Patient retention in antiretroviral therapy programs in sub-Saharan Africa: a systematic review.
Patient retention in antiretroviral therapy programs in sub-Saharan Africa: a systematic review.
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撒哈拉以南非洲抗逆转录病毒治疗计划的患者保留：系统评价。
DOI：
10.1371/journal.pmed.0040298
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发表时间：
2007-10-16
期刊：
影响因子：
15.8
通讯作者：
Gill CJ
中科院分区：
文献类型：
--
作者：
Rosen S;Fox MP;Gill CJ
在非洲迅速扩大的艾滋病毒/艾滋病抗逆转录病毒治疗（ART）项目中长期保留患者对于这些项目的成功至关重要，但受到的关注相对较少。在本文中，我们对撒哈拉以南非洲地区 ART 项目中的患者保留情况进行了系统回顾。我们检索了 2000 年至 2007 年间的 Medline、其他文献数据库、会议摘要、出版物档案和“灰色文献”（可在线获取的项目报告），以获取有关在撒哈拉以南非洲非研究性 ART 项目中接受或不接受捐助者支持的成年患者在 6 个月或更长时间后保留（即继续接受护理和接受 ART）的比例的报告。计算并绘制每个项目在 6、12 和 24 个月时的估计保留率。还使用 Kaplan-Meier 曲线估计保留率。在敏感性分析中，我们考虑了 2 年保留率的最佳情况、最坏情况和中点情况；最好的情况假设没有超出报告的进一步减员，而最坏的情况假设减员将以线性方式继续。我们回顾了 32 份出版物，报告了 33 个患者队列（74,192 名患者，13 个国家）。对于所有研究，报告的加权平均随访期为 9.9 个月，此后 77.5% 的患者被保留。失访和死亡分别占自然减员的 56% 和 40%。据报告，6、12 和 24 个月时的加权平均保留率分别为 79.1%、75.0% 和 61.6%。在那些报告 24 个月随访的患者中，最好的方案保留了 85% 的患者，最差的方案保留了 46%。报告期较短的研究中的流失率较高，导致报告周期为 6、12 和 24 个月的研究的月加权平均流失率分别为 3.3%/月、1.9%/月和 1.6%/月，这表明已发表的报告中总体患者保留率可能被高估。在敏感性分析中，估计的保留率在 2 年末从最差情况下的 24% 到最好情况下的 77% 不等，合理的中点情景为 50%。自本世纪初大规模开展 ART 服务以来，非洲的 ART 项目在 2 年后保留了约 60% 的患者。失访是人员流失的主要原因，其次是死亡。如果要提高保留率，就需要更好的患者追踪程序、更好地了解失访情况以及更早开始 ART 以降低死亡率。不同项目的保留率差异很大，并且已实现较高保留率的项目可以作为未来改进的模型。根据悉尼·罗森（Sydney Rosen）及其同事的系统审查，几乎一半进入非洲艾滋病毒治疗计划的人在两年内失访或死亡。撒哈拉以南非洲地区约有 2500 万人感染人类免疫缺陷病毒 (HIV)，这是导致获得性免疫缺陷综合症 (AIDS) 的原因。每年，该地区大约有 300 万人感染艾滋病毒，200 万人死于艾滋病，这种流行病缩短了该地区的预期寿命，使许多儿童成为孤儿，并逆转了经济增长。自 1996 年以来，生活在世界较富裕地区的艾滋病毒呈阳性者可以获得抗逆转录病毒药物混合物，这些药物可以控制艾滋病毒，让他们过上相对正常、健康的生活。但这些药物价格昂贵，而且直到过去五年，撒哈拉以南非洲地区才启动了抗逆转录病毒治疗（ART）计划，并且通常得到国际支持。为了使抗逆转录病毒疗法发挥作用，免疫系统受到病毒损害的艾滋病毒感染者必须在余生定期服用抗逆转录病毒药物。如果人们不规律地接受抗逆转录病毒疗法或停止服药，他们可能会病情加重或死亡，或者他们携带的病毒可能会对抗逆转录病毒药物产生耐药性。几项研究考察了接受 ART 的患者遵守日常用药计划的情况，但患者接受治疗计划的时间有多长（他们必须这样做才能预防艾滋病引起的疾病和死亡）却很少受到关注。在这项研究中，研究人员回顾了撒哈拉以南非洲地区患者是否继续接受 ART 项目治疗的报告，并研究了他们退出的原因。研究人员确定了 2000 年至 2007 年间发表或在会议上提出的 32 份科学报告，其中详细介绍了撒哈拉以南非洲 13 个国家在 ART 治疗计划（不包括研究）中保留的成年患者（活着并接受 ART）的比例。这些项目的平均随访时间（根据每个项目的患者数量进行调整）为 9.9 个月。此时，平均有77.5%的患者被保留。在未保留的患者中，近一半死亡，一半失去随访。也就是说，他们错过了诊所就诊或没有领取药物。 6、12 和 24 个月的估计平均保留率分别为 79.08%、75% 和 61.6%； 24 个月时报告的患者保留率在 46% 至 85% 之间。最后，研究人员利用敏感性分析（一种可以估计最好和最坏情况可能性的技术）估计，两年后实际保留 ART 计划的患者可能有四分之一到四分之三。这些结果表明，在非洲开始艾滋病毒治疗计划的人中，大约有一半在两年后不再接受治疗。如果考虑到保留率很低的项目可能不太可能公布其结果，那么非洲治疗项目的总体成功率实际上可能更低。因此，这项研究表明，撒哈拉以南非洲地区有大量需要 ART 的患者从治疗计划中流失，数量令人担忧。由于许多患者因死于艾滋病而失去生命，因此提高保留率的一种方法可能是在患者因艾滋病毒而病情严重之前，尽早开始接受抗逆转录病毒治疗。更好地努力找出患者退出项目的确切原因（例如，药物和/或前往诊所的交通费用）可能会减少失访的患者数量。研究人员还建议，保留率非常高的 ART 项目可以作为提高其他项目保留率的模型。请通过此摘要的在线版本访问这些网站：http://dx.doi.org/10.1371/journal.pmed.0040298。有关 HIV 感染和艾滋病的信息可从美国国家过敏和传染病研究所获取。 HIV InSite 是旧金山加利福尼亚大学关于撒哈拉以南非洲地区的区域页面。 美国疾病控制和预防中心提供美国总统艾滋病紧急救援计划在各个国家和地区的信息。 Avert 是一家国际艾滋病慈善机构，提供有关非洲艾滋病毒和艾滋病的信息。 Aidsmap 是一家国际艾滋病组织，总结有关艾滋病毒/艾滋病的研究并报告新闻。 （英语、西班牙语、葡萄牙语、法语和俄语）
Long-term retention of patients in Africa's rapidly expanding antiretroviral therapy (ART) programs for HIV/AIDS is essential for these programs' success but has received relatively little attention. In this paper we present a systematic review of patient retention in ART programs in sub-Saharan Africa. We searched Medline, other literature databases, conference abstracts, publications archives, and the “gray literature” (project reports available online) between 2000 and 2007 for reports on the proportion of adult patients retained (i.e., remaining in care and on ART) after 6 mo or longer in sub-Saharan African, non-research ART programs, with and without donor support. Estimated retention rates at 6, 12, and 24 mo were calculated and plotted for each program. Retention was also estimated using Kaplan-Meier curves. In sensitivity analyses we considered best-case, worst-case, and midpoint scenarios for retention at 2 y; the best-case scenario assumed no further attrition beyond that reported, while the worst-case scenario assumed that attrition would continue in a linear fashion. We reviewed 32 publications reporting on 33 patient cohorts (74,192 patients, 13 countries). For all studies, the weighted average follow-up period reported was 9.9 mo, after which 77.5% of patients were retained. Loss to follow-up and death accounted for 56% and 40% of attrition, respectively. Weighted mean retention rates as reported were 79.1%, 75.0% and 61.6 % at 6, 12, and 24 mo, respectively. Of those reporting 24 mo of follow-up, the best program retained 85% of patients and the worst retained 46%. Attrition was higher in studies with shorter reporting periods, leading to monthly weighted mean attrition rates of 3.3%/mo, 1.9%/mo, and 1.6%/month for studies reporting to 6, 12, and 24 months, respectively, and suggesting that overall patient retention may be overestimated in the published reports. In sensitivity analyses, estimated retention rates ranged from 24% in the worse case to 77% in the best case at the end of 2 y, with a plausible midpoint scenario of 50%. Since the inception of large-scale ART access early in this decade, ART programs in Africa have retained about 60% of their patients at the end of 2 y. Loss to follow-up is the major cause of attrition, followed by death. Better patient tracing procedures, better understanding of loss to follow-up, and earlier initiation of ART to reduce mortality are needed if retention is to be improved. Retention varies widely across programs, and programs that have achieved higher retention rates can serve as models for future improvements. Almost half of people entering African HIV treatment programs were lost to follow-up or died within two years, according to this systematic review by Sydney Rosen and colleagues. About 25 million people in sub-Saharan Africa are infected with the human immunodeficiency virus (HIV), the cause of acquired immunodeficiency syndrome (AIDS). Every year, about three million more people become infected with HIV and 2 million die from AIDS in this region, where the pandemic has reduced life expectancy, orphaned many children, and reversed economic growth. Since 1996, HIV-positive people living in wealthier parts of the world have had access to cocktails of antiretroviral drugs that hold HIV in check and allow them to live relatively normal, healthy lives. But these drugs are expensive and it is only in the past five years that antiretroviral therapy (ART) programs have been initiated in sub-Saharan Africa, often with international support. For ART to work, HIV-infected individuals whose immune systems have been damaged by the virus have to take antiretroviral drugs regularly for the rest of their lives. If people take ART irregularly or stop taking their medications they may become sicker or die, or the viruses they carry may become resistant to antiretroviral drugs. Several studies have looked at how well patients on ART stick to their day-to-day medication schedules, but how long patients stay in treatment programs, which they must do to prevent illness and death from AIDS, has received little attention. In this study the researchers reviewed reports of whether patients stay in treatment in ART programs in sub-Saharan Africa, and also looked at the reasons why they drop out. The researchers identified 32 scientific reports published or presented at meetings between 2000 and 2007 that gave details of the proportion of adult patients retained (alive and receiving ART) in ART treatment programs (not including research studies) in 13 countries in sub-Saharan Africa. The average follow-up time of the programs (adjusted for number of patients in each) was 9.9 months. At this time, 77.5% of the patients were retained on average. Of the patients not retained, just under half had died and half had been lost to follow up. That is, they had missed clinic visits or had not picked up their medication. Estimated average retention rates at 6, 12, and 24 months were 79.08%, 75% and 61.6%, respectively; retention rates reported at 24 months ranged between 46% and 85% of patients. Finally, using sensitivity analysis (a technique that can estimate best- and worst-case possibilities), the researchers estimated that actual retention in ART programs after 2 years probably lies between one-quarter and three-quarters of patients. These results show that roughly half of people starting HIV treatment programs in Africa are no longer receiving treatment after two years. The overall success rates of African treatment programs may actually be even lower, if one takes into account that programs with very low retention may be unlikely to publish their results. This study therefore indicates that a worrying number of patients in sub-Saharan Africa who need ART are lost from treatment programs. Because many of these patients are lost because they die from AIDS, one way to improve retention might be to start treating people with ART earlier, before they become seriously ill from HIV. Better efforts to find out exactly why patients drop out of programs (for example, the cost of drugs and/or of transport to clinics) might reduce the number of patients lost to follow up. The researchers also suggest that ART programs with very high retention rates might serve as models to improve retention rates in other programs. Please access these Web sites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.0040298. Information is available from the US National Institute of Allergy and Infectious Diseases on HIV infection and AIDS HIV InSite is a regional page on sub-Saharan Africa from the University of California, San Francisco Information is provided by the US Centers for Disease Control and Prevention on the US President's Emergency Plan for AIDS Relief in various countries and regions Avert is an international AIDS charity that provides information on HIV and AIDS in Africa Aidsmap is an international AIDS organization that summarizes research about HIV/AIDS and reports news (in English, Spanish, Portuguese, French, and Russian)
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影响因子：
11.8
作者：
Ivers, LC;Kendrick, D;Doucette, K
通讯作者：
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作者：
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DOI：
10.1080/09540120701244943
发表时间：
2007-01-01
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通讯作者：
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通讯作者：
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影响因子：
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