Human Immunodeficiency Virus Transmission at Each Step of the Care Continuum in the United States
Human Immunodeficiency Virus Transmission at Each Step of the Care Continuum in the United States
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DOI：
10.1001/jamainternmed.2014.8180
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发表时间：
2015-04-01
影响因子：
39
通讯作者：
Mermin, Jonathan H.
中科院分区：
文献类型：
--
作者：
Skarbinski, Jacek;Rosenberg, Eli;Mermin, Jonathan H.
重要：人类免疫缺陷病毒(HIV)的传播风险主要取决于行为(性行为和注射吸毒)和HIV病毒载量。国家目标强调最大限度地扩大HIV护理连续体的覆盖率，但对HIV预防的影响尚不清楚。目的估计在以下5个HIV护理连续体步骤中的每一个步骤中可归因于人的艾滋病毒传播率和数量：HIV感染但未确诊、HIV确诊但未保留在医疗护理中、保留在护理中但未开出抗逆转录病毒治疗处方、开出抗逆转录病毒疗法但未被病毒抑制、以及病毒被抑制。设计、设置和参与者多步骤、静态、确定性模型，将来自国家艾滋病毒监测系统的人口分母数据与来自国家艾滋病毒行为监测系统和医疗监测项目的详细临床和行为数据相结合，以估计沿护理连续体系的传播率和传播量。这项分析是在2013年1月至2014年6月进行的。结果在2009年估计的1 148 200名艾滋病毒携带者中，有207 600人(18.1%)未确诊，519 414人(45.2%)已知道感染但未被保留在护理中，47 453人(4.1%)仍在接受护理，82 809人(7.2%)接受抗逆转录病毒药物治疗但未被病毒抑制，290 924人(25.3%)被病毒抑制。在2009年估计的45000例艾滋病毒传播中，91.5%(分别为30.2%和61.3%)是艾滋病毒感染者(占感染艾滋病毒人口总数的18.1%)和确诊但未继续接受医疗护理的人(占人口的45.2%)造成的。与感染艾滋病毒但未确诊的人(每100人年传播6.6例)相比，确诊并未保留在医疗护理中的人传播艾滋病毒的可能性降低19.0%(每100人年传播5.3例)，经病毒抑制的人传播艾滋病毒的可能性降低94.0%(每100人年传播0.4例)。男性、通过男男性接触感染HIV的人和35-44岁的人分别是按性别、HIV感染风险类别和年龄组传播HIV最多的人。结论和相关性HIV护理连续统中的序贯步骤与HIV传播率的降低有关。主要针对未确诊和未接受抗逆转录病毒治疗的人，改进艾滋病毒诊断和保留护理，以及减少性行为和吸毒危险行为，将对美国的艾滋病毒传播产生重大影响。
IMPORTANCE Human immunodeficiency virus (HIV) transmission risk is primarily dependent on behavior (sexual and injection drug use) and HIV viral load. National goals emphasize maximizing coverage along the HIV care continuum, but the effect on HIV prevention is unknown.OBJECTIVES To estimate the rate and number of HIV transmissions attributable to persons at each of the following 5 HIV care continuum steps: HIV infected but undiagnosed, HIV diagnosed but not retained in medical care, retained in care but not prescribed antiretroviral therapy, prescribed antiretroviral therapy but not virally suppressed, and virally suppressed.DESIGN, SETTING, AND PARTICIPANTS A multistep, static, deterministic model that combined population denominator data from the National HIV Surveillance System with detailed clinical and behavioral data from the National HIV Behavioral Surveillance System and the Medical Monitoring Project to estimate the rate and number of transmissions along the care continuum. This analysis was conducted January 2013 to June 2014. The findings reflect the HIV-infected population in the United States in 2009.MAIN OUTCOMES AND MEASURES Estimated rate and number of HIV transmissions.RESULTS Of the estimated 1 148 200 persons living with HIV in 2009, there were 207 600 (18.1%) who were undiagnosed, 519 414 (45.2%) were aware of their infection but not retained in care, 47 453 (4.1%) were retained in care but not prescribed ART, 82 809 (7.2%) were prescribed ART but not virally suppressed, and 290 924 (25.3%) were virally suppressed. Persons who are HIV infected but undiagnosed (18.1% of the total HIV-infected population) and persons who are HIV diagnosed but not retained in medical care (45.2% of the population) were responsible for 91.5%(30.2% and 61.3%, respectively) of the estimated 45 000 HIV transmissions in 2009. Compared with persons who are HIV infected but undiagnosed (6.6 transmissions per 100 person-years), persons who were HIV diagnosed and not retained in medical care were 19.0%(5.3 transmissions per 100 person-years) less likely to transmit HIV, and persons who were virally suppressed were 94.0%(0.4 transmissions per 100 person-years) less likely to transmit HIV. Men, those who acquired HIV via male-to-male sexual contact, and persons 35 to 44 years old were responsible for the most HIV transmissions by sex, HIV acquisition risk category, and age group, respectively.CONCLUSIONS AND RELEVANCE Sequential steps along the HIV care continuum were associated with reduced HIV transmission rates. Improvements in HIV diagnosis and retention in care, as well as reductions in sexual and drug use risk behavior, primarily for persons undiagnosed and not receiving antiretroviral therapy, would have a substantial effect on HIV transmission in the United States.