Measuring the Impact of Antiretroviral Therapy Roll-Out on Population Level Fertility in Three African Countries.
Measuring the Impact of Antiretroviral Therapy Roll-Out on Population Level Fertility in Three African Countries.
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DOI：
10.1371/journal.pone.0151877
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发表时间：
2016
期刊：
影响因子：
3.7
通讯作者：
ALPHA network
中科院分区：
文献类型：
--
作者：
Marston M;Nakiyingi-Miiro J;Hosegood V;Lutalo T;Mtenga B;Zaba B;ALPHA network
艾滋病规划署对国家艾滋病毒流行率的官方估计是根据产前诊所监测中观察到的趋势，对艾滋病毒阳性妇女生育率下降进行调整后得出的。接受抗逆转录病毒治疗可能会影响艾滋病毒阳性妇女的生育能力，这意味着需要重新估计这些计算中使用的调整因子。我们分析了抗逆转录病毒治疗（ART）对南部和东部非洲人口水平生育率的影响，比较了感染艾滋病毒妇女的趋势与未感染妇女的长期趋势。我们使用了来自四个社区人口统计和艾滋病毒监测点的生育数据：Kisesa（坦桑尼亚）、Masaka和Rakai（乌干达）以及uMkhanyakude（南非）。所有15-44岁妇女的分娩都被纳入分析，并按母亲的年龄和分娩时的艾滋病毒状况以及社区中抗逆转录病毒治疗的可获得性进行分类。各试验点引入抗逆转录病毒治疗相关数据的日历时间段各不相同，从推出抗逆转录病毒治疗前的5年到推出抗逆转录病毒治疗后的9年不等。日历时间根据抗逆转录病毒治疗的可获得性进行分类，分为抗逆转录病毒治疗前、抗逆转录病毒治疗引入（至少在一个为研究地点服务的卫生机构提供）和可获得抗逆转录病毒治疗（在所有指定的为研究地点服务的卫生机构提供）。我们使用泊松回归计算HIV感染状况随时间变化的年龄调整生育率比率，并调查抗逆转录病毒治疗期间和HIV感染状况之间的相互作用，以确定HIV阳性和阴性妇女的趋势是否随时间变化而不同。在所有四项研究中，艾滋病毒阴性妇女的年龄调整生育率随着时间的推移显着下降。然而，艾滋病毒阳性者的生育率要么没有变化（Masaka, Rakai），要么在同一时期显著增加（Kisesa, uMkhanyakude）。抗逆转录病毒治疗前（年龄调整生育率（FRR）范围为0.51 95%CI 0.42-0.61 ~ 0.73 95%CI 0.64-0.83）和广泛应用抗逆转录病毒治疗时（FRR范围为0.57 95%CI 0.52-0.62 ~ 0.83 95%CI 0.78-0.87）， HIV阳性生育率均显著低于阴性生育率，但差异有所缩小。描述艾滋病毒阳性和阴性趋势差异的相互作用术语通常意义重大。随着抗逆转录病毒治疗在这些社区得到更广泛的应用，艾滋病毒阳性和艾滋病毒阴性妇女之间的生育能力差异正在逐渐缩小。为了估计国家艾滋病毒流行率，需要对ANC数据进行常规调整，以考虑到治疗的影响。
UNAIDS official estimates of national HIV prevalence are based on trends observed in antenatal clinic surveillance, after adjustment for the reduced fertility of HIV positive women. Uptake of ART may impact on the fertility of HIV positive women, implying a need to re-estimate the adjustment factors used in these calculations. We analyse the effect of antiretroviral therapy (ART) provision on population-level fertility in Southern and East Africa, comparing trends in HIV infected women against the secular trends observed in uninfected women. We used fertility data from four community-based demographic and HIV surveillance sites: Kisesa (Tanzania), Masaka and Rakai (Uganda) and uMkhanyakude (South Africa). All births to women aged 15–44 years old were included in the analysis, classified by mother’s age and HIV status at time of birth, and ART availability in the community. Calendar time period of data availability relative to ART Introduction varied across the sites, from 5 years prior to ART roll-out, to 9 years after. Calendar time was classified according to ART availability, grouped into pre ART, ART introduction (available in at least one health facility serving study site) and ART available (available in all designated health facilities serving study site). We used Poisson regression to calculate age adjusted fertility rate ratios over time by HIV status, and investigated the interaction between ART period and HIV status to ascertain whether trends over time were different for HIV positive and negative women. Age-adjusted fertility rates declined significantly over time for HIV negative women in all four studies. However HIV positives either had no change in fertility (Masaka, Rakai) or experienced a significant increase over the same period (Kisesa, uMkhanyakude). HIV positive fertility was significantly lower than negative in both the pre ART period (age adjusted fertility rate ratio (FRR) range 0.51 95%CI 0.42–0.61 to 0.73 95%CI 0.64–0.83) and when ART was widely available (FRR range 0.57 95%CI 0.52–0.62 to 0.83 95%CI 0.78–0.87), but the difference has narrowed. The interaction terms describing the difference in trends between HIV positives and negatives are generally significant. Differences in fertility between HIV positive and HIV negative women are narrowing over time as ART becomes more widely available in these communities. Routine adjustment of ANC data for estimating national HIV prevalence will need to allow for the impact of treatment.