Contemporary disengagement from antiretroviral therapy in Khayelitsha, South Africa: A cohort study
Contemporary disengagement from antiretroviral therapy in Khayelitsha, South Africa: A cohort study
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DOI：
10.1371/journal.pmed.1002407
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发表时间：
2017-11-01
期刊：
影响因子：
15.8
通讯作者：
Meintjes, Graeme
中科院分区：
文献类型：
--
作者：
Kaplan, Samantha R.;Oosthuizen, Christa;Meintjes, Graeme
背景 保留护理是实现联合国艾滋病规划署“90-90-90”艾滋病毒治疗目标的重要组成部分。在南非开普敦的 Khayelitsha 镇（人口约 50 万），自 2001 年该公共部门计划启动以来，已有超过 50,000 名患者接受了抗逆转录病毒治疗 (ART)。脱离护理仍然是一个重要的挑战。我们试图确定 2013 年至 2014 年期间脱离护理的发生率和风险因素，以及脱离护理者的结果。方法和结果我们对 2013 年至 2014 年访问过 13 个 Khayelitsha ART 诊所中的 1 个的所有 10 岁以上患者进行了回顾性队列研究，无论他们开始 ART 的日期如何。我们使用竞争风险方法描述了2013年1月1日至2014年12月31日期间首次脱离接触（> 180天不去诊所）的累积发生率，使我们能够估计开始ART后10年内的脱离接触发生率。我们还根据 Cox 比例风险模型，对缺失数据使用多重插补，描述了脱离接触的风险因素。我们利用全省健康数据库和国家死亡登记处确定了脱离接触后直至 2015 年 6 月 30 日的结果（死亡、返回护理、入院、与其他医院接触、活着但不在护理中、无信息）。在符合我们资格标准的 39,884 名患者中，截至 2014 年 12 月 31 日接受 ART 的中位时间为 33.6 个月（IQR 12.4-63.2）。在整个研究队列中，有 592 人（1.5%）在研究期间死亡，1,231 人（3.1%）正式转出，987 人（2.5%）默默转出并在 180 天内到另一家西开普省诊所就诊，9,005 人（22.6%）脱离，28,069 人（70.4%）仍在护理中。接受 ART 治疗后 2 年内脱离护理的累积发生率估计为 25.1%，5 年内脱离护理的累积发生率为 50.3%。调整后与脱离（年龄、男性、ART 开始时怀孕 [HR 1.58，95% CI 1.47-1.69]、最近的 CD4 计数）和保留（ART 俱乐部会员资格、基线 CD4）相关的关键因素与之前研究中发现的相似；然而，值得注意的是，在调整这些风险因素后，开始抗逆转录病毒治疗后不久就脱离接触的较高风险不再存在。在 9,005 名脱离治疗的人中，2 个最常见的初始结果是 180 天后返回 ART 护理（33%；n = 2,976）以及在西开普省还活着但不在护理中（25%；n = 2,255）。脱离接触后，共有 1,459 名患者（16%）住院，237 名患者（3%）死亡。从脱离接触之日到 2015 年 6 月 30 日的中位随访时间为 16.7 个月（IQR 11-22.4）。由于我们只设计了 2013 年至 2014 年的患者随访，以便最大限度地提高我们的研究结果对当前项目的普遍性，这限制了我们更全面地描述首次脱离治疗的时间趋势的能力。结论 Khayelitsha（南非最古老的公共部门 ART 项目之一）的大队列中，有 23% 的 ART 患者在当代 2 年期间至少脱离护理一次。这些患者中有 58% 随后返回护理（有些“默默地”）或在没有住院的情况下仍然活着，这表明许多被认为“迷失”的患者实际上返回了护理，并且“迷失”患者的错误分类在类似的城市人群中很可能很常见。实现 ART 保留目标的一个挑战是开发、测试和实施针对流动人群的计划设计，并将他们保留在终身护理中。这应该以脱离的风险因素为指导，并改善常规信息系统的相互联系，以更好地支持跨复杂护理平台的患者护理。
BackgroundRetention in care is an essential component of meeting the UNAIDS "90-90-90" HIV treatment targets. In Khayelitsha township (population similar to 500,000) in Cape Town, South Africa, more than 50,000 patients have received antiretroviral therapy (ART) since the inception of this public-sector program in 2001. Disengagement from care remains an important challenge. We sought to determine the incidence of and risk factors associated with disengagement from care during 2013-2014 and outcomes for those who disengaged.Methods and findingsWe conducted a retrospective cohort study of all patients >= 10 years of age who visited 1 of the 13 Khayelitsha ART clinics from 2013-2014 regardless of the date they initiated ART. We described the cumulative incidence of first disengagement (> 180 days not attending clinic) between 1 January 2013 and 31 December 2014 using competing risks methods, enabling us to estimate disengagement incidence up to 10 years after ART initiation. We also described risk factors for disengagement based on a Cox proportional hazards model, using multiple imputation for missing data. We ascertained outcomes (death, return to care, hospital admission, other hospital contact, alive but not in care, no information) after disengagement until 30 June 2015 using province-wide health databases and the National Death Registry. Of 39,884 patients meeting our eligibility criteria, the median time on ART to 31 December 2014 was 33.6 months (IQR 12.4-63.2). Of the total study cohort, 592 (1.5%) died in the study period, 1,231 (3.1%) formally transferred out, 987 (2.5%) were silent transfers and visited another Western Cape province clinic within 180 days, 9,005 (22.6%) disengaged, and 28,069 (70.4%) remained in care. Cumulative incidence of disengagement from care was estimated to be 25.1% by 2 years and 50.3% by 5 years on ART. Key factors associated with disengagement (age, male sex, pregnancy at ART start [HR 1.58, 95% CI 1.47-1.69], most recent CD4 count) and retention (ART club membership, baseline CD4) after adjustment were similar to those found in previous studies; however, notably, the higher hazard of disengagement soon after starting ART was no longer present after adjusting for these risk factors. Of the 9,005 who disengaged, the 2 most common initial outcomes were return to ART care after 180 days (33%; n = 2,976) and being alive but not in care in the Western Cape (25%; n = 2,255). After disengagement, a total of 1,459 (16%) patients were hospitalized and 237 (3%) died. The median follow-up from date of disengagement to 30 June 2015 was 16.7 months (IQR 11-22.4). As we included only patient follow-up from 2013-2014 by design in order to maximize the generalizability of our findings to current programs, this limited our ability to more fully describe temporal trends in first disengagement.Conclusions Twenty-three percent of ART patients in the large cohort of Khayelitsha, one of the oldest public-sector ART programs in South Africa, disengaged from care at least once in a contemporary 2-year period. Fifty-eight percent of these patients either subsequently returned to care (some "silently") or remained alive without hospitalization, suggesting that many who are considered "lost" actually return to care, and that misclassification of "lost" patients is likely common in similar urban populations.A challenge to meeting ART retention targets is developing, testing, and implementing program designs to target mobile populations and retain them in lifelong care. This should be guided by risk factors for disengagement and improving interlinkage of routine information systems to better support patient care across complex care platforms.