Adherence to antiretroviral therapy for HIV in sub-Saharan Africa and Asia: a comparative analysis of two regional cohorts.
Adherence to antiretroviral therapy for HIV in sub-Saharan Africa and Asia: a comparative analysis of two regional cohorts.
复制标题
DOI：
10.7448/ias.20.1.21218
复制
发表时间：
2017-03-03
影响因子：
6
通讯作者：
Hamers RL
中科院分区：
文献类型：
--
作者：
Bijker R;Jiamsakul A;Kityo C;Kiertiburanakul S;Siwale M;Phanuphak P;Akanmu S;Chaiwarith R;Wit FW;Sim BL;Boender TS;Ditangco R;Rinke De Wit TF;Sohn AH;Hamers RL
简介：我们对如何在艾滋病毒疾病负担最高的环境中实现最佳长期坚持抗逆转录病毒治疗 (ART) 的理解仍然有限。我们比较了撒哈拉以南非洲和亚洲双区域队列中接受抗逆转录病毒治疗的艾滋病毒阳性者随时间推移的依从性水平和决定因素。 方法：这项针对开始一线 ART 的成人的多中心前瞻性研究使用 30 天视觉模拟量表评估了患者在随访门诊就诊时报告的依从性。使用具有多重插补的广义估计方程多变量逻辑回归，以六个月为间隔评估次优依从性 (<95%) 的决定因素。居住地区（非洲与亚洲）被评估为潜在的影响因素。 结果：在 ART 的前 24 个月内，对 3934 名参与者进行了 13,001 次依从性评估，其中 6.4% (837) 的依从性评估不理想，其中非洲队列为 7.3% (619/8484)，而亚洲队列为 4.8% (218/4517)（p < 0.001）。在非洲队列中，依从性不佳的决定因素是男性（比值比 (OR) 1.27，95% 置信区间 (CI) 1.06–1.53；p = 0.009）、年龄较小（OR 每 10 年增加 0.8；0.8–0.9；p = 0.003）、同时服用药物（OR 1.8， 1.0–3.2；p = 0.044）并前往公共设施（OR 1.3，95% CI 1.1–1.7；p = 0.004）。在亚洲队列中，与异性恋者相比，男男性行为者的依从性较高（依从性不佳的 OR 为 0.6，95% CI 0.4-0.9；p = 0.029），而注射吸毒者的依从性较低（依从性不佳的 OR 1.6，95% CI 0.9-2.6；p = 0.075）。在这两个地区，随着 ART 持续时间的延长，依从性不佳的风险也会降低。与中高收入或高收入国家的参与者相比，低收入和中低收入国家的参与者依从性不佳的风险较高（OR 1.6、1.3-2.0；p < 0.001）。在非洲（OR 5.8，95% CI 4.3-7.7；p < 0.001）和亚洲（OR 9.0，95% CI 5.0-16.2；p < 0.001），次优依从性与病毒学失败密切相关。非洲参与者中患者报告的依从性障碍包括日程安排要求、药物缺货、健忘、疾病或不良事件、耻辱或抑郁、治疗方案复杂性和药物负担。 结论：心理社会因素和卫生系统资源可以解释区域差异。增强依从性的干预措施应根据当地情况解决患者报告的障碍，并优先考虑 ART 的最初几年。
Introduction: Our understanding of how to achieve optimal long-term adherence to antiretroviral therapy (ART) in settings where the burden of HIV disease is highest remains limited. We compared levels and determinants of adherence over time between HIV-positive persons receiving ART who were enrolled in a bi-regional cohort in sub-Saharan Africa and Asia. Methods: This multicentre prospective study of adults starting first-line ART assessed patient-reported adherence at follow-up clinic visits using a 30-day visual analogue scale. Determinants of suboptimal adherence (<95%) were assessed for six-month intervals, using generalized estimating equations multivariable logistic regression with multiple imputations. Region of residence (Africa vs. Asia) was assessed as a potential effect modifier. Results: Of 13,001 adherence assessments in 3934 participants during the first 24 months of ART, 6.4% (837) were suboptimal, with 7.3% (619/8484) in the African cohort versus 4.8% (218/4517) in the Asian cohort (p < 0.001). In the African cohort, determinants of suboptimal adherence were male sex (odds ratio (OR) 1.27, 95% confidence interval (CI) 1.06–1.53; p = 0.009), younger age (OR 0.8 per 10 year increase; 0.8–0.9; p = 0.003), use of concomitant medication (OR 1.8, 1.0–3.2; p = 0.044) and attending a public facility (OR 1.3, 95% CI 1.1–1.7; p = 0.004). In the Asian cohort, adherence was higher in men who have sex with men (OR for suboptimal adherence 0.6, 95% CI 0.4–0.9; p = 0.029) and lower in injecting drug users (OR for suboptimal adherence 1.6, 95% CI 0.9–2.6; p = 0.075), compared to heterosexuals. Risk of suboptimal adherence decreased with longer ART duration in both regions. Participants in low- and lower-middle-income countries had a higher risk of suboptimal adherence (OR 1.6, 1.3–2.0; p < 0.001), compared to those in upper-middle or high-income countries. Suboptimal adherence was strongly associated with virological failure, in Africa (OR 5.8, 95% CI 4.3–7.7; p < 0.001) and Asia (OR 9.0, 95% CI 5.0–16.2; p < 0.001). Patient-reported adherence barriers among African participants included scheduling demands, drug stockouts, forgetfulness, sickness or adverse events, stigma or depression, regimen complexity and pill burden. Conclusions: Psychosocial factors and health system resources may explain regional differences. Adherence-enhancing interventions should address patient-reported barriers tailored to local settings, prioritizing the first years of ART.