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THUC TRANG DUY TRI DIEU TRI ARV TAI CAC CO Sd DIEU TRj HIV/AIDS VA MOT SO YEU TO DICH VU Y TE LIEN QUAN TAI IVIOT SO TJNH/THANH PHO, GIAI DOAN 2011-2016
Hodng Thj Nhien', Tran Xuan Bach^ Phan Thj Thu HUtfng', Do Thj Nhan'
TOM T A T
Nghien cuu md ta cat ngang dugc tien hanh tren 23.960 benh nhan HIV/AIDS bit dku dilu tri nam 2011- 2015 cua 62 co sd dilu tri (CSDT), tai 15 tinh/thanh ph6 de tun hilu thuc trang duy tri dilu tri ARV cua benh nhan tai CSDT va radt s6 yiu td cua CSDT hen quan. Kit qua :nghien ciiu cho thiy ty le benh nhan duy tri dilu tri ARV sau 12 thang bat dSu dieu tri chung la 87,3% (dao ddng :86%-88,8%). Su dung md hinh hdi quy da bien cho thSy yeu to CLia CSDT nhu khu vuc, loai hinh ca sd, hd trg dieu itri, quy trinh kham benh, chiia benh va vi tri tiep ddn benh nhan HIV/AIDS cd lien quan tdi ty le benh nhan HIV/
AIDS duy tri dieu tri ARV sau 12 thang bat dau dieu tri (p<0,05). Tuyen dieu tri ciia CSDT khdng lien quan tdi ty ie duy tri dieu tri ARV sau 12 thang bat dau dieu tri; ben canh do, yeu td viing/mien (Bac, Trung, Nam) cua CSDT cQng khdng lien quan tdi ty le nay.
Tur khda: HIV/AIDS, duy tri dieu tri ARV, bd tri, ngijng theo ddi, ca sd dieu tri HIV/AIDS.
SUMMARY:
RETENTION ON ANTIRETROVIRAL THERAPY IN HIV/AIDS TREATMENT FACILITIES AND HEALTH SERVICE-RELATED FACTORS IN SOME PROVINCES, 2011-2016
A cross-sectional smdy was conducted on 23.960 HIV/AIDS patients who initiated antiretroviral therapy (ART) in 20H-2015 of 62 HIV/AIDS treatment facilities in 15 provinces to find out the reality of retention on ART and some factors related to the treatment facilities.
The results showed that percentage of patients retained in care 12 months after initiating ART was 87.3% (range 86%-88.8%). The multivanate logistic regression model showed that the factors of treatment facilities such as geographic characteristics, types of facility, mm over
health worker, treatment peer supporters, examination and treatment process and location of receptions associated with retention on ART at 12 months (p<0.05). The levels of treatment facilities was not asssocicated with retention rate at 12 months after ART initiation; Additionly, retention on ART was not associated with regions of treatment facilities across the country (north, central and south).
Keywords: HIV/AIDS, Retention on ARV, loss to follow-up, attrition, HIV/AIDS treatment facility.
I. D^T VAN DE
Dieu tri ARV lam giam ty le tii vong va benh tat d ngudi nhiem HIV va lam giam ty Ig nhiem HIV mdi trong cgng dong [1].
Tinh den thang 9/2017, tren ca nude cd 122.439 ngudi nhilm HIV dang dilu tri ARV [2]. Dilu tri ARV la dilu tri lien tyc, sudt ddi, dam bao benh nhan HTV/AIDS tuan thu va dugc theo doi trong suot qua trinh dieu tri ARV [3]. Ty le duy tri dieu tri ARV la mgt chi so d^nh gia su thanh cong cua chuong trinh dieu tri HIV/AIDS [4]. Day cung la mgt trong nhirng chi so canh bao sdm HIV khang thuoc do Td chiic Y te th6 gidi (WHO) lira chgn.
Trong bdi canh cac nha tai trg cat giam kinh phi vien trg true tiep cho cac dich vu HIV/AIDS, Chinh phii Viet Nam da xac dinh bao biem y te la ngudn tai chinh ben vimg ddi vdi dilu tri HIV/AIDS [5]. Tir nam 2014 trd lai day, cac nha tai trg da giam dan va hien da ngiing ho trg ddi vdi dieu tri benh nhiem tning co hgi va mgt sd xet nghiem theo doi dilu tri HIV/AIDS. Nam 2015, cac CSDT HIV/AIDS tren toan quoc bat dau thuc hien kien toan dap ung yeu cau kham chira benh qua bao hiem y te doi vdi HIV/AIDS. Theo do, phan Idn cac CSDT thuoc he thdng y te du phdng da chuyen sang he thong benh vien hoac bd sung chirc nang dieu tri, quy trinh kham chija benh HIV/AIDS da dieu chinh tu doc lap sang long
1. Cue Phong, chdng HIV/AIDS 2. Trirdng Dai hoc Y Ha N5i
I
Ngay nhan bai: 22/06/2018 |
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ghep vdi quy trinh kham chua benh ciia benh vien, Dieu nay c6 the lam anh hudng den viec duy tri dieu tri ARV cua ngudi nhilm HIV.
Tai Viet Nam, da cd mgt s6 nghien ciiu vl duy tri dilu tri ARV. Tuy nhien, chua cd nghien cuu nao vl duy tri dieu tri trong boi canh chuyen doi cac chinh sach lien quan din dilu tri HIVAIDS. Vi vay, nghien ciiu nay dugc thuc hien vdi muc tieu md ta thuc trang tinh hinh duy tri dieu tri va tim bieu mgt sd yeu to lien quan tai ca sd dieu tri HIV/AIDS d mgt s6 tinh/thanh phd, nam 2011-2016.
Tu do, dua ra cac giai phap tiep can phii hgp nham tang cudng duy tri hieu qua chuong trinh dieu tri ARV cho ngudi nhilm HIV.
II. PHLTONG PHAP N G H I E N ClTU 2.1. Doi tugng nghien cuu: Benh nhan va co sd dieu tri HIV/AIDS
2.2. Thiit ke nghien ciiu: Md ta ck ngang, kit ii;
phong van can bg y te, benh nhan
2.3. Dia diim nghien cuu: 62 ca sd dilu tri HIV/AD]
±udc 15 tinh/thanli pho 2.4. Thdi gian nghien cuu Tiithang 6/2017-5/2018 2.5. Phuong phap chon mau
- Chgn toan bg benh nhan HTV/AIDS bSt diu digue nam 20H-2015 t£ii 62 CSDT thudc 15 tinh/th^nh phi
- Phdng van can bg y te (bac sy, dieu duong) (i 62 CSDT
Benh nhan HIV/AIDS duy tri dilu tri sau 12 tlian]
bat dau dieu tri ARV la benh nhan con sdng va va daiij dugc dieu tri ARV tai thdi diem 12 thang sau khi bStdi dieu tri ARV (tir thang 1-12 hang nam) tinh din thdi dife thu thap.
Cach tinh ty le duy tri dieu tri ARV-
Ty le benh nhan duy tri dilu tri ARV sau 12 thang hk diu dilu tri
So benh nhan bat dau diSu tri ARV trong nam va con nhan thudc ARV tai thoi diem 12 thang sau khi bit dau dieu tri
Tdng so benh nhan bat dau dieu tri ARV trong nam (bao gdm benh nhan chuySo tdi, tii vong va bd dieu tri, tni benh nhan chuyin di)
2.6. Cong cu thu thap va phuong phap xu ly s6 lieu - Phdng van can bg y te vl thong tin CSDT bing bg cau hdi thiit kl san gdm vi tri dat CSDT, s6 lugng can bg tham gia hoat dgng dilu tri HIV/AIDS, cac dich vu y tl cham soc dilu tri HIV/AIDS sin co, s6 lugng benh nhan HIV/AIDS dieu tri ARV dang quan ly, tiin sudt phat thu6c, vi tri tiep don benh nhan HIV/AIDS;
- Hdi ciiu hi so benh an va sd dilu tri bSng thudc khang HIV
Nhap heu bang ph4n mem Epi Info 7, phan tich bang phan mem Stata 14.0.
2.7. Dao diic nghien ciiu
Nghien ciiu dugc thdng Hdi ddng dao diic cua Tnroi^
Dai hgc Y Ha Ndi, dam bao ddi tugng ddng y tham gia vao nghien cuu va mgi thdng tm ve ddi tugng nghien ciiu dirgt gift bi mat.
IH. KET QUA
Nghign ciiu dugc tiln hanh tren 23.960 benh nhan HIVl AIDS b4t diiu dilu tri ARV tir nam 2011 -2015 ciia 62 CSDl tai 15 tinh/thanh phd. Trong do, nam gidi chilm 63,6%, dj tuli trung binh ciia benh nhan la 33,6 mli, tap trung a nhoto 30-39 Uili (chilm 51,1 %, tuong duong 12.239 benh nhan), 3.1. Thuc tr?ng duy tri dieu tri ARV tai CSDT Biiu dd L Ty le duy tri diiu tri ARV sau 12 thdng bdt ddu diiu tri qua cdc nam
9 0 % -|
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Ty le benh nhan duy tri dieu tri ARV sau 12 thang bit dau dilu tri thay doi qua cac nam 2012-2016 va deu dat muc ieu ciia WHO (>S5%).
Biiu dd2. Ty 1^ duy tri dieu tri ARV sau 12 thdng bh ddu diiu trj theo khu vuc 9 0 % -
Cac CSDT thugc khu vuc thanh thi co ty le duy tri Su khac biet nay chi cd y nghia thdng ke nam 2012 va tilu trj ARV cao ban CSDT mdi triln khai hoat dgng. 2013 (p<0,05).
Bieu do 3. Ty li duy tri dieu tri ARV theo viing miin qua cdc nam
9 2 % 90% - 88%
86% - 84% - 8 2 %
7 8 % 8 9 %
8 7 %
84,2%^
2012
,.._^^ 87.3%
85,7%
8 0 %
2013
—•—Bic
88,4%
87,9%
79,7%
2014
• Tnmg
87,2%...--"^
86,4%
78.8%
2015 - . * - N a m
9 0 %
,••'82,8%
2016
Ty le duy tri dieu tn ARV sau 12 thang bat dau dieu duy tri dieu tri tai cac CSDT mien Bac cao ban mien Tnmg ri theo viing mien thay doi qua cac nam. Nhin chung, ty le va Nam, c6 y nghia thdng ke (p<0,05).
Biiu do 4. Ty li duy tri dieu tri ARV loai hinh CSDT qua cdc nam
92% - 90% -
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84% - 82% -
84.8% 84,9%
2012 2013
—•—BVDK
SO 5 (46) - Thing 09-10/2018 Website, yhoc Eongdong.™
2 - • - T
2014 2015 2016 TTYT 2 c/n —s™ Khac
Theo loai hinh CSDT, ty le benh nhan duy tri dieu loai hinh khac cao hon so vdi CSDT thudc benh \ tri ARV sau 12 thang bat dau dieu tri thay ddi theo da khoa va TTYT 2 ehiic nang, cd y nghia thine thdi gian. Trong dd, ty ie duy tri tai cac CSDT thudc (p<0,001).
TTYT 2 chiic nang cao hon so vdi cac CSDT khac nam Ty le duy tri dieu tn ARV theo tuyen dugc trinh I 2012-2015. Nam 2016, ty le duy tri dilu tri tai CSDT trong biludo 5.
Biiu do 5. Ty li duy tri dieu tri ARV theo tuyen diiu tri qua cdc nam 96% ,
8 7 , 3 % _ ^ — T r u n g Lfcrng
Cac CSDT tuySn tning uong co ty le duy tri diju tri ARV cao hem so voi tuyln tinh va huyen, co y nghia thSnisl
VOI p< 0,05 (trir nam 2014). ' Bieu as 6. Ty le duy tri diiu tri ARV theo sd Hnh nhan ARV dang qudn ly lai CSBT qua cdc nam
Ty l^duy Oi A „ , „ C.C CSDT > 500 benh nh.„ luong htah nian „ hon (trt, n.m 2015). S , « c h,e, * HIV/AIDS dang dilu tri ARV cao hon cac CSDT
CO so cd y nghia thing ke vdi p<0,05.
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Bang 1. Ty If duy tii diiu tri ARV sau 12 thdng bdt dau diiu tr} theo nhan s^ cua CSDT qua cdc nam Nhan sir
S6 luong y, bac sy tham gia
Thay doi can bo
Nhan vien ho trg dieu tri
<3 3-5
>5 P Co Khong
P Co Khong
P
Ty le duy tri dieu tri sau 12 thang qua cac nam (%) 2012
85,8 89,6 88,8 0,002 89 84,9 0,000 90,5 84,1 0,000
2013 85,7 87,5 80,5 0,000
87,6 80,9 0,000
87,9 83,2 0,000
lau
86,1 88,7 88,1 0,022
87,9 86,6 0,4S 88,2 86,7 0,09
2015 85,6 87,5 84,2 0,29 86,6 85,5 0,173
87,1 85,4 0,213
2016 88,2 89,2 89,3 0,134
89,3 87,3 0,128
89,2 88,2 0,47 Nhin chung, ty le benh nhan duy tri dieu tri ARV sau nam 2012, 2013 va 2014 (p<0,05).
" 2 thang bat dau dieu tri theo dac diem nhan su ciia CSDT Cac CSDT cd nhan vien hd trg dieu tri va thay ddi tdng nhat qua cac nam 2011-2015. CBYT cd ty le benh nhan duy tri dieu tri ARV cao hon Ty le duy tri dieu tri ARV tai CSDT cd 3-5 bac sy/y sy CSDT khdng cd, su khac bi?t co y nghia thSng ke nam
;ao hon so vdi cac CSDT khac, cd y nghia thdng ke trong 2012 va 2013 (p<0,001).
Bdng 2. Ty le duy tri dieu tri ARV sau 12 thdng bdt dau diiu tri theo tdn sudt hoat dgng vd dich vu kem theo cua CSDT qua cdc nam
Tan suat phat thudc/thang
'
Dich vu y te kem theo
<8lan 8-12 lin 16-20 lin
P 1 2 3 4 5 P
Ty le duy tri di^u tri sau 12 thang qua cac nam (%) 2012
89,7 83,1 88,7 0,001
86,3 88,8 87,4 87,1 88,9 0,005
2013 92,9 86,3 85,8 0,66 85 85,2 86,7 86,5 87,9 0,008
2014 83,6 85,4 88 0,047
86,6 88,6 84,8 88,6 89,6 0,017
2015 91,1 87,6 86 0,605
87 87,8 84,8 85,4 84,4 0,003
2016 81 91,4 88,4 0,01 87,6 90,1 87,8 88,5 88,2 0,004 Nam 2016, cac CSDT cd t3n suSt phat thudc 8-12 Ian/ CSDT cd 5 dich vu y te kem theo cao ban so vdi CSDT thang cd ty le b?nh nhan duy tri dieu tri ARV sau 12 thang khac. Sau2014,tyle duy tri dieu tri ARV cao tai cac CSDT b4t d5u dilu trj cao (>91%) so vdi cac CSDT co tin suat it cd 2 dich vu y te kem theo. Su khac biet cd y nghia thdng hem. Nam 2014 ve trudc, ty le duy tri dieu tri ARV tai cac ke (p<0,05).
B 36
S 6 5 (46) - Thang 09-10/2018 Website: yhoccongdong vnBang 3. Ty le duy Iri dilu tri ARV sau 12 thing bdl ddu dilu tri vd cdc yeu 1 Ty 1? duy tri dieu tri ARV sau 12 thang
bit d4u dieu tri Gioi tinh
Nam Nii Tuoi
Khu virc
Nong thon Thanh thi Loai hinh co so*
Benh vien da khoa TTYT 2 chuc nang Khac NhSn vien ho tro* dieu trj
Khong Co Tan suat phat thuoc/thang
<8lan 8-12 lin 16-20 lin Dich vu y te kem theo
1 3 4 5 Vi tri tiep don
Khoa kham benh PKDK/tniyln nhiem Khac
OR
1 1,93 0,99
1 1,15
1 1,58 0,89
1 1,36
1 0,57 0,67
1 0,93 1,11 0,8
1 1,6 4,91
P*
0,000 0,026
0,022
0,000 0,068
0,000
0,012 0,064
0,162 0,104 0,027
0,000 0,000
J djch VIA y le lien quan \
Khoiing tin c^
1.77 0,99
1,02
1,37 0,78
1,21
0,37 0,44
0,84 0,98 0,66
1,45 3,02
y (KTC) 95%
2,11 1
1
1,3
i 1,83 i 1,01
1,54
0,89 1,02
1,03 1,27 0,98
1,75 7,96 /J*- Gia tri p trong Mo hinh logistic da biln
Cac yeu td thuoc ve CSDT lien quan tdi ty le duy tri dieu tri ARV sau 12 thang bat dau dieu tri trong md hinh hii quy logistic nay phat hien: Cac CSDT khu vuc thanh thi cd ty le benh nhan duy tri dilu tn ARV cao gIp 1,15 lin (KTC 95%: 1,02-1,3) so vdi khu vuc ndng thon. Cac CSDT la TTYT 2 chiic nang co ty le benh nhan duy tri
dieu tri ARV sau 12 thang bdt dSu dilu tri cao gap 1,51 I3n (KTC 95%: 1,37-1,83) so vdi CSDT la benh viendi khoa. Cac CSDT cd nhan vien hi tro dilu tri cd ty le b?ii!i nhan duy tri dilu tri ARV cao gip I, 36 Un (KTC 95%:
1,21-1,54) so vdi CSDT khdng cd nhan vien hd tro dies tri- Cac CSDT phat thudc ARV 8-12 lln/thang c6 i\ '••
benh nhan duy tri dilu tri thap hem 0,57 lin (KTC 95%
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i7-0,89) so vdi CSDT cd tin suSt phat thudc it hon.
le CSDT cd 5 dich vu y te kem theo ngoai thudc ARV cac xet nghiem co ban cd ty le benh nhan duy tri dilu thlp han 0,8 lin (KTC 95%: 0,66-0,98) so vdi CSDT i cd 1 dich vu kem theo.
Cac CSDT tilp ddn benh nhan HIV/AIDS tai
•^DK/khoa truyen nhiem va khac cd ty le benh nhan .y tri dilu tri cao gip 1,6 lin (KTC 95%: 1,45-1,75) 4,91 ian (KTC 95%,: 3,02-7,96) so vdi CSDT tilp
•n t^i khoa kham benh. Su khac biet cd y nghia thdng
•p<0,001.
IV. BAN LUAN
Ty le duy tri dieu tri ARV sau 12 thang bk diu dilu tri
•ung giai doan 2012-2016 la 87,3% (dao dong 86-88,8%).
3t qua nay cao ban ket qua nghien cuu cua Nguyin Bui jc va cgng su (84,6%), nghien ciiu cua Dd Thi Nhan va
•ng sir (81,2%i) nhung thap hon ket qua nghien cuu ciia guyen Van Kinh va cong s^r (89,8%) [6],[7],[8].
Cac CSDT thuoc khu vuc thanh thi co ty le duy dilu tri ARV sau 12 thang cao gip 1,15 lin (KTC
>%>: 1,02-1,3) so vdi khu vuc ndng thdn. Kef qua nay ing tuong dong vdi cac nghien ciiu khac [6],[9]. Dieu ly cd the dugc giai thich do thanh thi la noi tap trung ic CSDT tuyen tinh, trung ucmg vdi dpi ngii CBYT co inh do chuyen mdn va nhan vien hd trg dieu tri, nhan ) trg tii cac du an. Vi vay, ho trg va chii trgng han 3ng viec hd trg benh nhan tuan thii dieu tri, giiip tang
le duy tri dieu tri.
Dieu tri ARV la lien tuc, suot ddi, dam bao man thu eu tri. Su hd trg tir ngudi than trong gia dinh, ddng dang en, CBYT, nhan vien ho trg dieu tri (la benh nhan dang eu tri ARV khoe manh, man thii tdt) tai CSDT,... la mgt )ng cac bien phap quan trpng giiip benh nhan HIV/AIDS an thu dieu tri ARV tdt ban. Trong nghien cuu nay, 25 5DT cd nhan vien hd trg dieu tri - ia benh nhan phong lam ARV khoe manh, tuan thii tot. Cac CSDT co nhan en ho trg dieu tri cd ty le benh nhan duy tri dieu tri ARV o gIp 1,36 lin so vdi CSDT khdng cd (KTC 95%: 1,21- 54). Ket qua nay kha tuong ddng vdi nghien cuu ciia livier va cgng su [9].
Ty le benh nhan duy tri dieu tri ARV sau 12 thang bat u dilu tri tai cac TTYT 2 chirc nang cao gap 1,58 Ian so a cac CSDT khac. Sd dT co ket qua nhu vay la do co ca chiic nang du phdng cung nhu dieu Uj, trong khi khdi ong, ap luc cong viec khdng nhieu nhu khdi benh vien
da khoa, cd nhieu thdi gian tu van, hd trg benh nhan tuan thu dilu tri. Ngoai ra, TTYT con cd chiic nang quan ly va nang cao sue khde cho ngudi dan [10]. Dieu nay giiip TTYT chu trgng han trong viec theo doi, quan ly benh nhan man tinh, trong dd cd benh nhan HIV/AIDS.
Trudc nam 2013, benh nhan HIV/AIDS true tilp vao cac phdng kham ARV de kham, linh thudc va thuc hi?n cac xet nghiem theo ddi dieu tri. Sau nam 2013, cac CSDT phai kien toan de dap ling yeu cau cung cap djch vu kham b^nh, chiia benh HIV/AIDS qua bao hiem y te. Theo do, quy trinh kham chiia benh HIV/AIDS phai tuan theo quy trinh kham b?nh, chira benh chung theo cac budc: Tiep ddn, kham benh, can lam sang, tra ket qua can lam sang, bac sT quyet djnh phac do dieu tri, giam dinh bao hiem y te, thanh toan (neu can), Imh thudc [11]. Tuy tirng CSDT, vi tri tiep ddn dugc dat tai khoa kham benh hoac phdng kham da khoa/khoa truyen nhiem (ket ndi vdi mang khoa kham benh). Tai cac CSDT benh nhan true tiep vao phdng kham da khoa/
khoa truyen nhiem co ty le duy tri diSu tri ARV cao hon cac CSDT tiep ddn benh nhan tai khoa kham benh (bang 3) do giam thdi gian chd kham cQng nhu ki thi, phan biet ddi xir hay Id tinh trang benh.
Tan suat phat thudc ARV ciia CSDT ciing anh hudng tdi ty le benh nhan duy tri dieu tri ARV sau 12 thang bat dau dieu tri. Ket qua chi ra CSDT thuc hien cap phat thudc ARV dudi 8 lan/thang co ty le duy tri cao ban (bang 3).
CSDT thuc hien cap phat dudi 8 lan/thang giiip benh nhan man thu tot hon trong viec tai kham, ITnh thudc, dam bao hieu qua dieu tri ARV.
V. KET LUAN
Ty le duy tri dieu tri ARV sau 12 thang bat dau dieu tri thay ddi qua cac nam 2012-2016 nhung deu dat muc tieu ciia WHO (>85%);
Cac yeu to dich vu y te nhu thay ddi quy trinh kham chija benh, vi tri tiep don, loai hinh CSDT va hd trg dieu tri benh nhan HIV/AIDS co hen quan tdi ty le duy tri dieu tri ARV sau 12 thang bat dau dieu trj.
VL KHUYEN NGHI
Cac CO sd dieu tri can dieu chinh quy trinh kham benh, chiia benh HIV/AIDS qua bao hiem y te phii hgp giiip giam thdi gian chd cho benh nhan; tang cudng truyen thdng giam ki thi, phan biet doi xu cho can bg tiep don, giam dinh va thanh toan bao hiem y te cua ca sd.
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SOS (46)-Th^g 09-10/2018 I ^ ^ Website' yhoccongdoag.vn |
