with HIV in Yunnan from 2004 to 2018 were included in the analysis. the median time from the diagnosis of HIV to the start of ART was 47 (11 550) days, and the median follow-up was 2.63 (0.88, 5.28) years. Out of the total cases, 47 974 (43.5%) patients started ART within 30 days post-HIV-diagnosis, 15 811 (14.3%) patients had an interval of 31-90 days, 14 253 (12.9%) patients had an interval of 91-365 days, and 32 335 (29.3%) patients had an interval above 365 days. The total dropout rate was 6.77/100 person-years (95% CI:6.69-6.85). With the < 30 day group as the reference, the dropout risk in the 30-90 day group, the 91-365 day group and the >365 day group increased by 10%, 22% and 14%, respectively. In the groups of < 30- day, the 30-90 day, the 91-365 day and the >365 day, the cumulative dropout rates were respectively 11.4%, 12.7%, 15.0% and 15.7%. Conclusions Real-world data confirmed that shortening the time interval from HIV diagnosis to ART initiation (preferably within 30 days) can reduce treatment dropout. The results support the implementation of "one-stop AIDS testing and treatment service" as a prevention and treatment measure. This study provides powerful suggestions for Yunnan Province to guide the mobilization of treatment counseling.
- HIV/AIDS /
- Antiretroviral therapy /
- Treatment dropout

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图 1 不同诊断到启动治疗时间间隔的患者累计脱失率曲线

Figure 1. Cumulative loss rate curve of patients with different time intervals from diagnosis to initiation of treatment

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表 1 云南省不同HIV确诊到启动ART时间间隔病例人口学特征和相关变量情况[n(%)]

Table 1. The demographic characteristics and related variables of different groups at the time interval from HIV diagnosis to ART initiation in Yunnan Province [n(%)]

变量	从HIV确诊到启动ART时间间隔(d)				χ²/H值	P值
变量	< 30	30~	91~	>365	χ²/H值	P值
性别					8.2	0.041
男	29 954(62.4)	9 937(62.8)	8 740(61.3)	20 154(62.3)
女	18 020(37.6)	5 874(37.2)	5 513(38.7)	12 181(37.7)
婚姻					71 749.0	< 0.001
未婚	8 539(17.8)	3 115(19.8)	2 920(20.5)	7 249(22.4)
已婚或同居	31 916(66.5)	10 422(65.9)	9 251(64.9)	19 748(61.1)
离异或分居	4 425(9.2)	1 380(8.7)	1 309(9.2)	3 528(10.9)
丧偶	2 986(6.2)	844(5.3)	713(5.0)	1 526(4.7)
不详	108(0.2)	50(0.3)	60(0.4)	284(0.9)
传播途径					11 279.0	< 0.001
同性性传播	2 463(5.1)	635(4.0)	413(2.9)	495(1.5)
异性性传播	39 594(82.6)	1 2056(76.3)	9 899(69.6)	19 309(59.9)
静脉吸毒	3 039(6.3)	2 028(12.8)	2 936(20.6)	1 1052(34.3)
其他	2 828(5.9)	1 077(6.8)	982(6.9)	1 392(4.3)
HIV确诊年龄[岁, M(P₂₅，P₇₅)]	39.86(31.25, 50.38)	37.87(30.44, 47.32)	35.46(28.82, 44.01)	31.10(25.86, 37.54)	9 896.1	< 0.001
HIV确诊年龄(岁)					7 983.7	< 0.001
15~	10 328(21.5)	3 720 (23.5)	4 211(29.5)	14 478(44.8)
31~	25 295(52.7)	8 850(56.0)	7 877(55.3)	15 743(48.7)
>50	12 351(25.7)	3 241 (20.5)	2 164(15.2)	2 114(6.5)
ART启动时间(年)					6 488.6	< 0.001
< 2008	2 871(6.0)	1 892(12.0)	2 236(15.7)	2 744(8.5)
2008-2012	8 297(17.3)	4 588(29.0)	4 488(31.5)	10 546(32.6)
2013-2016	22 680(47.3)	6 488 (41.0)	5 459(38.3)	14 483(44.8)
>2016	14 126(29.4)	2 843(18.0)	2 070(14.5)	4 562(14.1)
开始ART时CD4计数[个/mm³, M(P₂₅，P₇₅)]	237(122, 357)	222(108, 334)	256(158, 361)	275(173, 386)	1 524.5	< 0.001
开始ART时CD4计数(个/mm³)					1 375.6	< 0.001
0~	19 728(41.9)	7 011(45.2)	4 914(35.4)	9 832(31.2)
200~	15 078(32.0)	5 068 (32.6)	5 278(38.0)	12 179(38.7)
350~	7 351(15.6)	2 034(13.1)	2 092(15.1)	5 450(17.3)
＞500	4 904(10.4)	1 413(9.1)	1 601(11.5)	4 035(12.8)
随访年[ M(P₂₅，P₇₅)]	2.21(0.75, 4.39)	3.03(0.99, 5.99)	3.22(0.98, 6.41)	3.13(0.99, 5.67)	1 646.3	< 0.001
HIV确诊到启动ART时间间隔[d, M(P₂₅，P₇₅)]	10(5, 17)	48(38, 65)	182(126, 26)	1 260(724, 2 099)	97 988.0	< 0.001

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表 2 从HIV确诊到启动ART时间间隔不同组脱失发生率

Table 2. Incidence of dropout in different groups at the time interval from HIV diagnosis to ART initiation

从HIV诊断到启动ART时间间隔(d)	病例数(n)	随访人年	脱失人数	脱失率(人/100人年)(95% CI)值
< 30	47 974	143 342.0	8 667	6.05(5.92~6.17)
30~	15 811	60 644.8	3 688	6.08(5.89~6.27)
91~	14 253	57 666.8	4 015	6.96(6.76~7.17)
>365	32 335	118 559.0	9 372	7.90(7.75~8.06)

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表 3 从HIV确诊到启动ART时间间隔与治疗中脱失的COX回归分析

Table 3. COX regression analysis of the time interval from HIV diagnosis to ART initiation and loss in treatment

变量	单因素HR(95% CI)值	P值	多因素调整HR(95% CI)值	P值
从HIV诊断到启动ART时间间隔(d)
< 30	1.00		1.00
30~	1.14(1.10~1.19)	< 0.001	1.10(1.06~1.14)	< 0.001
91~	1.35(1.30~1.40)	< 0.001	1.22(1.18~1.27)	< 0.001
>365	1.43(1.39~1.47)	< 0.001	1.14(1.10~1.18)	< 0.001
性别
男	1.00		1.00
女	0.80(0.78~0.83)	< 0.001	0.87(0.85~0.90)	< 0.001
婚姻
未婚	1.00		1.00
已婚或同居	0.72(0.70~0.74)	< 0.001	0.78(0.76~0.81)	< 0.001
离异或分居	0.96(0.92~1.00)	0.067	1.00(0.95~1.05)	0.998
丧偶	0.79(0.75~0.84)	< 0.001	0.94(0.88~1.00)	0.044
不详	0.92(0.77~1.11)	0.405	0.90(0.74~1.09)	0.293
HIV确诊年龄(岁)
15~	1.00		1.00
31~	0.88(0.86~0.91)	< 0.001	0.87(0.84~0.89)	< 0.001
>50	0.85(0.82~0.88)	< 0.001	1.00(0.96~1.05)	0.800
ART启动时间(年)
< 2008	1.00		1.00
2008-2012	1.13(1.08~1.18)	< 0.001	1.21(1.16~1.27)	< 0.001
2013-2016	1.12(1.07~1.16)	< 0.001	1.23(1.18~1.29)	< 0.001
>2016	0.79(0.75~0.84)	< 0.001	0.92(0.86~0.98)	0.008
传播途径
同性性传播	1.00		1.00
异性性传播	1.61(1.47~1.76)	< 0.001	2.04(1.85~2.24)	< 0.001
静脉吸毒	2.88(2.63~3.16)	< 0.001	3.36(3.05~3.70)	< 0.001
其他	1.56(1.40~1.73)	< 0.001	2.02(1.80~2.25)	< 0.001
入组时CD4计数(个/mm³)
< 200	1.00		1.00
200~	1.18(1.15~1.22)	< 0.001	1.17(1.13~1.20)	< 0.001
351~	1.14(1.10~1.19)	< 0.001	1.17(1.12~1.21)	< 0.001
>500	1.26(1.20~1.31)	< 0.001	1.29(1.23~1.35)	< 0.001
注：11 0373例病例纳入分析，有25 742例发生脱失，观察结局为病例首次发生脱失(定义为《成人随访及用药情况表》随访状态首次由“在治”转为“失访”或“停药”)，病例发生死亡或到2018年12月31日前最近1次随访时，该病例以右删失处理。

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