本文關(guān)鍵詞： 人類免疫缺陷病毒 靜脈注射吸毒者 抗反轉(zhuǎn)錄病毒治療 美沙酮維持治療　出處：《中國(guó)疾病預(yù)防控制中心》2013年博士論文　論文類型：學(xué)位論文

【摘要】：背景HIV感染的靜脈注射吸毒者(Injecting drug users, IDUs)(以下簡(jiǎn)稱"HIV吸毒者”)的管理和治療仍然是棘手的公共衛(wèi)生問題,美沙酮維持治療(Methadone maintenance treatment, MMT)和抗反轉(zhuǎn)錄病毒治療(Antiretroviral therapy, ART)是改善HIV吸毒者生存狀況的重要手段。現(xiàn)有科學(xué)證據(jù)表明,MMT可以增加HIV吸毒者的ART覆蓋率和依從性,降低病死率。中國(guó)建立了國(guó)家MMT及ART項(xiàng)目,兩個(gè)項(xiàng)目的各自效果都有評(píng)價(jià),但是對(duì)合并治療者的效果評(píng)價(jià)鮮有報(bào)告。 目的分析HIV吸毒者接受ART及MMT的效果及影響因素。 方法以HIV吸毒者為研究對(duì)象,建立兩個(gè)觀察性研究隊(duì)列。以29個(gè)抗病毒治療門診在2011年達(dá)治療標(biāo)準(zhǔn)(CD4350個(gè)/μl)的所有初治HIV吸毒者為研究對(duì)象,建立抗病毒治療隊(duì)列。對(duì)合并使用ART與MMT的患者所在的63個(gè)美沙酮門診中2011年內(nèi)所有符合ART標(biāo)準(zhǔn)(CD4350個(gè)/μl)的患者為研究對(duì)象,建立美沙酮治療隊(duì)列。合并使用ART和MMT者同時(shí)包括在兩個(gè)隊(duì)列中。前瞻性隨訪觀察1年,對(duì)抗病毒治療隊(duì)列的病死率、病毒載量抑制功率及影響因素進(jìn)行分析；對(duì)美沙酮治療隊(duì)列的病死率、MMT維持率及相關(guān)影響因素進(jìn)行分析。 結(jié)果抗病毒治療隊(duì)列共入選1633例HIV吸毒者,其中324例合并使用MMT,625例仍在使用毒品,684例未使用毒品。整個(gè)隊(duì)列隨訪觀察1年,80.3%在治,13.5%退出,6.2%死亡。MMT組、未使用毒品組、使用毒品組病死率分別為5.5、1.7、15.2/百人年。對(duì)死亡影響因素進(jìn)行Cox比例風(fēng)險(xiǎn)模型多因素回歸分析：無業(yè)死亡風(fēng)險(xiǎn)最高[AHR=23.5(95%CI:3.3-170.4)];其它影響因素包括使用毒品[AHR=6.2(95%CI:3.1-12.3)]或MMT [AHR=2.7(95%CI:1.2-6.0)]、低級(jí)別治療機(jī)構(gòu)[縣級(jí):AHR=6.2(95%CI:1.7-23.0),地市級(jí)：AHR=4.9(95%CI:1.3-17.9)]、男性[AHR=2.2(95%CI:1.1-4.5)、血紅蛋的120g/l[AHR=2.2(95%CI:1.4-3.3)]. CD4200個(gè)/μl [AHR=2.1(95%CI:1.3-3.4)]。 1070例有1年病毒載量結(jié)果,血漿病毒載量抑制率(400拷貝/ml)達(dá)到83.6%。其中,未使用毒品組的病毒載量抑制率最高,為87.7%,MMT組與使用毒品組的病毒抑制率相同,均為79.6%。對(duì)患者病毒載量抑制失敗的多因素logistic回歸分析中,未婚或離異[AOR=1.63(95%CI:1.13-2.35)]、無工作[AOR=1.64(95%CI:1.05-2.56)]、少數(shù)民族[AOR=1.95(95%CI:1.33-2.88)],使用毒品[AOR=1.68(95%CI:1.10-2.57)]或MMT [AOR=1.65(95%CI:1.02-2.66)],在疾控中心門診治療[AOR=2.53(95%CI:1.30-4.94)]均增加病毒載量抑制失敗風(fēng)險(xiǎn)。 美沙酮治療隊(duì)列509名患者中包括324例合并使用MMT及ART者,還有185例未接受ART的患者。隨訪1年,ART組總病死率為5.5/百人年,無ART組總病死率7.4/百人年。對(duì)死亡影響因素進(jìn)行Cox比例風(fēng)險(xiǎn)模型回歸分析：CD4200個(gè)/μl是唯一的死亡影響因素[AHR=5.5(95%CI:2.2-13.9)]。 美沙酮治療隊(duì)列觀察1年,ART組美沙酮使用劑量為72.8(IQR:50.3-106.9)mg/日,維持率66.1%(IQR:26.2%-94.0%);無ART組劑量55.7(IQR:35.3-80.0)mg/日,維持率60.9%(IQR：9.8%-92.1%)。影響美沙酮高維持率(≥50%)的多因素Logistic回歸分析：高劑量(≥60mg/日)與維持率明顯相關(guān)[AOR=3.07(95%CI:2.06-4.57)],其它有統(tǒng)計(jì)學(xué)意義的因素是CD4：200-350個(gè)/μl [AOR=1.60(95%CI:1.07-2.39)]。 結(jié)論對(duì)于HIV吸毒患者來說,如果停止使用毒品,可以取得最佳的抗病毒治療效果；與使用毒品相比,MMT明顯降低患者病死率。但是,使用MMT或毒品的患者病毒載量抑制率學(xué)效果有待提高。美沙酮治療維持率與美沙酮服用劑量相關(guān),ART不會(huì)降低美沙酮治療維持率。 今后應(yīng)該加強(qiáng)ART機(jī)構(gòu)與MMT機(jī)構(gòu)的整合和協(xié)作,以改善這兩個(gè)項(xiàng)目的衛(wèi)生質(zhì)量。關(guān)注改善美沙酮與抗病毒藥物相互作用,美沙酮門診監(jiān)督服抗病毒藥物等措施。對(duì)于就業(yè)、醫(yī)療機(jī)構(gòu)治療水平等因素也要重視。
[Abstract]:Background intravenous drug users infected with HIV (Injecting drug users, IDUs) (hereinafter referred to as "HIV addicts") management and treatment is still a public health problem difficult, methadone maintenance treatment (Methadone maintenance treatment, MMT) and anti retroviral therapy (Antiretroviral therapy ART) is an important means to improve HIV drug addicts living conditions. The existing scientific evidence shows that MMT can increase the HIV of drug addicts ART coverage and compliance, reduce the mortality rate. Chinese established national MMT and ART project, the results of two projects are evaluation, but evaluation of treatment effect with little report.
Objective to analyze the effect and influencing factors of HIV drug addicts receiving ART and MMT.
Methods HIV drug addicts as the research object, the establishment of two observational study cohort. In 29 outpatient treatment standards of antiviral therapy in 2011 (CD4350 / L) of all drug untreated HIV as the research object, the establishment of antiviral therapy on queue. The combined use of ART and MMT in 2011 63 outpatient methadone in all conform to the ART standard (CD4350 / L) patients as the research object, the establishment of methadone treatment cohort. The combined use of ART and MMT are also included in the two cohort. Prospective follow-up of 1 years, the mortality rate of antiviral treatment cohort, for the suppression of viral load power and influence factors analysis of mortality; cohort of methadone treatment rate, MMT rate of maintenance and analysis of related factors.
The results of antiviral therapy cohort a total of 1633 patients with HIV drug addicts, including 324 cases with MMT, 625 cases were still in use of drugs, 684 cases without the use of drugs. The entire cohort were followed up for 1 years, 80.3% out of 13.5% in the treatment, 6.2% died in group.MMT, without the use of drugs, drug use group of disease death rate respectively. 5.5,1.7,15.2/ hundred years. The influencing factors of death Cox regression model multivariate regression analysis: unemployed highest death risk of [AHR=23.5 (95%CI:3.3-170.4)]; other factors include the use of drugs [AHR=6.2 (95%CI:3.1-12.3) or MMT [AHR=2.7 (95% CI:1.2-6.0)], [the low level treatment mechanism: AHR=6.2 (95%CI:1.7-23.0), the AHR=4.9 (95%CI:1.3-17.9), male [AHR=2.2 (95%CI:1.1-4.5), hemoglobin 120g/l[AHR=2.2 (95%CI:1.4-3.3). CD4200 / L [AHR=2.1 (95%CI:1.3-3.4).
1070 cases of 1 years of viral load, plasma viral load suppression rate (400 copies /ml) which reached 83.6%., without the use of drugs was the suppression of viral load rate was 87.7%, MMT group and drug use group virus inhibition rates were the same, logistic 79.6%. multiple factors on patients with viral load suppression the failure of the regression analysis, unmarried or divorced [AOR=1.63 (95%CI:1.13-2.35)], no [AOR=1.64 (95%CI:1.05-2.56)], the minority [AOR=1.95 (95%CI:1.33-2.88)], the use of drugs [AOR=1.68 (95%CI:1.10-2.57) or MMT [AOR=1.65 (95%CI: 1.02-2.66)], the CDC outpatient treatment [AOR=2.53 (95%CI:1.30-4.94)] increased suppression of viral load failure risk.
Methadone treatment cohort of 509 patients including 324 patients with MMT and ART, and 185 patients did not receive ART patients. ART group of 1 years of follow-up, the total mortality rate was 5.5/ person years, ART group total mortality rate 7.4/ 100 years. The influencing factors of death of Cox proportional hazard model regression analysis: CD4200 [AHR=5.5 / L is the only influence factors of death (95%CI:2.2-13.9).
緹庢矙閰不鐤楅槦鍒楄瀵，

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