How have ART treatment programmes changed the patterns of excess mortality in people living with HIV? Estimates from four countries in East and Southern Africa.
How have ART treatment programmes changed the patterns of excess mortality in people living with HIV? Estimates from four countries in East and Southern Africa.
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DOI：
10.3402/gha.v7.22789
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发表时间：
2014
影响因子：
2.6
通讯作者：
Zaba B
中科院分区：
文献类型：
--
作者：
Slaymaker E;Todd J;Marston M;Calvert C;Michael D;Nakiyingi-Miiro J;Crampin A;Lutalo T;Herbst K;Zaba B
自从在撒哈拉以南非洲采用抗逆转录病毒疗法以来，艾滋病毒感染者的死亡率已大幅下降福尔斯。然而，在许多国家，抗逆转录病毒疗法的获得和使用情况各不相同。我们报告了艾滋病病毒携带者在引入抗逆转录病毒疗法前后的超额死亡情况。我们使用了来自马拉维、南非、坦桑尼亚和乌干达的五项纵向研究的数据，这些研究是非洲纵向人口艾滋病数据分析网络（ALPHA）的成员。来自五个进行艾滋病毒检测的人口监测点的个人数据被用来估计艾滋病毒导致的死亡率，计算为艾滋病毒携带者和艾滋病毒阴性者死亡率之间的差异。PLWH中的过量死亡按年龄和性别差异进行标准化，并在ART普遍可用之前和之后的时期进行总结。指数回归模型被用来探索ART在不同地点的影响差异。五个地点的127，585名成年人总共贡献了487，242人年。在引入ART之前，艾滋病毒导致的死亡率为每1，000人年45至88人死亡。在提供抗逆转录病毒疗法后，死亡人数减少到每1 000人年14-46人。指数回归模型显示，与ART可用之前的时期相比，所有5个研究中心15-54岁的死亡率降低了50%以上（HR =0.43，95%CI：0.32-0.58）。自抗逆转录病毒疗法问世以来，撒哈拉以南非洲五个社区的艾滋病毒感染者的超额死亡率降低了50%以上。然而，艾滋病毒感染者的死亡率仍然比艾滋病毒阴性者高出10倍，这表明在进一步降低死亡率方面还可以作出重大改进。该分析显示了不同地点的影响差异，并与发达国家形成对比，在发达国家，艾滋病毒携带者艾滋病病毒感染者接受抗逆转录病毒治疗的死亡率与一般人群相似。迫切需要进一步研究，以确定为什么观察到对死亡率的不同影响，以及这些国家的护理和治疗方案如何能够更有效地进一步降低死亡率。
Substantial falls in the mortality of people living with HIV (PLWH) have been observed since the introduction of antiretroviral therapy (ART) in sub-Saharan Africa. However, access and uptake of ART have been variable in many countries. We report the excess deaths observed in PLWH before and after the introduction of ART. We use data from five longitudinal studies in Malawi, South Africa, Tanzania, and Uganda, members of the network for Analysing Longitudinal Population-based HIV/AIDS data on Africa (ALPHA). Individual data from five demographic surveillance sites that conduct HIV testing were used to estimate mortality attributable to HIV, calculated as the difference between the mortality rates in PLWH and HIV-negative people. Excess deaths in PLWH were standardized for age and sex differences and summarized over periods before and after ART became generally available. An exponential regression model was used to explore differences in the impact of ART over the different sites. 127,585 adults across the five sites contributed a total of 487,242 person years. Before the introduction of ART, HIV-attributable mortality ranged from 45 to 88 deaths per 1,000 person years. Following ART availability, this reduced to 14–46 deaths per 1,000 person years. Exponential regression modeling showed a reduction of more than 50% (HR =0.43, 95% CI: 0.32–0.58), compared to the period before ART was available, in mortality at ages 15–54 across all five sites. Excess mortality in adults living with HIV has reduced by over 50% in five communities in sub-Saharan Africa since the advent of ART. However, mortality rates in adults living with HIV are still 10 times higher than in HIV-negative people, indicating that substantial improvements can be made to reduce mortality further. This analysis shows differences in the impact across the sites, and contrasts with developed countries where mortality among PLWH on ART can be similar to that of the general population. Further research is urgently needed to establish why the different impacts on mortality were observed and how the care and treatment programmes in these countries can be more effective in reducing mortality further.