Loss to Follow-Up within the Prevention of Mother-to-Child Transmission Care Cascade in a Large ART Program in Nigeria.
Loss to Follow-Up within the Prevention of Mother-to-Child Transmission Care Cascade in a Large ART Program in Nigeria.
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DOI：
10.2174/1570162x1303150506183256
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发表时间：
2015
影响因子：
1
通讯作者：
APIN PEPFAR Team
中科院分区：
文献类型：
--
作者：
Rawizza HE;Chang CA;Chaplin B;Ahmed IA;Meloni ST;Oyebode T;Banigbe B;Sagay AS;Adewole IF;Okonkwo P;Kanki PJ;APIN PEPFAR Team
2013年世卫组织指南纳入了简化和更有效的抗逆转录病毒方案，以防止艾滋病毒母婴传播。随着这些建议的理想实施，围产期艾滋病毒传播率可能会降低到2%以下。然而，失访(LTFU)有可能侵蚀项目的成功，一些研究报告称，在预防母婴传播(PMTCT)护理级联中，LTFU的发生率很高。我们在尼日利亚的一个大型预防母婴传播方案队列中评估了LTFU的时机和规模，以便集中未来的努力，在这种高负担的情况下减少损失。从2004年到2014年，APIN/哈佛PEPFAR项目支持了近100万孕妇的产前艾滋病毒筛查，并为30,000多名妇女提供了预防母婴传播治疗。为参加预防母婴传播计划的妇女提供的护理级联包括产前、分娩和12-18个月的婴儿随访服务。在这项回溯性队列分析中，我们检查了2004-2014年间从尼日利亚31个临床地点收集的数据，并评估了登记的母亲和婴儿数量以及沿护理级联的不同时间点的LTFU。在31,504名在产前接受母婴传播治疗的妇女(年龄中值为30岁，智商：27-34)中，20,679人(66%)完成了一整套服务，包括产前、分娩和至少一次婴儿随访。产前护理服务提出时的孕周中位数为23周(IQR：17-29)。最后一次随访的婴儿年龄中位数为12个月(智商：5-18)。在母婴传播护理级联中，最大的损失发生在分娩护理之前(21%)，还有16%的损失发生在第一次婴儿探视之前。在沿着母婴传播级联的任何时间点进入的38,223名妇女中，有20,202名(53%)的婴儿可以获得艾滋病毒DNA聚合酶链式反应。在有DNA PCR结果的婴儿中，母亲接受过产前和/或分娩护理的婴儿的艾滋病毒传播率为2.8%，而母亲没有接受过任何护理的婴儿的艾滋病毒传播率为20.0%。在这项大型队列分析中，女性LTFU在预防母婴传播护理级联中的比例低于先前队列分析中报告的比例。然而，这一比例仍然高得令人无法接受，并阻碍了该计划最大限度地实现防止母婴传播护理的目标。我们还提供了迄今为止关于围产期艾滋病毒传播率的最大规模的分析，接受NNRTI或PI方案的妇女的感染率较低，接近临床试验报告的水平。然而，在接受过产前护理的母亲中，48%的母亲不知道婴儿的结局，而且妇女在怀孕期间出现的时间晚于当前指南所建议的时间。迫切需要开展实施研究，评估改善服务整合的方法，特别是从产前到分娩和儿科护理的过渡，以减少预防母婴传播方案中的LTFU，并实现消除儿科艾滋病毒感染的最终目标。
The 2013 WHO guidelines incorporated simplified and more effective antiretroviral regimens for the purposes of preventing mother-to-child transmission of HIV. With ideal implementation of these recommendations, perinatal HIV transmission could be reduced to less than 2%. However, loss to follow-up (LTFU) has the potential to erode the success of programs and a number of studies report high rates of LTFU within the prevention of mother-to-child transmission (PMTCT) care cascade. We evaluated the timing and magnitude of LTFU in a large programmatic PMTCT cohort in Nigeria in order to focus future efforts to reduce loss in this high burden setting. From 2004-2014, the APIN/Harvard PEPFAR program supported antenatal HIV screening for nearly one million pregnant women and provided PMTCT care to over 30,000 women. The care cascade for women enrolling in the PMTCT program includes antenatal, delivery, and infant follow-up services through 12-18 months of life. In this retrospective cohort analysis, we examined data collected between 2004-2014 from 31 clinical sites in Nigeria and assessed the numbers of mothers and infants enrolled and LTFU at various points along the care cascade. Among 31,504 women (median age 30, IQR: 27-34) entering PMTCT care during the antenatal period, 20,679 (66%) completed the entire cascade of services including antenatal, delivery, and at least one infant follow-up visit. The median gestational age at presentation for antenatal care services was 23 weeks (IQR: 17-29). The median infant age at last follow-up visit was 12 months (IQR: 5-18). The greatest loss in the PMTCT care cascade occurred prior to delivery care (21%), with a further 16% lost prior to first infant visit. Of the 38,223 women who entered at any point along the PMTCT cascade, an HIV DNA PCR was available for 20,202 (53%) of their infants. Among infants for whom DNA PCR results were available, the rate of HIV transmission for infants whose mothers received any antenatal and/or delivery care was 2.8% versus 20.0% if their mother received none. In this large cohort analysis, the proportion of women LTFU in the PMTCT care cascade was lower than that reported in previous cohort analyses. Nevertheless, this proportion remains unacceptably high and inhibits the program from maximally achieving the goals of PMTCT care. We also provide the largest analysis to date on rates of perinatal HIV transmission, with low rates among women receiving NNRTI- or PI-based regimens, approaching that reported in clinical trials. However, among mothers who received any antenatal care, infant outcomes were unknown for 48%, and women presented later in pregnancy than that recommended by current guidelines. Implementation research to evaluate ways to improve integration of services, particularly transitions from antenatal to delivery and pediatric care, are critically needed to reduce LTFU within PMTCT programs and achieve the ultimate goal of eliminating pediatric HIV infection.