早期HIV 診斷對感染HIV 男男間性行為者生活品質調整後平均餘命的影響

Abstract

背景：臺灣自1997年起全面普及提供本國籍HIV感染者高效抗逆轉錄病毒藥物治療 (Highly active antiretroviral therapy, HAART)，使得HIV感染者的死亡率大幅度降低。但晚期就醫者(late presenter) 就醫後死亡率仍顯著高於早期診斷及早期接受治療的感染者。因此，藉由鼓勵高危險群接受篩檢，降低晚期就醫者的比率，可能是未來進一步提升HIV醫療效果的重要努力方向。在防疫上，早期診斷可以及早給予抗病毒藥物及提供介入衛教如鼓勵保險套的使用等，而顯著的降低傳染給他人的風險。但對感染者本身，早期診斷是否確實能延長壽命目前仍未能定論，因先前研究並未控制前導時間偏誤 (Lead time bias)。 方法：本研究比較早期診斷與晚期診斷感染者（晚期診斷定義為AIDS發病與HIV診斷時間相隔小於一個月）相較於年齡與性別配對的參照族群在生活品質調整後平均餘命 (Quality-adjusted life expectancy, QALE) 的損失，以調整前導時間偏誤 (lead time bias)。本研究以疾病管制署提供之全國HIV/AIDS資料庫分析2005-2014年感染之危險因子為男男間性行為之感染者追縱迄2014年底之實際存活資料，以恆定額外風險模式 (Constant excess hazard model) 外插70年。生活品質測量使用EuroQoL 5 dimensions (EQ-5D) 效用測量問卷來對目前在台大醫院就醫的HIV男男性行為者施測。並配合存活外插方法，來估計不同診斷時機HIV感染危險因子為男男間性行為者的生活品質調整後平均餘命 (Quality-adjusted life expectancy, QALE)差別。 本研究使用的統計軟體為iSQoL (integration of Survival with Quality of Life)。 結果：早期診斷組的感染HIV MSM族群與年齡、性別配對健康參考族群比較損失了6.71±0.06 年的平均餘命，晚期診斷損失了13.76±0.05 年的平均餘命。相較晚期診斷、早期診斷可以減少7.05±0.08年的平均餘命損失。調整生活品質後早期診斷組相較於年齡、性別配對的參考族群損失了5.44±1.42個健康人年，晚期診斷組減少了13.95±1.30個健康人年，相較晚期診斷組、早期診斷可以減少8.51±1.93個健康人年的損失。 結論：在所有病人皆可接受高效抗逆轉錄病毒藥物的治療的情境下，早期HIV診斷可以幫助感染HIV的MSM增加8.51個健康人年。 中文關鍵詞：後天免疫缺乏症候群 ; 生活品質調整後平均餘命 ; 男男間性行為者 ; 人類免疫缺乏病毒 ; 健康效用值 ; 早期診斷 ; 前導時間偏誤 ; 存活外差 ; 生活品質調整健康人年 ; 篩檢

Background: Since 1997, Taiwan provided universal access to highly active antiretroviral therapy (ART) for all HIV-infected citizens, including the key population of men having sex with men (MSM). Early HIV diagnosis allows timely ART to reduce infectivity of infected MSM, as well as behavioral intervention to promote condom use to protect other people. However, whether early HIV diagnosis actually improves survival of infected MSM themselves remain unclear. Previous studies did not adjust for lead time bias from early diagnosis. Methods: To adjust for lead time bias, we measured the impact of early versus late HIV diagnosis (defined as the presence of AIDS within one month of HIV diagnosis) on the survival by comparing the loss in quality-adjusted life expectancy (QALE) relative to age- and sex- matched reference populations. The life expectancy of HIV-infected MSM was projected from Taiwan 2003-2014 national HIV surveillance data (with survival followed until December 31, 2014), using a validated constant excess hazard model. We empirically measured the health utility in HIV-infected MSM treated at National Taiwan University Hospital (NTUH), using EuroQoL 5 dimensions (EQ-5D) instrument. Results: Compared to age- and sex-matched reference population, the loss in life expectancy was 6.71±0.06 years for the early diagnosed HIV-infected MSM versus 13.76±0.05 years for these late diagnosed. Early HIV diagnosis is associated with an increase in life expectancy by 7.05±0.08 years. After adjusting for health utility, the loss in QALE was 5.44±1.42 years for the early diagnosed HIV-infected MSM versus 13.95±1.30 years for the late diagnosed. Early HIV diagnosis is associated with an increase in QALE by 8.51±1.93 years. Conclusions: In the setting of universal access to ART, early HIV diagnosis before the onset of AIDS helps the HIV-infected MSM gain 8.51 healthy life years. Key words: Acquired Immunodeficiency Syndrome (AIDS), quality-adjusted life expectancy (QALE), Men having Sex with Men (MSM), Human Immunodeficiency Virus (HIV), health utility score, early diagnosis, lead time bias, survival extrapolation, quality adjusted life expectancy, screening