Clinical outcomes and CD4 cell response in children receiving antiretroviral therapy at primary health care facilities in Zambia
Clinical outcomes and CD4 cell response in children receiving antiretroviral therapy at primary health care facilities in Zambia
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DOI：
10.1001/jama.298.16.1888
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发表时间：
2007-10-24
影响因子：
120.7
通讯作者：
Stringer, Jeffrey S. A.
中科院分区：
文献类型：
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作者：
Bolton-Moore, Carolyn;Mubiana-Mbewe, Mwangelwa;Stringer, Jeffrey S. A.
赞比亚卫生部在卢萨卡的初级保健诊所提供儿科抗逆转录病毒治疗（ART），尽管在那里扩大了围产期预防工作，但许多儿童已经感染了人类免疫缺陷病毒（HIV）。目的报告参加儿科治疗项目的儿童的早期临床和免疫学结果。设计、设置和患者使用常规收集的临床和结果数据进行开放式队列评估，这些数据来自赞比亚卢萨卡18个政府初级卫生机构使用的电子病历系统。护理主要由护士和临床官员（“医师扩展者”，类似于美国的医师助理）提供。患者为2004年5月1日至2007年6月29日期间接受艾滋病毒治疗的儿童（< 16岁）。对符合国家治疗标准的儿童进行三种药物ART治疗（齐多夫定或司他夫定+拉米夫定+奈韦拉平或依非韦伦）。主要结局指标：生存、体重增加、CD4细胞计数和血红蛋白反应。结果4975名儿童接受HIV护理后，有2938名（59.1%）开始抗逆转录病毒治疗。在开始抗逆转录病毒治疗的患者中，中位年龄为81个月（四分位数范围为36-125），1531名（52.1%）为女性，2087名（72.4%）根据世界卫生组织的分期信息处于III期或IV期。在分析时，158名儿童（5.4%）已经退出护理，382名（13.0%）至少延迟30天随访。在剩余的2398名接受抗逆转录病毒治疗的儿童中，198名（8.3%）在随访的3018个儿童年期间死亡（死亡率，每100个儿童年6.6例死亡；95%置信区间[CI]， 5.7-7.5）；在这些死亡中，112例（56.6%）发生在治疗开始后90天内（早期死亡率，17.4/100儿童年；90天后死亡率，2.9/100儿童年）。在多变量分析中，死亡率与CD4细胞消耗、较低的年龄体重、较年轻的年龄和贫血有关。在1561名至少进行过一次重复检测的儿童中，抗逆转录病毒治疗开始时的平均CD4细胞百分比为12.9% (95% CI, 12.5%-13.3%)， 6个月时增加到23.7% (95% CI, 23.1%-24.3%)， 12个月时增加到27.0% (95% CI, 26.3%-27.6%)， 18个月时增加到28.0% (95% CI, 27.2%-28.8%)， 24个月时增加到28.4% （95% CI, 27.4%-29.4%）。结论：在撒哈拉以南非洲的初级卫生保健机构中，护士和临床官员等临床医生提供的护理可以为感染艾滋病毒的儿童带来良好的结果。在治疗的前90天死亡率很高，表明需要早期干预。
Context The Zambian Ministry of Health provides pediatric antiretroviral therapy (ART) at primary care clinics in Lusaka, where, despite scale-up of perinatal prevention efforts, many children are already infected with the human immunodeficiency virus (HIV).Objective To report early clinical and immunologic outcomes of children enrolled in the pediatric treatment program.Design, Setting, and Patients Open cohort assessment using routinely collected clinical and outcome data from an electronic medical record system in use at 18 government primary health facilities in Lusaka, Zambia. Care was provided primarily by nurses and clinical officers ("physician extenders" akin to physician assistants in the United States). Patients were children (< 16 years of age) presenting for HIV care between May 1, 2004, and June 29, 2007.Intervention Three-drug ART (zidovudine or stavudine plus lamivudine plus nevirapine or efavirenz) for children who met national treatment criteria.Main Outcome Measures Survival, weight gain, CD4 cell count, and hemoglobin response.Results After enrollment of 4975 children into HIV care, 2938 (59.1%) started ART. Of those initiating ART, the median age was 81 months (interquartile range, 36-125), 1531 (52.1%) were female, and 2087 (72.4%) with World Health Organization stage information were in stage III or IV. At the time of analysis, 158 children (5.4%) had withdrawn from care and 382 (13.0%) were at least 30 days late for follow-up. Of the remaining 2398 children receiving ART, 198 (8.3%) died over 3018 child-years of follow-up (mortality rate, 6.6 deaths per 100 child-years; 95% confidence interval [CI], 5.7-7.5); of these deaths, 112 (56.6%) occurred within 90 days of therapy initiation (early mortality rate, 17.4/100 child-years; post-90-day mortality rate, 2.9/100 child-years). Mortality was associated with CD4 cell depletion, lower weight-for-age, younger age, and anemia in multivariate analysis. The mean CD4 cell percentage at ART initiation among the 1561 children who had at least 1 repeat measurement was 12.9% (95% CI, 12.5%-13.3%) and increased to 23.7% (95% CI, 23.1%-24.3%) at 6 months, 27.0% (95% CI, 26.3%-27.6%) at 12 months, 28.0% (95% CI, 27.2%-28.8%) at 18 months, and 28.4% (95% CI, 27.4%-29.4%) at 24 months.Conclusions Care provided by clinicians such as nurses and clinical officers can result in good outcomes for HIV-infected children in primary health care settings in sub-Saharan Africa. Mortality during the first 90 days of therapy is high, pointing to a need for earlier intervention.