The Effect of Antiretroviral Treatment on Health Care Utilization in Rural South Africa: A Population-Based Cohort Study.
The Effect of Antiretroviral Treatment on Health Care Utilization in Rural South Africa: A Population-Based Cohort Study.
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DOI：
10.1371/journal.pone.0158015
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发表时间：
2016
期刊：
影响因子：
3.7
通讯作者：
Bärnighausen T
中科院分区：
文献类型：
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作者：
Hontelez JA;Tanser FC;Naidu KK;Pillay D;Bärnighausen T
在撒哈拉以南非洲迅速扩大艾滋病毒垂直抗逆转录病毒治疗方案对整个卫生系统的影响正在激烈辩论中。有些人认为，这些方案减少了患有与艾滋病毒无关的疾病的人获得治疗的机会，因为抗逆转录病毒疗法方案耗尽了卫生系统其他部分的人力和物力;另一些人则声称，通过抗逆转录病毒疗法方案进行的投资加强了一般卫生系统，抗逆转录病毒疗法对人口健康的影响释放了医疗保健能力，用于治疗与艾滋病毒无关的疾病。为了确定公共部门卫生系统中ART项目对卫生保健利用的人口水平影响，我们比较了在ART快速扩大期间接受和未接受ART的HIV感染者与HIV未感染者的卫生保健利用趋势。我们使用了来自Wellcome Trust非洲人口健康中心的数据，该中心每年从2009-2012年期间的所有监测参与者（N = 32，319）中获取有关医疗保健利用的信息。我们确定了在该社区快速扩大抗逆转录病毒治疗规模的一段时间内（2009-2012年），艾滋病毒感染者和未感染者的住院率、公共部门和私营部门初级卫生保健（PHC）诊所就诊率的趋势。在控制性别、年龄和居住地区的情况下，我们回归了不同日历年的艾滋病毒感染状况和抗逆转录病毒治疗状况对卫生保健利用的影响。在2009-2012年期间，报告在过去6个月内去过公共部门初级保健诊所的人数比例显著增加，艾滋病毒感染者（从59%增加到67%; p<0.001）和未感染艾滋病毒者（从41%增加到47%; p<0.001）。相比之下，到私营部门初级保健诊所就诊的艾滋病毒感染者比例从22%下降到12%（p<0.001），住院率从每1000 PY 128下降到82（p<0.001）。对于未感染艾滋病毒的人，到私营部门初级保健诊所就诊的比例从16%下降到9%，住院率从78/1000 PY下降到44/1000 PY（p<0.001）。在控制潜在混杂因素后，所有趋势的幅度和意义均相似。我们的研究结果表明，在这个艾滋病毒高流行率的社区，抗逆转录病毒疗法的规模扩大，已将医疗保健利用从医院和私营部门的初级保健转移到公共部门的初级保健。值得注意的是，这一转变是观察到的艾滋病毒感染和未感染的人口，支持和扩展的假设'治疗公民'，即艾滋病毒感染的患者接受抗逆转录病毒治疗促进家庭和社区成员获得初级保健。我们的研究结果的一个解释是，ART已经提高了这个社区的初级保健的能力或质量，因此，越来越多地满足整体的医疗保健需求，而不是在二级的初级保健水平。未来的研究需要确认我们的研究结果的因果解释，使用定性工作来理解因果机制或准实验定量研究，以增加因果推理的强度。
The effect of the rapid scale-up of vertical antiretroviral treatment (ART) programs for HIV in sub-Saharan Africa on the overall health system is under intense debate. Some have argued that these programs have reduced access for people suffering from diseases unrelated to HIV because ART programs have drained human and physical resources from other parts of the health system; others have claimed that the investments through ART programs have strengthened the general health system and the population health impacts of ART have freed up health care capacity for the treatment of diseases that are not related to HIV. To establish the population-level impact of ART programs on health care utilization in the public-sector health system, we compared trends in health care utilization among HIV-infected people receiving and not receiving ART with HIV-uninfected people during a period of rapid ART scale-up. We used data from the Wellcome Trust Africa Centre for Population Health, which annually elicited information on health care utilization from all surveillance participants over the period 2009–2012 (N = 32,319). We determined trends in hospitalization, and public-sector and private-sector primary health care (PHC) clinic visits for HIV-infected and -uninfected people over a time period of rapid ART scale-up (2009–2012) in this community. We regressed health care utilization on HIV status and ART status in different calendar years, controlling for sex, age, and area of residence. The proportion of people who reported to have visited a public-sector primary health care (PHC) clinic in the last 6 months increased significantly over the period 2009–2012, for both HIV-infected people (from 59% to 67%; p<0.001), and HIV-uninfected people (from 41% to 47%; p<0.001). In contrast, the proportion of HIV-infected people visiting a private-sector PHC clinic declined from 22% to 12% (p<0.001) and hospitalization rates declined from 128 to 82 per 1000 PY (p<0.001). For HIV-uninfected people, the proportion visiting a private-sector PHC clinic declined from 16% to 9%, and hospitalization rates declined from 78 to 44 per 1000 PY (p<0.001). After controlling for potential confounding factors, all trends remained of similar magnitude and significance. Our results indicate that the ART scale-up in this high HIV prevalence community has shifted health care utilization from hospitals and private-sector primary care to public-sector primary care. Remarkably, this shift is observed for both HIV-infected and -uninfected populations, supporting and extending hypotheses of ‘therapeutic citizenship’ whereby HIV-infected patients receiving ART facilitate primary care access for family and community members. One explanation of our findings is that ART has improved the capacity or quality of primary care in this community and, as a consequence, increasingly met overall health care needs at the primary care level rather than at the secondary level. Future research needs to confirm this causal interpretation of our findings using qualitative work to understand causal mechanisms or quasi-experimental quantitative studies to increase the strength of causal inference.