Estimating retention in HIV care accounting for patient transfers: A national laboratory cohort study in South Africa.
Estimating retention in HIV care accounting for patient transfers: A national laboratory cohort study in South Africa.
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估计患者转学的艾滋病毒护理会计保留率：南非的国家实验室队列研究。
DOI：
10.1371/journal.pmed.1002589
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发表时间：
2018-06
期刊：
影响因子：
15.8
通讯作者：
Carmona S
中科院分区：
文献类型：
--
作者：
Fox MP;Bor J;Brennan AT;MacLeod WB;Maskew M;Stevens WS;Carmona S
系统性综述描述了接受抗逆转录病毒治疗（ART）的HIV患者的高脱落率。然而，迁移和临床转移可能导致高估损耗（死亡和失访）。使用一个新链接的南非国家实验室数据库，我们评估了南非国家艾滋病规划的国家保留。在南非国家艾滋病毒项目中接受治疗的患者通过定期的CD 4计数和病毒载量检测进行监测。自2004年以来，南非国家卫生实验室服务局一直在维护一个所有公共部门CD 4计数和病毒载量结果的数据库。我们使用概率匹配技术将个体实验室结果与患者联系起来，创建了一个全国性的HIV队列。与手动匹配的数据集相比，我们的方法的验证显示9.0%的匹配不足和9.5%的匹配过度。我们分析了2004年4月1日至2006年12月31日在公共部门开始ART的患者的数据，当时ART的开始可以根据治疗遵循指南的患者中的首次病毒载量来确定。在患者最后一次观察到实验室测量的日期发生Atremoval，允许患者在该日期之前退出和重新进入护理。所有患者均接受了6年的潜在随访，并在6年时保留额外2年的最终实验室测量结果。数据于2012年12月31日删失。我们评估了（a）国家保留，包括所有实验室检测，无论检测设施如何;（B）启动设施保留，其中忽略了其他设施的实验室检测。我们在2004年至2006年期间对55，836名开始ART的患者进行了随访。在ART开始时，中位年龄为36岁（IQR：30-43），中位CD 4计数为150个细胞/mm 3（IQR：81-230），66.7%为女性。6年初始门诊保留率为29.1%（95% CI：28.7%-29.5%）。考虑到转移后，全国6年保留率为63.3%（95% CI：62.9%-63.7%）。当收紧或放松匹配程序时，结果差别不大。我们发现各省的保留率存在很大差异，6年时从西开普省的74.2%（95%CI：73.2%-75.2%）到普马兰加省的52.2%（95%CI：50.6%-53.7%）。在较低的CD 4计数和较高的病毒载量开始的患者中，以及在较大设施开始ART的患者中，国家损耗较高。该研究的主要局限性是缺乏完美的队列匹配，这可能导致过度或低估的保留。我们也没有夸祖鲁-纳塔尔省2010年之前的数据。在这项研究中，艾滋病毒护理保留是从国家的角度来看，远远高于从设施的角度来看。我们的研究结果表明，传统的临床队列低估了保留。在一项大型观察性研究中，Matthew Fox及其同事调查了南非艾滋病护理的保留情况，允许诊所之间的患者转移。自从在资源有限的环境中大规模推出艾滋病毒治疗以来，有证据表明，保留艾滋病毒治疗方案（即，患者存活并在护理中）一直是次优的。然而，到目前为止，大多数分析都是从单个队列的角度进行的，研究人员没有能力追踪从一个艾滋病毒治疗地点转移到另一个艾滋病毒治疗地点的患者，我们怀疑这是常见的。如果不考虑诊所之间的病人流动（有时被称为“无声转移”），可能会使对护理保留的估计看起来比实际情况更糟，这对规划和在哪里采取干预措施以减少艾滋病毒项目的损失产生影响。我们利用了这样一个事实，即南非有一个全国性的实验室调查提供者，即国家卫生实验室服务（NHLS），自2004年开始实施治疗计划以来，该服务一直保持着南非大多数患者的结果（夸祖鲁-纳塔尔省除外）。我们使用概率匹配技术将这些数据转化为纵向队列，可用于确定患者何时失访以及何时在诊所之间移动。这使我们能够从诊所的角度（最常报告的角度）和国家的角度（考虑到站点之间的移动）比较护理保留。我们发现，从临床角度来看，在2004年至2006年期间根据国家指南开始艾滋病毒治疗的患者中，29.1%的患者在6年后仍在接受治疗。然而，从国家的角度来看，考虑到诊所之间的流动，6年时的保留率估计为63.3%。我们的研究结果表明，在南非的艾滋病毒诊所之间有很大的流动，忽视这些流动有可能大大低估艾滋病毒护理的保留。未来的努力，看看这些趋势是否继续在以后的队列将是重要的，以制定有效的干预措施，旨在减少艾滋病毒护理的损失。
Systematic reviews have described high rates of attrition in patients with HIV receiving antiretroviral therapy (ART). However, migration and clinical transfer may lead to an overestimation of attrition (death and loss to follow-up). Using a newly linked national laboratory database in South Africa, we assessed national retention in South Africa’s national HIV program. Patients receiving care in South Africa’s national HIV program are monitored through regular CD4 count and viral load testing. South Africa’s National Health Laboratory Service has maintained a database of all public-sector CD4 count and viral load results since 2004. We linked individual laboratory results to patients using probabilistic matching techniques, creating a national HIV cohort. Validation of our approach in comparison to a manually matched dataset showed 9.0% undermatching and 9.5% overmatching. We analyzed data on patients initiating ART in the public sector from April 1, 2004, to December 31, 2006, when ART initiation could be determined based on first viral load among those whose treatment followed guidelines. Attrition occurred on the date of a patient’s last observed laboratory measure, allowing patients to exit and reenter care prior to that date. All patients had 6 potential years of follow-up, with an additional 2 years to have a final laboratory measurement to be retained at 6 years. Data were censored at December 31, 2012. We assessed (a) national retention including all laboratory tests regardless of testing facility and (b) initiating facility retention, where laboratory tests at other facilities were ignored. We followed 55,836 patients initiating ART between 2004 and 2006. At ART initiation, median age was 36 years (IQR: 30–43), median CD4 count was 150 cells/mm3 (IQR: 81–230), and 66.7% were female. Six-year initiating clinic retention was 29.1% (95% CI: 28.7%–29.5%). After allowing for transfers, national 6-year retention was 63.3% (95% CI: 62.9%–63.7%). Results differed little when tightening or relaxing matching procedures. We found strong differences in retention by province, ranging from 74.2% (95% CI: 73.2%–75.2%) in Western Cape to 52.2% (95% CI: 50.6%–53.7%) in Mpumalanga at 6 years. National attrition was higher among patients initiating at lower CD4 counts and higher viral loads, and among patients initiating ART at larger facilities. The study’s main limitation is lack of perfect cohort matching, which may lead to over- or underestimation of retention. We also did not have data from KwaZulu-Natal province prior to 2010. In this study, HIV care retention was substantially higher when viewed from a national perspective than from a facility perspective. Our results suggest that traditional clinical cohorts underestimate retention. In a large observational study, Matthew Fox and colleagues investigate retention in HIV care in South Africa allowing for patient transfers between clinics. Since the large-scale rollout of HIV treatment in resource-limited settings, evidence suggests that retention in HIV treatment programs (i.e., patients being alive and in care) has been suboptimal. However, to date, most analyses have been from the perspective of individual cohorts where researchers do not have the ability to trace patients who move from one HIV treatment site to another, something we suspect is common. Failure to account for patient movement between clinics (sometimes referred to as “silent transfer”) can make estimates of retention in care seem worse than they really are, and this has implications for planning and where to target interventions to reduce losses from HIV programs. We took advantage of the fact that South Africa has a national provider of laboratory investigations, the National Health Laboratory Service (NHLS), that has maintained results on most patients in South Africa since the beginning of the treatment program in 2004 (with the exception of KwaZulu-Natal province). We used probabilistic matching techniques to turn these data into a longitudinal cohort that could be used to determine when patients were lost to follow-up and when they moved between clinics. This allowed us to compare retention in care from the perspective of the clinic (the perspective most often reported) and from the national perspective, which accounts for movement between sites. We found that from the clinic perspective, among patients who started HIV treatment according to national guidelines between 2004 and 2006, 29.1% were still in care 6 years later. However, when looking from a national perspective, which accounted for movement between clinics, retention was estimated to be 63.3% at 6 years. Our findings suggest that there is substantial movement between HIV clinics in South Africa, and that ignoring these movements has the potential to strongly underestimate retention in HIV care. Future efforts to see if these trends continue in later cohorts will be important to developing effective interventions aimed at reducing loss from HIV care.
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DOI：
10.1097/qai.0000000000001284
发表时间：
2017-04-01
期刊：
Journal of acquired immune deficiency syndromes (1999)
影响因子：
--
作者：
Clouse K;Vermund SH;Maskew M;Lurie MN;MacLeod W;Malete G;Carmona S;Sherman G;Fox MP
通讯作者：
Fox MP
DOI：
10.1097/qai.0000000000000553
发表时间：
2015-05-01
期刊：
Journal of acquired immune deficiency syndromes (1999)
影响因子：
--
作者：
Fox MP;Rosen S
通讯作者：
Rosen S
影响因子：
7.7
作者：
Fox, Matthew P.;Maskew, Mhairi;Sanne, Ian M.
通讯作者：
Sanne, Ian M.
影响因子：
3.7
作者：
Brinkhof, Martin W. G.;Spycher, Ben D.;Sterne, Jonathan A. C.
通讯作者：
Sterne, Jonathan A. C.
影响因子：
158.5
作者：
Danel, Christine;Moh, Raoul;Anglaret, Xavier
通讯作者：
Anglaret, Xavier