Cross-Sectional Analysis of Late HAART Initiation in Latin America and the Caribbean: Late Testers and Late Presenters

BackgroundStarting HAART in a very advanced stage of disease is assumed to be the most prevalent form of initiation in HIV-infected subjects in developing countries. Data from Latin America and the Caribbean is still lacking. Our main objective was to determine the frequency, risk factors and trends in time for being late HAART initiator (LHI) in this region. MethodologyCross-sectional analysis from 9817 HIV-infected treatment-naïve patients initiating HAART at 6 sites (Argentina, Chile, Haiti, Honduras, Peru and Mexico) from October 1999 to July 2010. LHI had CD4+ count ≤200cells/mm3 prior to HAART. Late testers (LT) were those LHI who initiated HAART within 6 months of HIV diagnosis. Late presenters (LP) initiated after 6 months of diagnosis. Prevalence, risk factors and trends over time were analyzed. Principal FindingsAmong subjects starting HAART (n = 9817) who had baseline CD4+ available (n = 8515), 76% were LHI: Argentina (56%[95%CI:52–59]), Chile (80%[95%CI:77–82]), Haiti (76%[95%CI:74–77]), Honduras (91%[95%CI:87–94]), Mexico (79%[95%CI:75–83]), Peru (86%[95%CI:84–88]). The proportion of LHI statistically changed over time (except in Honduras) (p≤0.02; Honduras p = 0.7), with a tendency towards lower rates in recent years. Males had increased risk of LHI in Chile, Haiti, Peru, and in the combined site analyses (CSA). Older patients were more likely LHI in Argentina and Peru (OR 1.21 per +10-year of age, 95%CI:1.02–1.45; OR 1.20, 95%CI:1.02–1.43; respectively), but not in CSA (OR 1.07, 95%CI:0.94–1.21). Higher education was associated with decreased risk for LHI in Chile (OR 0.92 per +1-year of education, 95%CI:0.87–0.98) (similar trends in Mexico, Peru, and CSA). LHI with date of HIV-diagnosis available, 55% were LT and 45% LP. ConclusionLHI was highly prevalent in CCASAnet sites, mostly due to LT; the main risk factors associated were being male and older age. Earlier HIV-diagnosis and earlier treatment initiation are needed to maximize benefits from HAART in the region.研究背景：在疾病极晚期启动高效抗反转录病毒治疗（Highly Active Antiretroviral Therapy, HAART）被认为是发展中国家HIV感染者中最常见的治疗启动模式。目前拉丁美洲与加勒比地区的相关研究数据仍较为匮乏。本研究的核心目标为明确该地区HIV感染者中晚启动HAART者（late HAART initiator, LHI）的发生频率、危险因素及时间变化趋势。 研究方法：本研究对1999年10月至2010年7月期间，在阿根廷、智利、海地、洪都拉斯、秘鲁及墨西哥6个研究中心启动HAART的9817例HIV初治感染者开展横断面分析。将HAART启动前CD4+细胞计数≤200cells/mm³的受试者定义为晚启动HAART者（LHI）。其中，晚检测者（late tester, LT）指在HIV诊断后6个月内启动HAART的LHI；晚就诊者（late presenter, LP）指在HIV诊断6个月后才启动HAART的LHI。本研究对该人群的相关患病率、危险因素及时间趋势进行了统计分析。 主要研究结果：在9817例启动HAART的受试者中，具备基线CD4+细胞计数数据者共8515例，其中76%为LHI：阿根廷（56%[95%置信区间：52–59]）、智利（80%[95%置信区间：77–82]）、海地（76%[95%置信区间：74–77]）、洪都拉斯（91%[95%置信区间：87–94]）、墨西哥（79%[95%置信区间：75–83]）、秘鲁（86%[95%置信区间：84–88]）。除洪都拉斯外，各地区LHI的占比随时间呈现显著变化（p≤0.02；洪都拉斯p=0.7），整体呈现近年发生率逐步降低的趋势。在智利、海地、秘鲁及联合中心分析（combined site analyses, CSA）中，男性发生LHI的风险显著升高。在阿根廷和秘鲁，年龄较大的受试者更易成为LHI（每增加10岁，比值比（Odds Ratio, OR）=1.21，95%置信区间：1.02–1.45；OR=1.20，95%置信区间：1.02–1.43），但在CSA中未观察到该关联（OR=1.07，95%置信区间：0.94–1.21）。在智利，受教育程度更高与LHI风险降低相关（每增加1年受教育时间，OR=0.92，95%置信区间：0.87–0.98），墨西哥、秘鲁及CSA中也呈现类似趋势。在有明确HIV诊断日期记录的LHI中，55%为LT，45%为LP。 研究结论：CCASAnet各研究中心中LHI的患病率极高，且此类人群主要以LT为主；相关的独立危险因素为男性及高龄。该地区需进一步推进HIV早期诊断与尽早启动治疗，以最大化HAART在该地区的临床获益。