Excess mortality associated with mental illness in people living with HIV in Cape Town, South Africa: a cohort study using linked electronic health records.
Excess mortality associated with mental illness in people living with HIV in Cape Town, South Africa: a cohort study using linked electronic health records.
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DOI：
10.1016/s2214-109x(20)30279-5
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发表时间：
2020-10
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影响因子：
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通讯作者：
IeDEA Southern Africa collaboration
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作者：
Haas AD;Ruffieux Y;van den Heuvel LL;Lund C;Boulle A;Euvrard J;Orrell C;Prozesky HW;Tiffin N;Lovero KL;Tlali M;Davies MA;Wainberg ML;IeDEA Southern Africa collaboration
精神障碍会对艾滋病毒的治疗结果和存活率产生不利影响。关于艾滋病毒阳性人群中精神障碍患者过早死亡的数据很少，特别是在低收入和中等收入国家。在这项研究中，我们量化了南非HIV阳性人群中与精神障碍相关的超额死亡率，并根据HIV治疗结果进行了调整。在这项队列研究中，我们分析了2004年1月1日至2017年12月31日期间在南非开普敦接受抗逆转录病毒治疗(ART)的艾滋病毒阳性成年人的常规收集数据。来自三个ART项目的数据与2010年1月1日至2017年12月31日期间精神健康治疗的常规医疗记录以及截至2017年12月31日的南非国家人口登记的死亡监测数据相关联。在项目现场发起抗逆转录病毒治疗的15岁或15岁以上的艾滋病毒携带者有资格接受分析。我们对患者进行了随访，从ART启蒙或2010年1月1日起，以发生时间较晚的为准，到2017年12月31日或转院、死亡。如果患者曾接受过精神药物治疗或因精神障碍住院，则被视为有精神病史。我们使用COX比例风险回归和多状态模型计算了95%的CI的调整后的风险比(即精神病病史、死亡率和艾滋病毒治疗结果之间的关系)(保留在病毒载量抑制的护理中[病毒载量≥每毫升1000拷贝]，保留在非抑制性病毒载量的护理中[病毒载量NVL；病毒载量每毫升1000拷贝]，以及失去随访[LTFU；>；在关闭数据库时延迟180天进行临床访问])。对58664例患者进行了中位时间4.3年(IQR2.16.4.)的随访，其中2927例(5.0%)有精神病史。在调整了年龄、性别、治疗方案和开始抗逆转录病毒治疗的年份后，与无精神病史相比，精神疾病史与各种原因(AHR 2·98[95%CI 2·69-3·30])、自然原因(3·00[2·69-3·36])和非自然原因(2·10[1·27-3·49])的死亡风险增加相关。根据年龄、性别、治疗方案、开始抗逆转录病毒治疗的年份、开始抗逆转录病毒治疗时的CD4计数和世界卫生组织临床分期、在接受或不接受VLS的HIV治疗中的留存情况以及LTFU(2·73[2·46-3·02])进行多变量分析，有精神疾病病史的人全因死亡的风险仍然增加。在我们的多态模型中，根据年龄、性别、首次接受ART治疗的年份、NVL的累积时间、WHO临床分期和ART开始时的CD4细胞计数进行调整后，有精神疾病病史的患者中有精神疾病史的患者的超额全因死亡率在接受VLS治疗的患者中最高(AHR 3·43[95%CI 2·83-4·15])，其次是接受NVL治疗的患者(2·74[2·32-3·24])，而在LTFU患者中最小(2·12[1·78-2·53])。精神病史还与VLS患者HIV病毒反弹(从VLS转变为NVL；1·50[1·32-1·69])和LTFU(1·19[1·06-1·34])的风险增加相关。在开普敦，精神疾病与艾滋病毒阳性成年人的大量超额死亡率有关。有精神疾病病史的人死亡率过高与艾滋病毒治疗的成功无关。减少过高死亡率的干预措施应满足艾滋病毒携带者和精神病患者复杂的身心健康护理需求。国家卫生研究院、瑞士国家科学基金会、南非医学研究理事会。
Mental disorders can adversely affect HIV treatment outcomes and survival. Data are scarce on premature deaths in people with mental disorders in HIV-positive populations, particularly in low-income and middle-income countries. In this study, we quantified excess mortality associated with mental disorders in HIV-positive people in South Africa, adjusting for HIV treatment outcomes. For this cohort study, we analysed routinely collected data on HIV-positive adults receiving antiretroviral therapy (ART) in Cape Town, South Africa between Jan 1, 2004, to Dec 31, 2017. Data from three ART programmes were linked with routine medical records on mental health treatment from Jan 1, 2010, to Dec 31, 2017, and mortality surveillance data from the South African National Population Register up to Dec 31, 2017. People living with HIV aged 15 years or older who initiated ART at a programme site were eligible for analysis. We followed up patients from ART initiation or Jan 1, 2010, whichever occurred later, to transfer, death, or Dec 31, 2017. Patients were considered as having a history of mental illness if they had ever received psychiatric medication or been hospitalised for a mental disorder. We calculated adjusted hazard ratios (aHRs) with 95% CIs for associations between history of mental illness, mortality, and HIV treatment outcomes (retention in care with viral load suppression [VLS; viral load <1000 copies per mL], retention in care with non-suppressed viral load [NVL; viral load ≥1000 copies per mL], and loss to follow-up [LTFU; >180 days late for a clinic visit at closure of the database]) using Cox proportional hazard regression and multistate models. 58 664 patients were followed up for a median of 4·3 years (IQR 2·1–6·4), 2927 (5·0%) of whom had a history of mental illness. After adjustment for age, sex, treatment programme, and year of ART initiation, history of mental illness was associated with increased risk of mortality from all causes (aHR 2·98 [95% CI 2·69–3·30]), natural causes (3·00 [2·69–3·36]), and unnatural causes (2·10 [1·27–3·49]), compared with no history of mental illness. Risk of all-cause mortality in people with a history of mental illness remained increased in multivariable analysis adjusted for age, sex, treatment programme, year of ART initiation, CD4 count and WHO clinical stage at ART initiation, retention in HIV care with or without VLS, and LTFU (2·73 [2·46–3·02]). In our multistate model, adjusted for age, sex, year of ART initiation, cumulative time with NVL, and WHO clinical stage and CD4 cell count at ART initiation, rates of excess all-cause mortality in people with history of mental illness were greatest in patients retained in care with VLS (aHR 3·43 [95% CI 2·83–4·15]), followed by patients retained in care with NVL (2·74 [2·32–3·24]), and smallest in those LTFU (2·12 [1·78–2·53]). History of mental illness was also associated with increased risk of HIV viral rebound (transitioning from VLS to NVL; 1·50 [1·32–1·69]) and LTFU in people with VLS (1·19 [1·06–1·34]). Mental illness was associated with substantial excess mortality in HIV-positive adults in Cape Town. Excess mortality among people with a history of mental illness occurred independently of HIV treatment success. Interventions to reduce excess mortality should address the complex physical and mental health-care needs of people living with HIV and mental illness. National Institutes of Health, Swiss National Science Foundation, South African Medical Research Council.