From HIV infection to therapeutic response: a population-based longitudinal HIV cascade-of-care study in KwaZulu-Natal, South Africa
From HIV infection to therapeutic response: a population-based longitudinal HIV cascade-of-care study in KwaZulu-Natal, South Africa
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DOI：
10.1016/s2352-3018(16)30224-7
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发表时间：
2017-05-01
期刊：
影响因子：
16.1
通讯作者：
Barnighausen, Till
中科院分区：
文献类型：
--
作者：
Haber, Noah;Tanser, Frank;Barnighausen, Till
背景标准的方法来估计艾滋病毒级联护理的损失通常是横截面，不包括人口阶段之前的联系到临床护理。我们使用个人层面的纵向级联数据，过渡的过渡，包括人口阶段，既要确定在级联的卫生系统损失，并显示标准方法和纵向approach.Methods之间的推断差异，我们使用非参数生存分析，估计一个纵向艾滋病毒护理级联的人居住在农村夸祖鲁-纳塔尔，南非的一个大的人口。我们将纵向人口健康监测（由非洲卫生研究所维护）的数据与当地公共部门艾滋病毒治疗方案的患者记录（包含在电子临床艾滋病毒治疗和护理数据库ARTemis中）联系起来。我们随访了2006年1月1日至2011年12月31日期间新检测到艾滋病毒感染的所有人，包括六个级联阶段：三个人口阶段（首次阳性艾滋病毒检测，艾滋病毒状态知识和与护理的联系）和三个临床阶段（抗逆转录病毒治疗[ART]的资格，ART的启动和治疗反应）。我们将我们的估计与同一人群中的横截面级联进行了比较。我们估计的累积发病率达到一个特定的级联阶段，在特定的时间Kaplan-Meier survival analysis.Findings我们的人群包括5205个人与HIV谁被随访24 031人年。我们记录了598例死亡。4539人获得了他们的艾滋病毒阳性状态的知识，2818人与护理有关，2151人有资格接受抗逆转录病毒治疗，1839人开始抗逆转录病毒治疗，1456人对治疗有成功的反应。我们使用Kaplan-Meier生存分析来调整由于数据收集结束而进行的审查，并发现在人群健康监测中检测呈阳性的8年后，16%的人已经死亡。在活着的患者中，82%知道自己的艾滋病毒状况，45%与护理有关，39%有资格接受抗逆转录病毒治疗，35%开始接受抗逆转录病毒治疗，33%达到治疗反应。这些级联阶段的中位过渡时间分别为52个月、52个月、20个月、3个月和9个月。与级联中的群体阶段相比，临床阶段之间的过渡很快。随着时间的推移，与护理的联系率有所下降，首次接受护理的患者平均来说更健康，解释艾滋病毒方案应侧重于与护理的联系，因为这是级联中最重要的瓶颈。级联估计应该是纵向的，而不是横截面，并开始与人口阶段之前的临床护理。
Background Standard approaches to estimation of losses in the HIV cascade of care are typically cross-sectional and do not include the population stages before linkage to clinical care. We used indiviual-level longitudinal cascade data, transition by transition, including population stages, both to identify the health-system losses in the cascade and to show the differences in inference between standard methods and the longitudinal approach.Methods We used non-parametric survival analysis to estimate a longitudinal HIV care cascade for a large population of people with HIV residing in rural KwaZulu-Natal, South Africa. We linked data from a longitudinal population health surveillance (which is maintained by the Africa Health Research Institute) with patient records from the local public-sector HIV treatment programme (contained in an electronic clinical HIV treatment and care database, ARTemis). We followed up all people who had been newly detected as having HIV between Jan 1, 2006, and Dec 31, 2011, across six cascade stages: three population stages (first positive HIV test, HIV status knowledge, and linkage to care) and three clinical stages (eligibility for antiretroviral therapy [ART], initiation of ART, and therapeutic response). We compared our estimates to cross-sectional cascades in the same population. We estimated the cumulative incidence of reaching a particular cascade stage at a specific time with Kaplan-Meier survival analysis.Findings Our population consisted of 5205 individuals with HIV who were followed up for 24 031 person-years. We recorded 598 deaths. 4539 individuals gained knowledge of their positive HIV status, 2818 were linked to care, 2151 became eligible for ART, 1839 began ART, and 1456 had successful responses to therapy. We used Kaplan-Meier survival analysis to adjust for censorship due to the end of data collection, and found that 8 years after testing positive in the population health surveillance, 16% had died. Among living patients, 82% knew their HIV status, 45% were linked to care, 39% were eligible for ART, 35% initiated ART, and 33% had reached therapeutic response. Median times to transition for these cascade stages were 52 months, 52 months, 20 months, 3 months, and 9 months, respectively. Compared with the population stages in the cascade, the transitions across the clinical stages were fast. Over calendar time, rates of linkage to care have decreased and patients presenting for the first time for care were, on average, healthier.Interpretation HIV programmes should focus on linkage to care as the most important bottleneck in the cascade. Cascade estimation should be longitudinal rather than cross-sectional and start with the population stages preceding clinical care.