Mortality estimates by age and sex among persons living with HIV after ART initiation in Zambia using electronic medical records supplemented with tracing a sample of lost patients: A cohort study
Mortality estimates by age and sex among persons living with HIV after ART initiation in Zambia using electronic medical records supplemented with tracing a sample of lost patients: A cohort study
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DOI：
10.1371/journal.pmed.1003107
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发表时间：
2020-05-01
期刊：
影响因子：
15.8
通讯作者：
Geng, Elvin H.
中科院分区：
文献类型：
--
作者：
Kerkhoff, Andrew D.;Sikombe, Kombatende;Geng, Elvin H.
与妇女相比，撒哈拉以南非洲地区的男性对艾滋病毒服务的参与和保留程度较低，这可能导致生存差异。然而，接受抗逆转录病毒治疗（ART）的男性和女性在艾滋病毒相关死亡率方面的真正差异程度尚未完全确定。方法和发现我们评估了4个赞比亚省（东部、卢萨卡、南部和西部）的hiv阳性成人（0 ~ 18岁）新开始抗逆转录病毒治疗。除了从常规电子医疗记录中获得的死亡率数据外，我们还深入追踪了失访患者（LTFU）的随机样本，并通过逆概率权重纳入了追踪结果。使用泊松回归确定性别特异性死亡率和死亡率差异。参数g计算用于估计按性别和年龄调整的死亡率。该研究包括2013年8月至2015年7月期间新开始接受抗逆转录病毒治疗的49129名成年人；总体而言，患者的中位年龄为35岁，中位基线CD4细胞计数为262细胞/ μ l， 37.2%为男性。与女性相比，男性在开始抗逆转录病毒治疗的个体中所占比例较小（37.2%对62.8%），往往年龄较大（中位年龄37对33岁），并且在开始抗逆转录病毒治疗时CD4细胞计数往往较低（中位220对289细胞/ μ l）。男性的总死亡率为10.3 （95% CI 8.2-12.4）例死亡/100人年（PYs），而女性为5.5 （95% CI 4.3-6.8）例死亡/100人年（差异+4.7 [95% CI 2.3-7.2]例死亡/100人年；p < 0.001）。与同一年龄组的妇女相比，男性死亡率在以下人群中特别高：< 30岁（增加6.7例死亡/100个生命年差异）、在农村保健中心就诊（增加9.4例死亡/100个生命年差异）、初始CD4细胞计数< 100个细胞/1（增加9.2例死亡/100个生命年差异）以及未婚（增加8.0例死亡/100个生命年差异）。在对包括CD4计数在内的潜在混杂因素和中介因素进行调整后，预测男性的死亡率要高得多= 50岁的男性死亡率与年龄匹配的男性相似，但远高于年轻女性（< 30岁）的死亡率。男性和女性在设施转移率或护理脱离率方面没有明显的临床显著差异。研究的主要局限性是无法成功确定所有选择追踪的患者的结果，以及由于使用医疗记录而丢失临床和实验室数据。结论本研究发现，hiv阳性成人新开始抗逆转录病毒治疗的男性死亡率高于女性死亡率；这种差异在年轻患者中最为明显。然而，老年妇女的死亡率也很高。需要针对死亡风险最高的男性和老年妇女采取具体干预措施，以改善艾滋病毒治疗结果。
BackgroundMen in sub-Saharan Africa have lower engagement and retention in HIV services compared to women, which may result in differential survival. However, the true magnitude of difference in HIV-related mortality between men and women receiving antiretroviral therapy (ART) is incompletely characterized.Methods and findingsWe evaluated HIV-positive adults >= 18 years old newly initiating ART in 4 Zambian provinces (Eastern, Lusaka, Southern, and Western). In addition to mortality data obtained from routine electronic medical records, we intensively traced a random sample of patients lost to follow-up (LTFU) and incorporated tracing outcomes through inverse probability weights. Sex-specific mortality rates and rate differences were determined using Poisson regression. Parametric g-computation was used to estimate adjusted mortality rates by sex and age. The study included 49,129 adults newly initiated on ART between August 2013 and July 2015; overall, the median age among patients was 35 years, the median baseline CD4 count was 262 cells/mu l, and 37.2% were men. Men comprised a smaller proportion of individuals starting ART (37.2% versus 62.8%), tended to be older (median age 37 versus 33 years), and tended to have lower CD4 counts (median 220 versus 289 cells/mu l) at the time of ART initiation compared to women. The overall rate of mortality among men was 10.3 (95% CI 8.2-12.4) deaths/100 person-years (PYs), compared to 5.5 (95% CI 4.3-6.8) deaths/100 PYs among women (difference +4.7 [95% CI 2.3-7.2] deaths/100 PYs; p < 0.001). Compared to women in the same age groups, men's mortality rates were particularly elevated among those < 30 years old (+6.7 deaths/100 PYs difference), those attending rural health centers (+9.4 deaths/100 PYs difference), those who had an initial CD4 count < 100 cells/mu l (+9.2 deaths/100 PYs difference), and those who were unmarried (+8.0 deaths/100 PYs difference). After adjustment for potential confounders and mediators including CD4 count, a substantially higher mortality rate was predicted among men = 50 years old had a mortality rate similar to that of age-matched men, but considerably higher than that predicted among young women (< 30 years old). No clinically significant differences were evident with respect to rates of facility transfer or care disengagement between men and women. The main study limitations were the inability to successfully ascertain outcomes in all patients selected for tracing and missing clinical and laboratory data due to the use of medical records.ConclusionsIn this study, we found that among HIV-positive adults newly initiating ART, mortality among men exceeded mortality among women; disparities were most pronounced among young patients. Older women, however, also experienced high mortality. Specific interventions for men and older women at highest mortality risk are needed to improve HIV treatment outcomes.