Medicine
®
Observational Study
OPEN
Outcomes and factors associated with survival of patients with HIV/AIDS initiating antiretroviral treatment in Liangshan Prefecture, southwest of China A retrospective cohort study from 2005 to 2013 Guang Zhang (PhD)a, Yuhan Gong (MD)b, Qixing Wang (MD)b, Ling Deng (MD)c, Shize Zhang (MD)b, Qiang Liao (MD)b, Gang Yu (BS)b, Ke Wang (MD)b, Ju Wang (MD)b, Shaodong Ye (MD)a, ∗ Zhongfu Liu (MD, PhD)a, Abstract Human immunodeficiency virus (HIV)–positive cases have been reported among people who injected drugs in Liangshan Prefecture in southwest of China since 1995 and Liangshan has become one of the most seriously affected epidemic areas in China. In 2004, several patients with HIV/acquired immunodeficiency syndrome (AIDS) initiated antiretroviral treatment (ART) at the Central Hospital of Liangshan Prefecture. From 2005 to 2013, the number of patients receiving ART dramatically increased. We conducted a retrospective cohort study to analyze the long-term survival time and associated factors among patients with HIV/ AIDS who received ART in Liangshan Prefecture for the first time. Data were collected from the Chinese AIDS Antiretroviral Therapy DATAFax Information System. A life table and the Kaplan–Meier and Cox proportion hazard regression were used to calculate the survival time and its associated factors, respectively. Among 8310 ART-naïve patients with HIV/AIDS who initiated ART, 436 patients died of AIDS-related diseases, and their median time of receiving ART was 15.0 ± 12.3 months, whereas 28.7% of them died within the first 6 months after treatment. The cumulative survival rates of those receiving ART in 1, 2, 3, 4, and 5 years were 97.1%, 93.4%, 90.6%, 88.8%, and 86.0%, respectively. Multivariate Cox regression analysis showed that male patients on ART were at a higher risk of death from AIDS-related diseases (adjusted hazard ratio [AHR] = 1.5, 95% confidence interval [CI]: 1.1–2.1) than female patients. Patients infected with HIV through injection drug use (IDU) were at a higher risk of death (AHR = 1.6, 95% CI: 1.2–2.2) than those infected through heterosexual transmission. Patients with a baseline CD4 cell count 45 0 1 (4.5) 5 (8.9) Sex Male 6 (75.0) 17 (77.3) 48 (85.7) Female 2 (25.0) 5 (22.7) 8 (14.3) Marital status Unmarried 3 (37.5) 5 (22.7) 7 (12.5) Married 3 (37.5) 13 (59.1) 43 (76.8) Separated 2 (25.0) 4 (18.2) 6 (10.7) Infection route Heterosexual 1 (12.5) 6 (27.3) 11 (19.6) Homosexual 0 0 1 (1.8) Injection drug use 7 (87.5) 15 (68.2) 44 (78.6) Blood transfusion or donation 0 1 (4.5) 0 Unknown 0 0 0 Suffered from pulmonary tuberculosis before receiving ART services or not Yes 0 0 1 (1.8) No 3 (37.5) 12 (54.5) 41 (73.2) Unknown 5 (62.5) 10 (45.5) 14 (25.0) Suffered AIDS-related diseases or symptoms 3 mo before receiving ART services or not Yes 4 (50.0) 12 (54.5) 37 (66.1) No 4 (50.0) 10 (45.5) 19 (33.9) WHO clinical stage 1 1 (12.5) 4 (18.2) 21 (37.5) 2 1 (12.5) 0 2 (3.5) 3 5 (62.5) 14 (63.6) 24 (42.9) 4 1 (12.5) 0 0 Unknown 0 4 (18.2) 9 (16.1) Baseline CD4 cell count, cells/mm3 350 0 0 8 (14.3) Unknown 1 (12.5) 1 (4.5) 1 (1.7) Months from HIV/AIDS diagnoses to ART initiation 12 3 (37.5) 9 (40.9) 24 (42.9) 13–36 2 (25.0) 5 (22.7) 22 (39.2) >37 2 (25.0) 6 (27.3) 10 (17.9) Unknown 1 (12.5) 2 (9.1) 0 Total 8 22 56
Variables
(32.4) (0.6) (65.0) (0.1) (1.9)
(1.6) (22.9) (59.1) (13.3) (3.1)
(53.7) (17.9) (23.1) (5.3) 0
410 (35.4) 603 (52.0) 146 (12.6) 0 1159
19 265 685 154 36
622 207 269 61
230 (19.8) 929 (80.2)
66 (5.7) 1077 (92.9) 16 (1.4)
375 7 754 1 22
127 (11.0) 944 (81.4) 88 (7.6)
855 (73.8) 304 (26.2)
392 (33.8) 684 (59.0) 83 (7.2)
2010
(29.0) (0.3) (68.3) (0.1) (2.3)
(1.3) (15.2) (40.7) (30.2) (12.6)
(41.9) (14.1) (39.5) (4.5) 0
779 (34.2) 1029 (45.2) 468 (20.6) 0 2276
30 346 926 687 287
953 321 899 103
502 (22.1) 1774 (77.9)
133 (5.8) 2011 (88.4) 132 (5.8)
660 7 1553 3 53
264 (11.6) 1888 (83.0) 124 (5.4)
1732 (76.1) 544 (23.9)
775 (34.1) 1299 (57.1) 202 (8.8)
2011
(33.8) (0.6) (61.1) (0.7) (3.8)
(2.0) (14.1) (34.6) (24.6) (24.7)
(47.8) (16.3) (33.2) (2.7) 0
623 (37.2) 503 (30.1) 547 (32.7) 0 1673
33 236 580 411 413
800 273 554 46
292 (17.5) 1384 (82.5)
52 (3.1) 1584 (94.7) 37 (2.2)
565 10 1023 11 64
174 (10.4) 1355 (81.0) 144 (8.6)
1178 (70.4) 495 (29.6)
496 (29.6) 976 (58.3) 201 (12.1)
2012
Distribution of sociodemographic and medical characteristics by ART initiation year among patients receiving ART services in Liangshan Prefecture.
(32.5) (0.5) (64.8) (0.1) (2.1)
(2.8) (13.3) (32.9) (26.3) (24.7)
(34.1) (29.2) (35.2) (1.5) 0
1023 (37.0) 771 (27.9) 971 (35.1) 0 2765
77 368 910 726 684
943 808 972 42
576 (20.8) 2189 (79.2)
64 (2.3) 2589 (93.6) 112 (4.1)
898 14 1792 3 58
261 (9.5) 2310 (83.5) 194 (7.0)
1972 (71.3) 793 (28.7)
903 (32.7) 1585 (57.3) 277 (10.0)
2013
(31.3) (0.5) (65.5) (0.2) (2.5)
(2.0) (16.3) (40.4) (24.1) (17.2)
(42.4) (20.0) (34.1) (3.1) (0.4)
3037 (36.5) 3071 (37.0) 2197 (26.4) 5 (0.1) 8310
170 1349 3361 2002 1428
3527 1659 2836 255 33
1748 (21.0) 6562 (79.0)
319 (3.8) 7636 (91.9) 355 (4.3)
2602 45 5443 20 200
872 (10.5) 6856 (82.5) 582 (7.0)
6073 (73.1) 2237 (26.9)
2684 (32.3) 4826 (58.1) 800 (9.6)
Total
Zhang et al. Medicine (2016) 95:27 www.md-journal.com
Zhang et al. Medicine (2016) 95:27
Medicine
treatment in stage I, 20.0% (1659/8310) in stage II, 34.1% (2836/8310) in stage III, and 3.1% (255/8310) in stage IV. The overall median CD4 cell count for 6884 patients who received CD4 testing when enrolling in ART services was 321.2 ± 200.3 cells/mm3. Among those (6884) having a CD4 cell count, 2.5% (170) of the patients were 350 cells/mm3 at the start of ART. The number of patients initiating ART significantly increased by year from 8 cases in 2005 to 2765 cases in 2013. The proportions of patients between 30 and 45 years of age decreased from 72.1% (62/86) in the first period, 2005 to 2007, to 57.5% (3860/6714) in the third period, 2011 to 2013 (P < 0.001). The proportion of patients suffering from AIDS-related diseases or symptoms 3 months before receiving ART services decreased from 61.6% (53/86) in the first period to 20.4% (1370/6714) in the third period (P < 0.001), and patients with a baseline CD4 cell count
®
Observational Study
OPEN
Outcomes and factors associated with survival of patients with HIV/AIDS initiating antiretroviral treatment in Liangshan Prefecture, southwest of China A retrospective cohort study from 2005 to 2013 Guang Zhang (PhD)a, Yuhan Gong (MD)b, Qixing Wang (MD)b, Ling Deng (MD)c, Shize Zhang (MD)b, Qiang Liao (MD)b, Gang Yu (BS)b, Ke Wang (MD)b, Ju Wang (MD)b, Shaodong Ye (MD)a, ∗ Zhongfu Liu (MD, PhD)a, Abstract Human immunodeficiency virus (HIV)–positive cases have been reported among people who injected drugs in Liangshan Prefecture in southwest of China since 1995 and Liangshan has become one of the most seriously affected epidemic areas in China. In 2004, several patients with HIV/acquired immunodeficiency syndrome (AIDS) initiated antiretroviral treatment (ART) at the Central Hospital of Liangshan Prefecture. From 2005 to 2013, the number of patients receiving ART dramatically increased. We conducted a retrospective cohort study to analyze the long-term survival time and associated factors among patients with HIV/ AIDS who received ART in Liangshan Prefecture for the first time. Data were collected from the Chinese AIDS Antiretroviral Therapy DATAFax Information System. A life table and the Kaplan–Meier and Cox proportion hazard regression were used to calculate the survival time and its associated factors, respectively. Among 8310 ART-naïve patients with HIV/AIDS who initiated ART, 436 patients died of AIDS-related diseases, and their median time of receiving ART was 15.0 ± 12.3 months, whereas 28.7% of them died within the first 6 months after treatment. The cumulative survival rates of those receiving ART in 1, 2, 3, 4, and 5 years were 97.1%, 93.4%, 90.6%, 88.8%, and 86.0%, respectively. Multivariate Cox regression analysis showed that male patients on ART were at a higher risk of death from AIDS-related diseases (adjusted hazard ratio [AHR] = 1.5, 95% confidence interval [CI]: 1.1–2.1) than female patients. Patients infected with HIV through injection drug use (IDU) were at a higher risk of death (AHR = 1.6, 95% CI: 1.2–2.2) than those infected through heterosexual transmission. Patients with a baseline CD4 cell count 45 0 1 (4.5) 5 (8.9) Sex Male 6 (75.0) 17 (77.3) 48 (85.7) Female 2 (25.0) 5 (22.7) 8 (14.3) Marital status Unmarried 3 (37.5) 5 (22.7) 7 (12.5) Married 3 (37.5) 13 (59.1) 43 (76.8) Separated 2 (25.0) 4 (18.2) 6 (10.7) Infection route Heterosexual 1 (12.5) 6 (27.3) 11 (19.6) Homosexual 0 0 1 (1.8) Injection drug use 7 (87.5) 15 (68.2) 44 (78.6) Blood transfusion or donation 0 1 (4.5) 0 Unknown 0 0 0 Suffered from pulmonary tuberculosis before receiving ART services or not Yes 0 0 1 (1.8) No 3 (37.5) 12 (54.5) 41 (73.2) Unknown 5 (62.5) 10 (45.5) 14 (25.0) Suffered AIDS-related diseases or symptoms 3 mo before receiving ART services or not Yes 4 (50.0) 12 (54.5) 37 (66.1) No 4 (50.0) 10 (45.5) 19 (33.9) WHO clinical stage 1 1 (12.5) 4 (18.2) 21 (37.5) 2 1 (12.5) 0 2 (3.5) 3 5 (62.5) 14 (63.6) 24 (42.9) 4 1 (12.5) 0 0 Unknown 0 4 (18.2) 9 (16.1) Baseline CD4 cell count, cells/mm3 350 0 0 8 (14.3) Unknown 1 (12.5) 1 (4.5) 1 (1.7) Months from HIV/AIDS diagnoses to ART initiation 12 3 (37.5) 9 (40.9) 24 (42.9) 13–36 2 (25.0) 5 (22.7) 22 (39.2) >37 2 (25.0) 6 (27.3) 10 (17.9) Unknown 1 (12.5) 2 (9.1) 0 Total 8 22 56
Variables
(32.4) (0.6) (65.0) (0.1) (1.9)
(1.6) (22.9) (59.1) (13.3) (3.1)
(53.7) (17.9) (23.1) (5.3) 0
410 (35.4) 603 (52.0) 146 (12.6) 0 1159
19 265 685 154 36
622 207 269 61
230 (19.8) 929 (80.2)
66 (5.7) 1077 (92.9) 16 (1.4)
375 7 754 1 22
127 (11.0) 944 (81.4) 88 (7.6)
855 (73.8) 304 (26.2)
392 (33.8) 684 (59.0) 83 (7.2)
2010
(29.0) (0.3) (68.3) (0.1) (2.3)
(1.3) (15.2) (40.7) (30.2) (12.6)
(41.9) (14.1) (39.5) (4.5) 0
779 (34.2) 1029 (45.2) 468 (20.6) 0 2276
30 346 926 687 287
953 321 899 103
502 (22.1) 1774 (77.9)
133 (5.8) 2011 (88.4) 132 (5.8)
660 7 1553 3 53
264 (11.6) 1888 (83.0) 124 (5.4)
1732 (76.1) 544 (23.9)
775 (34.1) 1299 (57.1) 202 (8.8)
2011
(33.8) (0.6) (61.1) (0.7) (3.8)
(2.0) (14.1) (34.6) (24.6) (24.7)
(47.8) (16.3) (33.2) (2.7) 0
623 (37.2) 503 (30.1) 547 (32.7) 0 1673
33 236 580 411 413
800 273 554 46
292 (17.5) 1384 (82.5)
52 (3.1) 1584 (94.7) 37 (2.2)
565 10 1023 11 64
174 (10.4) 1355 (81.0) 144 (8.6)
1178 (70.4) 495 (29.6)
496 (29.6) 976 (58.3) 201 (12.1)
2012
Distribution of sociodemographic and medical characteristics by ART initiation year among patients receiving ART services in Liangshan Prefecture.
(32.5) (0.5) (64.8) (0.1) (2.1)
(2.8) (13.3) (32.9) (26.3) (24.7)
(34.1) (29.2) (35.2) (1.5) 0
1023 (37.0) 771 (27.9) 971 (35.1) 0 2765
77 368 910 726 684
943 808 972 42
576 (20.8) 2189 (79.2)
64 (2.3) 2589 (93.6) 112 (4.1)
898 14 1792 3 58
261 (9.5) 2310 (83.5) 194 (7.0)
1972 (71.3) 793 (28.7)
903 (32.7) 1585 (57.3) 277 (10.0)
2013
(31.3) (0.5) (65.5) (0.2) (2.5)
(2.0) (16.3) (40.4) (24.1) (17.2)
(42.4) (20.0) (34.1) (3.1) (0.4)
3037 (36.5) 3071 (37.0) 2197 (26.4) 5 (0.1) 8310
170 1349 3361 2002 1428
3527 1659 2836 255 33
1748 (21.0) 6562 (79.0)
319 (3.8) 7636 (91.9) 355 (4.3)
2602 45 5443 20 200
872 (10.5) 6856 (82.5) 582 (7.0)
6073 (73.1) 2237 (26.9)
2684 (32.3) 4826 (58.1) 800 (9.6)
Total
Zhang et al. Medicine (2016) 95:27 www.md-journal.com
Zhang et al. Medicine (2016) 95:27
Medicine
treatment in stage I, 20.0% (1659/8310) in stage II, 34.1% (2836/8310) in stage III, and 3.1% (255/8310) in stage IV. The overall median CD4 cell count for 6884 patients who received CD4 testing when enrolling in ART services was 321.2 ± 200.3 cells/mm3. Among those (6884) having a CD4 cell count, 2.5% (170) of the patients were 350 cells/mm3 at the start of ART. The number of patients initiating ART significantly increased by year from 8 cases in 2005 to 2765 cases in 2013. The proportions of patients between 30 and 45 years of age decreased from 72.1% (62/86) in the first period, 2005 to 2007, to 57.5% (3860/6714) in the third period, 2011 to 2013 (P < 0.001). The proportion of patients suffering from AIDS-related diseases or symptoms 3 months before receiving ART services decreased from 61.6% (53/86) in the first period to 20.4% (1370/6714) in the third period (P < 0.001), and patients with a baseline CD4 cell count
