Implementation and outcomes of dolutegravir-based first-line antiretroviral therapy for people with HIV in South Africa: a retrospective cohort study.
Implementation and outcomes of dolutegravir-based first-line antiretroviral therapy for people with HIV in South Africa: a retrospective cohort study.
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DOI：
10.1016/s2352-3018(23)00047-4
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发表时间：
2023-05
期刊：
影响因子：
16.1
通讯作者：
Garrett, Nigel
中科院分区：
文献类型：
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作者：
Dorward, Jienchi;Sookrajh, Yukteshwar;Khubone, Thokozani;van der Molen, Johan;Govender, Riona;Phakathi, Sifiso;Lewis, Lara;Bottomley, Christian;Maraj, Munthra;Lessells, Richard J.;Naidoo, Kogieleum;Butler, Christopher C.;Van Heerden, Rose;Garrett, Nigel
在低收入和中等收入国家，很少有数据评估艾滋病毒携带者中男性和女性对多洛替格韦一线的吸收情况，以及随后在非试验环境中的临床结果。我们的目标是确定女性对多洛替格雷的摄取，以及在南非常规护理中多洛替格韦对临床结果的影响。我们使用两个不同的队列，分析了2019年12月至2022年2月期间在南非59家诊所接受一线抗逆转录病毒治疗的成年人的未确认数据。在“启动者队列”中，我们使用泊松回归模型按性别评估基于多洛替格韦的抗逆转录病毒疗法的启动，以及多洛替格韦的使用与12个月的保留期和病毒抑制&50拷贝/毫升之间的关系。在2019年12月接受非多氯替格列韦一线抗逆转录病毒治疗的成年人组成的“过渡队列”中，我们使用COX比例风险模型按性别评估过渡到一线多洛替格韦的风险。然后，我们使用与时间相关的倾向评分匹配，比较了在同一时间点过渡到多洛替格雷的人和那些尚未过渡的人之间随后12个月的留院护理和病毒抑制情况。在45,392名启动抗逆转录病毒治疗的成年人中，28,725名(63.3%)是女性，中位年龄为31岁(IQR 26，38)，启动多洛替格韦的患者为31,264名(69.9%)。非孕组(危险度差异[RD]−18.4%[−21.6，−15.2])和孕妇组(RD−35.4%[−42.3，−28.5])的多洛替格韦起始量均低于男性。在12个月时，多洛替格韦启动剂的保留率(调整后的RD5.2%[2.2.8.4])和病毒抑制(ARD3.1%[1.2.5.1%])较高。在2019年12月接受一线抗逆转录病毒治疗的180,956名成年人中，年龄中值为38岁(32，45岁)，其中124,168名(68.6%)为女性，98.6%接受了Eefavirenz治疗。到2022年2月，121,210/158,999名接受护理的患者(76.2%)过渡到一线多洛替格雷。女性过渡较低(风险比为0·56，[0·56，0·57])。在92,318个倾向得分匹配的人中，多洛替格韦组的12个月保留期(ARD 2.5%[2.1-2.9])和病毒抑制(ARD 0.8%[0.3，1.4])略高于非多洛替格韦组。女性接受多洛替格列韦的可能性较小。由于多洛替格列韦与更好的结果相关，应该继续推广，特别强调纳入妇女。惠康信托；非洲牛津倡议；国际艾滋病护理提供者协会，比尔和梅琳达·盖茨基金会
There is little data evaluating uptake of first-line dolutegravir among men and women living with HIV in low- and middle-income countries, and subsequent clinical outcomes in non-trial settings. We aimed to determine dolutegravir uptake in women, and the impact of dolutegravir on clinical outcomes in routine care in South Africa. We analysed de-identified data from adults receiving first-line ART at 59 South African clinics from December 2019 to February 2022, using two distinct cohorts. In the ‘initiator cohort’, we used Poisson regression models to assess initiation with dolutegravir-based ART by gender, and associations between dolutegravir use and 12-month retention-in-care and viral suppression <50 copies/mL. In the ‘transition cohort’, consisting of adults receiving non-dolutegravir-based first-line ART in December 2019, we used Cox proportional hazards models to assess the hazard of transition to first-line dolutegravir by gender. We then used time-dependent propensity score matching to compare subsequent 12-month retention-in-care and viral suppression between people transitioned to dolutegravir, and those who had not yet transitioned at the same timepoint. Of 45,392 adults initiating ART, 28,725 (63·3%) were women, median age was 31 years (IQR 26,38), and 31,264 (69·9%) initiated dolutegravir. Dolutegravir initiation was lower in non-pregnant (risk difference [RD] −18·4% [−21·6,−15·2]) and pregnant women (RD −35·4% [−42·3,−28·5]) versus men. At 12-months, retention-in-care (adjusted RD 5·2% [2·2,8·4)) and viral suppression (aRD 3·1% [1·2,5·1]) was higher in dolutegravir initiators. Among 180,956 adults receiving first-line ART in December 2019, median age was 38 years (32,45), 124,168 (68·6%) were women and 98·6% received efavirenz. By February 2022, 121,210/158,999 (76·2%) of those in care were transitioned to first-line dolutegravir. Transition was lower in women (hazard ratio 0·56, [0·56,0·57]). Among 92,318 propensity score matched people, 12-month retention-in-care (aRD 2·5% [2·1–2·9]) and viral suppression (aRD 0.8% [0.3,1.4]) were slightly higher in the dolutegravir versus non-dolutegravir group. Women were less likely to receive dolutegravir. As dolutegravir was associated with better outcomes, the rollout should continue, with a particular emphasis on inclusion of women. Wellcome Trust; Africa Oxford Initiative; International Association of Providers of AIDS Care, Bill & Melinda Gates Foundation