Retention in care among clinically stable antiretroviral therapy patients following a six-monthly clinical consultation schedule: findings from a cohort study in rural Malawi
Retention in care among clinically stable antiretroviral therapy patients following a six-monthly clinical consultation schedule: findings from a cohort study in rural Malawi
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DOI：
10.1002/jia2.25207
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发表时间：
2018-11-18
影响因子：
6
通讯作者：
Nicholas, Sarala
中科院分区：
文献类型：
--
作者：
Wringe, Alison;Cawley, Caoimhe;Nicholas, Sarala
对于临床稳定的抗逆转录病毒治疗（ART）患者，更长的门诊时间间隔可能会提高护理保留率并减少设施工作量。我们评估了参加六个月一次的临床咨询（SMCC）并接受三个月一次的快速通道药物补充的临床稳定的ART患者的长期保留，并估计了马拉维农村地区这种ART交付模式节省的咨询数量。（年龄18岁，一线抗逆转录病毒治疗12个月，CD 4计数300个细胞/mL（3），无机会性感染，未妊娠/哺乳）有资格参加SMCC，社区卫生工作者每三个月会给他们补充一次药早期登记者是在获得资格后6个月内开始工作人员-管理层协调委员会的人，而晚期登记者是在首次获得资格后至少6个月开始工作的人。Kaplan-Meier方法用于计算累积保留概率，根据入组时间和首次6个月临床咨询进行分层。使用考克斯回归来衡量第一个六个月临床咨询的损耗风险和损耗的风险因素，解释了他们在这种护理模式中的资格和入组的时变性质。从2008年到2015年，来自11个机构的22，633名临床稳定患者有资格参加SMCC至少三个月，贡献了74，264人-年的观察，18，363人（81%）开始了这种护理模式。从合格到入组的中位时间为12个月，员工和管理当局协调委员会的中位累积时间为14.5个月。在第一次SMCC资格后5年，早期入组者的累积保留概率为85.5%（95%CI：84.0%至86.9%），晚期入组者为93%（95%CI：92.8%至94.0%）。1年和5年时，自首次SMCC的累积保留概率分别为97.0%（95% CI：96.7%-97.3%）和86%（95% CI：85%-87%）。在开始SMCC治疗的合格患者中，SMCC停药期间调整后的损耗风险是SMCC治疗期间的2.4倍（95% CI：2.0 - 2.8）。男性、年龄较小、最近符合员工和管理当局协调会的资格以及过去一年中的世卫组织3/4期疾病也与员工和管理当局协调会的减员独立相关。2014年期间约有26，000次咨询被保存。结论5年后，参加SMCC的患者的保留率很高，特别是女性和老年患者，其规模的扩大可以促进ART的普及。
IntroductionLonger intervals between clinic consultations for clinically stable antiretroviral therapy (ART) patients may improve retention in care and reduce facility workload. We assessed long-term retention among clinically stable ART patients attending six-monthly clinical consultations (SMCC) with three-monthly fast-track drug refills, and estimated the number of consultations saved by this model of ART delivery in rural Malawi.MethodsResultsStable patients (aged 18years, on first-line ART 12months, CD4 count 300cells/mL(3), without opportunistic infections, not pregnant/breastfeeding) were eligible for SMCC, with three-monthly drug refills from community health workers. Early enrollees were those starting SMCC within six months of eligibility, while late enrollees started at least 6months after first eligibility. Kaplan-Meier methods were used to calculate cumulative probabilities of retention, stratified by timing of their enrolment and from first six-monthly clinical consultation. Cox regression was used to measure attrition hazards from the first six-monthly clinical consultation and risk factors for attrition, accounting for the time-varying nature of their eligibility and enrolment in this model of care.From 2008 to 2015, 22,633 clinically stable patients from 11 facilities were eligible for SMCC for at least three months, contributing 74,264 person-years of observation, and 18,363 persons (81%) initiated this model of care. The median time from eligibility to enrolment was 12months and the median cumulative time on SMCC was 14.5months. Five years after first SMCC eligibility, cumulative probabilities of retention were 85.5% (95% CI: 84.0% to 86.9%) among early enrollees and 93% (95% CI: 92.8% to 94.0%) among late enrollees. The cumulative probability of retention from first SMCC was 97.0% (95% CI: 96.7% to 97.3%) and 86% (95% CI: 85% to 87%) at one and five years respectively. Among eligible patients initiating SMCC, the adjusted hazards of attrition were 2.4 (95% CI: 2.0 to 2.8) times higher during periods of SMCC discontinuation compared to periods on SMCC. Male sex, younger age, more recent SMCC eligibility and WHO Stage 3/4 conditions in the past year were also independently associated with attrition from SMCC. Approximately 26,000 consultations were saved during 2014.ConclusionAfter five years, retention among patients attending SMCC was high, especially among women and older patients, and its scale-up could facilitate universal access to ART.