Method for realizing accurate follow-up visit for HIV infected person

Abstract

The invention belongs to the technical field of infectious disease monitoring, and more specifically relates to a method for realizing accurate follow-up visit for an HIV infected person. The method comprises the following steps: collecting basic data from a Chinese disease prevention and control information system, managing the basic data and importing the basic data into the information system; the diagnosis and treatment receiving service information, the sociology information, the behavioral information and the biological information of the HIV infected persons are synthesized, and grading standards are formulated for the HIV infected persons; querying the case information of the HIV infected person according to the information system query condition template, judging the grade of the case of the current HIV infected person belonging to the grading standard, and carrying out grading marking; respectively formulating corresponding intervention measures for infected persons of different grades; and the primary-level workers carry out accurate follow-up work on the HIV infected persons according to the grading marks and corresponding intervention measures. The problems that in the prior art, individual case information cannot be provided, the risk cannot be judged by integrating infected person information, and complexity, time consumption and low accuracy are solved.

Description

Technical Field

[0001] The present invention belongs to the technical field of infectious disease monitoring, and more specifically, relates to a method for achieving accurate follow-up for HIV-infected persons. Background Art

[0002] At present, AIDS is mainly transmitted through sex in my country, and the situation of AIDS prevention and control is becoming more severe. Studies have found that reducing the viral load in HIV-infected people (including HIV-infected people and AIDS patients) can not only delay their onset and prolong their lifespan, but also effectively reduce the risk of HIV transmission, that is, the treatment-prevention strategy. With the implementation of the expanded treatment strategy, the follow-up service rate, antiviral treatment rate and treatment success rate of HIV-infected people have reached 90%.

[0003] However, because there is currently no drug that can cure AIDS, once HIV-infected people receive antiviral treatment, they need to take medication regularly throughout their lives to ensure good treatment results. With relatively limited public health resources, how to maintain a high follow-up service rate, treatment coverage rate and treatment success rate, reduce the dropout rate and drug resistance rate, and further promote the high-quality follow-up diagnosis and treatment services for HIV-infected people are the key and difficult issues that need to be urgently addressed in the prevention and control of AIDS.

[0004] Precise follow-up is one of the effective prevention and control strategies to solve the above problems and meet the challenges. Improving the formulation and implementation of classified management strategies and measures, allocating existing resources scientifically and rationally, and focusing on follow-up, referral and diagnosis and treatment of special cases can maximize the efficiency of diagnosis and treatment, promote the high-quality development of diagnosis and treatment services, thereby improving the quality of life of HIV-infected people, prolonging life and reducing the risk of transmission. Classifying HIV-infected people according to their social behavioral characteristics, the status of receiving diagnosis and treatment services and the treatment effect is a prerequisite for achieving precise follow-up. At present, the relevant information of HIV-infected people is entered into the China Disease Prevention and Control Information System by disease control agencies and designated medical institutions for AIDS antiviral treatment, including sociological information (such as age, gender, marital status, education level, etc.), behavioral information (such as condom use and sexual behavior), information on receiving diagnosis and treatment services (follow-up or loss of follow-up time, time of receiving or withdrawing antiviral treatment, treatment plan) and biological information (CD4+T lymphocyte detection time and results, viral load detection time and results, etc.).

[0005] The existing information system can be used to regularly count the number of HIV-infected people who have not received follow-up, have not received treatment during follow-up, have not received viral load testing during treatment, or have failed viral load testing, but it cannot provide individual case information; and it cannot comprehensively judge the transmission risk of HIV-infected people based on their social behavioral information and biological information. If grassroots staff want to obtain individual cases included in precise follow-up, they need to browse all the information of HIV-infected people one by one, manually search and compare eligible cases, which is cumbersome, time-consuming, and cannot guarantee accuracy. It greatly increases the workload of grassroots professional and technical personnel, affects the high-quality development of diagnosis and treatment services for HIV-infected people, and does not meet the current requirements of the times for "promoting the application of information technology such as artificial intelligence to carry out health management, etc." There is an urgent need for a method that can accurately analyze the follow-up diagnosis and treatment status of HIV-infected people to provide support for precise follow-up and achieve precise follow-up.

[0006] Chinese patent document CN109686455A discloses a follow-up monitoring technology for high-risk groups of AIDS, including the following steps: a data processing system extracts part or all of the examination items of the follow-up plan from a data processing center and imports them into a doctor's order system, wherein the data processing center stores the follow-up plans of multiple patients, wherein each of the follow-up plans of the patients includes corresponding examination items and a planned date; the data processing system traverses the examination items and corresponding planned dates of the follow-up plan, combines the examination items whose planned dates are close to the current date, and performs data processing to generate this follow-up plan. However, this method is only for high-risk groups, and still requires a lot of search time, and cannot achieve accurate follow-up of each infected person.

[0007] In view of this, the present invention designs a method for accurate follow-up of HIV-infected persons to solve the problems that the prior art cannot provide case information, cannot comprehensively analyze the information of infected persons to judge risks, and is cumbersome, time-consuming, and has low accuracy. Summary of the invention

[0008] The present invention aims to overcome at least one of the defects of the above-mentioned prior art and provide a method for accurate follow-up of HIV-infected persons, so as to solve the problems that the prior art cannot provide individual case information, cannot comprehensively analyze the information of infected persons to judge risks, and is cumbersome, time-consuming and inaccurate.

[0009] The detailed technical scheme of the present invention is as follows:

[0010] A method for achieving accurate follow-up for HIV-infected persons, the method comprising:

[0011] S1. Collect basic data from the Chinese Disease Prevention and Control Information System, and import the basic data into the information system after governance; the governed data contains detailed information on the patients' medical services, biological information, sociological information, and behavioral information;

[0012] S2. Based on the diagnosis and treatment service information, sociological information, behavioral information and biological information of HIV-infected persons, a grading standard is established for HIV-infected persons, which are divided into five levels: very low-risk HIV-infected persons, low-risk HIV-infected persons, medium-risk HIV-infected persons, high-risk HIV-infected persons and very high-risk HIV-infected persons;

[0013] S3, querying the case information of HIV infected persons according to the information system query condition template, determining whether the current HIV infected person case belongs to the level in the classification standard, and marking the level;

[0014] The case information includes comprehensive HIV-infected person's diagnosis and treatment service information, sociological information, behavioral information, biological information, and cardiovascular disease, chronic tumors, viral hepatitis, tuberculosis, and sexually transmitted diseases comorbidity;

[0015] S4. Develop corresponding intervention measures for people with very low risk of HIV infection, low risk of HIV infection, medium risk of HIV infection, high risk of HIV infection and very high risk of HIV infection;

[0016] S5. Grassroots staff conduct precise follow-up work on HIV-infected people according to the grading labels and corresponding intervention measures.

[0017] Preferably, according to the present invention, the basic data includes a medical record table Card, a basic treatment table, a treatment follow-up table and a treatment detection information table; the basic data is imported into the system after being managed, including the following steps:

[0018] S11, using the ID number and name of the HIV-infected person as the link variable, merge the Card database with the treatment database, generate a new medical record database and import it into the system to achieve the association between the patient's basic information and the treatment code ptid;

[0019] S12, using the ID number, name and treatment code ptid of HIV-infected patients as link variables, merge the new medical record database with the treatment follow-up database, generate a new treatment database and import it into the system to achieve treatment data integrity;

[0020] S13. Using the treatment code ptid of HIV-infected patients as the link variable, merge the new treatment database with the follow-up database, generate a new database and import it into the information system to ensure the integrity of the follow-up data and screen out useless follow-up data.

[0021] Preferably, according to the present invention, the extremely low-risk HIV infected persons in the classification standard refer to those who are under follow-up of antiviral treatment, have two consecutive viral load test results <50 copies / ml in the past two years, the interval between viral load tests is 3-18 months, and there is no information indicating that they have engaged in high-risk behavior;

[0022] Low-risk HIV-infected people refer to those who are on follow-up antiretroviral treatment, have two consecutive viral load test results <50 copies / ml in the past two years, but have self-reported or epidemiological survey information showing high-risk behavior in the past six months;

[0023] Medium-risk HIV infection refers to those who are on antiretroviral treatment and have the most recent viral load test result within the past two years.

[0024] <50 copies / ml, but do not meet the requirement of two consecutive viral load test results <50 copies / ml in the past two years;

[0025] High-risk HIV-infected persons refer to those who are on follow-up antiretroviral treatment, whose most recent viral load test result in the past two years is >50 copies / ml, and who have no information indicating that they have engaged in high-risk behavior or whose genotype resistance test shows that they are not resistant; or those who have no viral load test results in the past two years, and who have no information indicating that they have engaged in high-risk behavior or whose genotype resistance test shows that they are not resistant;

[0026] Extremely high-risk HIV-infected persons refer to: HIV-infected persons who have not received antiviral treatment, whose antiviral treatment has been interrupted or who have not been followed up; or HIV-infected persons who are undergoing antiviral treatment follow-up, whose most recent viral load test result in the past two years is >50 copies / ml, and whose self-reported or epidemiological information shows that they have engaged in high-risk behavior in the past six months, or whose genotypic resistance test shows drug resistance in the past year; or HIV-infected persons who have no viral load test results in the past two years, and whose self-reported or epidemiological information shows that they have engaged in high-risk behavior in the past six months, or whose genotypic resistance test shows drug resistance in the past year.

[0027] Preferably according to the present invention, the information system query condition template includes: case information of HIV-infected persons who have not been followed up, case information of HIV-infected persons who have not been treated during follow-up, case information of HIV-infected persons who have been treated but have not had their viral load tested, case information of HIV-infected persons whose viral load has been tested and is >50 copies / ml, case information of HIV-infected persons who have interrupted treatment, case information of HIV-infected persons whose spouses or regular sexual partners have not been tested, case information of HIV-infected persons who have not been screened for tuberculosis, case information of HIV-infected persons who have not been treated within 30 days of being newly diagnosed, case information of HIV-infected persons who have not received their first CD4+T lymphocyte test, case information of HIV-infected persons who need to receive a baseline viral load test for treatment, and case information of HIV-infected persons who have not received a viral load test after 6 months of treatment.

[0028] According to the preferred embodiment of the present invention, the intervention measures for very low-risk HIV-infected persons are health education and routine diagnosis and treatment services for infected persons, including health guidance and behavioral intervention, medical consultation, CD4+T lymphocyte detection, viral load detection, compliance assessment and safety assessment, as follows:

[0029] The health guidance and behavior intervention mentioned above refer to: introducing the relevant policies on AIDS prevention and control and the legal responsibilities for intentionally spreading AIDS; in accordance with national requirements, asking the infected person about their high-risk behaviors, judging their possible infection routes, time and place of infection, and whether they are likely to spread the disease to others; asking the infected person about their marital status, sexual partners and sexual behaviors, condom use, and injection drug use, and guiding the infected person to adopt safe sex; recommending spouses, sexual partners, and injection drug users to undergo HIV testing; and understanding the living habits of the infected person, discussing with them the importance of establishing healthy living habits, introducing health knowledge, guiding the infected person to improve their self-care skills, and encouraging the infected person to actively seek relevant support services;

[0030] The medical consultation means: understanding the physical condition of the infected person and informing them of the possible clinical symptoms of HIV infection, conducting tuberculosis questionnaire screening, and helping the infected person to be referred to relevant medical institutions for tuberculosis examination; helping the infected person to be referred to antiviral treatment medical institutions based on their clinical symptoms; understanding the infected person's reproductive desire and needs, introducing mother-to-child transmission prevention policies and strategies to those infected who have reproductive desires and are already pregnant, providing basic mother-to-child transmission information consultation, and further referring them to maternal and child health institutions;

[0031] The CD4+T lymphocyte test is performed 3 months before antiviral treatment, 3 months after the first antiviral treatment, and every 3-6 months within 2 years after antiviral treatment. After 2 years of antiviral treatment, if the viral load of HIV-infected patients is <50 copies / ml and the CD4+T lymphocyte count is between 350-500 cells / ul, it is recommended to test once a year. If the CD4+T lymphocyte count is ≥500 cells / ul, the infected person can choose the time for testing.

[0032] The viral load test is conducted before antiviral treatment and 4-8 weeks after the first antiviral treatment, and then every 8-12 weeks until the viral load of the infected person is less than 50 copies / ml. After that, HIV-infected people who have been on antiviral treatment for 2 years should be tested every 3-4 months, and after 2 years of antiviral treatment, every 6 months. If antiviral treatment fails, the treatment regimen should be adjusted and tested once 4-8 weeks later, and the rest is the same as above. For those with viral load less than 50 copies / ml due to drug toxicity or simplified drug regimen, the treatment regimen should be adjusted and tested once 4-8 weeks later, and then every 3 months.

[0033] The compliance assessment refers to: helping HIV-infected people find the motivation factors for compliance medication, emphasizing personal benefits, discussing and formulating medication regimens and plans, informing HIV-infected people of ways to improve compliance, and understanding the standardization, accuracy and timeliness of medication taken by HIV-infected people during each follow-up visit;

[0034] The safety assessment means that the infected person's blood sugar, blood lipids, liver and kidney function and bone density are tested at least once a year, the impact of antiviral treatment drugs is evaluated, and comorbid diseases are regularly screened, diagnosed and treated.

[0035] Preferably, according to the present invention, the intervention measures for low-risk HIV-infected persons are to strengthen health guidance and behavioral intervention on the basis of health education and routine diagnosis and treatment services, urge them to change their behavior, eliminate high-risk behaviors, and reduce the risk of transmission and reinfection.

[0036] According to the preferred embodiment of the present invention, the intervention measures for medium-risk HIV-infected persons are to test the viral load once within 3 months on the basis of health education and routine diagnosis and treatment services, re-determine the risk level based on the test results, and adopt targeted diagnosis and treatment services:

[0037] If the viral load test result is <50 copies / ml and there is no information indicating that the person has engaged in high-risk behavior, he or she will be defined as a very low-risk HIV-infected person and appropriate intervention measures will be taken;

[0038] If the viral load test result is <50 copies / ml, and self-report or epidemiological survey information shows high-risk behavior in the past six months, the individual is defined as a low-risk HIV-infected person and corresponding intervention measures are taken;

[0039] If the viral load test result is >50 copies / ml and there is no information indicating that the person has engaged in high-risk behavior, he or she will be defined as a high-risk HIV infected person and appropriate intervention measures will be taken;

[0040] If the viral load test result is >50 copies / ml, and self-reported or epidemiological information shows high-risk behavior in the past six months, the individual is defined as an extremely high-risk HIV-infected person and corresponding intervention measures are taken.

[0041] According to the present invention, the intervention measures for high-risk HIV infected persons are preferably as follows:

[0042] For HIV-infected individuals whose most recent viral load test result is >50 copies / ml in the past two years, we analyze the reasons why their virus is not completely suppressed, and provide symptomatic treatment for HIV-infected individuals whose compliance is poor due to adverse drug reactions but who are not yet drug-resistant, and change treatment plans when necessary; for cases with poor compliance due to other reasons, we conduct compliance reinforcement education, and after compliance improves, we select appropriate treatment plans based on drug resistance test results; at the same time, we conduct viral load tests every 3 months to monitor the occurrence of high-risk behaviors, further re-determine the risk level based on the test and monitoring results, and take targeted diagnosis and treatment services;

[0043] For HIV-infected individuals who have no viral load test results in the past two years, we analyze the reasons why their viral load was not tested and take targeted measures. At the same time, we conduct viral load tests every three months, further determine the risk level based on the test monitoring results, and provide targeted diagnosis and treatment services.

[0044] According to the preferred embodiment of the present invention, the intervention measures for extremely high risk HIV infection are as follows:

[0045] For HIV-infected persons who have been lost to follow-up: The CDC will work with government departments to search for HIV-infected persons based on their personal information, while maintaining confidentiality; once found, they will be mobilized to receive diagnosis and treatment services, with special attention paid to their mobility and compliance, and monitoring will be strengthened; for HIV-infected persons who have been lost to follow-up for more than one year, their death will be verified;

[0046] For HIV-infected people who have not received antiviral treatment: The CDC will work with professionals to analyze and sort out the reasons for not receiving treatment, conduct physiological, psychological, treatment cognition, treatment willingness and compliance assessments, and adopt targeted mobilization treatment strategies based on the reasons for not receiving treatment; for those who refuse treatment, adopt a one-person-one-strategy based on the fundamental needs of the infected person; on the premise of protecting their privacy, ask psychological counselors to intervene; for those who are still unwilling to receive treatment after repeated mobilization three times, follow up every 6 months to closely observe the progression of the disease, and cooperate with the public security to carry out mobilization referrals when necessary;

[0047] For those who interrupt antiviral treatment: The CDC will work with professionals to analyze the reasons for dropout or interruption of treatment, and recall HIV-infected people who have interrupted treatment by contacting them and their families and providing home diagnosis and treatment services. If necessary, it will work with the public security department to carry out this task;

[0048] For those whose most recent viral load test result is >50 copies / ml within the past two years:

[0049] If the case information shows that the individual has engaged in high-risk behavior in the past six months, the government should work with the individual to conduct legal education, emphasize family responsibility, social responsibility and the legal liability for intentionally spreading HIV, and urge the individual to change risky behavior and reduce transmission;

[0050] The CDC will work with designated hospitals for antiviral treatment to analyze the reasons why the virus is not completely suppressed, and provide symptomatic treatment for HIV-infected patients whose compliance is poor due to adverse drug reactions but who are not yet drug-resistant. If necessary, they will consider changing the treatment plan. For cases with poor compliance due to other reasons, they will carry out compliance reinforcement education. For those with drug-resistant HIV, they will analyze the reasons for drug resistance and optimize the antiviral treatment plan in a timely manner.

[0051] Face-to-face health education should be provided at least twice a year to remind HIV-infected people to cooperate with treatment and avoid high-risk behaviors, and the intervention effect should be closely monitored; if drug resistance testing has not been carried out, a genotype drug resistance test should be completed within 6 months; at the same time, viral load testing should be carried out every 3 months until the viral load test result is <50 copies / ml;

[0052] Based on the results of viral load, drug resistance testing and behavioral monitoring, further comprehensive assessments will be conducted, risk levels will be adjusted, and targeted diagnosis and treatment services will be provided.

[0053] Compared with the prior art, the present invention has the following beneficial effects:

[0054] (1) The present invention integrates the social behavior, biology and treatment service information of HIV-infected persons, and classifies HIV-infected persons into five levels according to the transmission risk. Low-risk HIV-infected persons who do not engage in high-risk behaviors for HIV infection, receive treatment services and have good treatment effects are included in the low-level group for continued routine follow-up, and high-risk HIV-infected persons who have not been treated, have interrupted treatment, have been lost to follow-up, have poor treatment effects, and have high-risk behaviors for HIV infection are included in the high-level group for precise follow-up. Under the condition of limited public health resources, precise intervention can be carried out for each level, and grassroots staff can be guided to carry out their work to effectively prevent and control the spread of AIDS.

[0055] (2) Based on digital information technology, the present invention can timely, accurately and scientifically obtain case information of HIV-infected persons who have not achieved high-quality development indicators, help grassroots follow-up professionals to identify key populations, provide accurate follow-up, and promote high-quality development of follow-up diagnosis and treatment. BRIEF DESCRIPTION OF THE DRAWINGS

[0056] Figure 1 It is a flow chart of a method for achieving accurate follow-up for HIV-infected persons described in the present invention.

[0057] Figure 2 This is a diagram showing the classification results of HIV infected persons after the method of the present invention is applied in Example 1 of the present invention. DETAILED DESCRIPTION

[0058] The present disclosure is further described below in conjunction with the accompanying drawings and embodiments.

[0059] Embodiment 1,

[0060] This embodiment provides a method for achieving accurate follow-up of HIV-infected persons, such as Figure 1 , the method comprising:

[0061] S1. Data collection and governance: Collect basic data from the China Disease Prevention and Control Information System, and import the basic data into the information system after governance; the data after governance includes detailed information on the patients’ medical services, biological information, sociological information, and behavioral information;

[0062] S2. Develop grading standards: Based on the information of HIV-infected people receiving diagnosis and treatment services, sociological information, behavioral information and biological information, develop grading standards for HIV-infected people, which are divided into five levels: very low risk HIV-infected people, low risk HIV-infected people, medium risk HIV-infected people, high risk HIV-infected people and very high risk HIV-infected people, and are represented by green, yellow, orange, red and purple respectively;

[0063] S3. HIV infection classification: query the case information of HIV infection according to the information system query condition template, determine whether the current HIV infection case belongs to the level in the classification standard, and mark the level;

[0064] The case information includes comprehensive HIV-infected person's diagnosis and treatment service information, sociological information, behavioral information, biological information, and cardiovascular disease, chronic tumors, viral hepatitis, tuberculosis, and sexually transmitted diseases comorbidity;

[0065] S4. Personalized intervention measures: formulate corresponding intervention measures for very low risk HIV infection, low risk HIV infection, medium risk HIV infection, high risk HIV infection and very high risk HIV infection;

[0066] S5. Precision follow-up: Grassroots staff conduct precise follow-up work on HIV-infected people according to the grading labels and corresponding intervention measures.

[0067] The basic data includes a medical record table Card, a basic treatment table, a treatment follow-up table and a treatment detection information table; the basic data is managed and imported into the system, which includes the following steps:

[0068] S11, using the ID number and name of the HIV-infected person as the link variable, merge the Card database with the treatment database, generate a new medical record database and import it into the system to achieve the association between the patient's basic information and the treatment code ptid;

[0069] S12, using the ID number, name and treatment code ptid of HIV-infected patients as link variables, merge the new medical record database with the treatment follow-up database, generate a new treatment database and import it into the system to achieve treatment data integrity;

[0070] S13. Using the treatment code ptid of HIV-infected patients as the link variable, merge the new treatment database with the follow-up database, generate a new database and import it into the information system to ensure the integrity of the follow-up data and screen out useless follow-up data.

[0071] The extremely low-risk HIV-infected persons in the classification standard are those who are on follow-up antiviral treatment, have two consecutive viral load test results of <50 copies / ml in the past two years, the interval between viral load tests is 3-18 months, and there is no information indicating that they have engaged in high-risk behavior;

[0072] Low-risk HIV-infected people refer to those who are on follow-up antiretroviral treatment, have two consecutive viral load test results <50 copies / ml in the past two years, but have self-reported or epidemiological survey information showing high-risk behavior in the past six months;

[0073] Medium-risk HIV infection refers to those who are on antiretroviral treatment and have the most recent viral load test result within the past two years.

[0074] <50 copies / ml, but do not meet the requirement of two consecutive viral load test results <50 copies / ml in the past two years;

[0075] High-risk HIV-infected persons refer to those who are on follow-up antiretroviral treatment, whose most recent viral load test result in the past two years is >50 copies / ml, and who have no information indicating that they have engaged in high-risk behavior or whose genotype resistance test shows that they are not resistant; or those who have no viral load test results in the past two years, and who have no information indicating that they have engaged in high-risk behavior or whose genotype resistance test shows that they are not resistant;

[0076] Extremely high-risk HIV-infected persons refer to: HIV-infected persons who have not received antiviral treatment, whose antiviral treatment has been interrupted or who have not been followed up; or HIV-infected persons who are undergoing antiviral treatment follow-up, whose most recent viral load test result in the past two years is >50 copies / ml, and whose self-reported or epidemiological information shows that they have engaged in high-risk behavior in the past six months, or whose genotypic resistance test shows drug resistance in the past year; or HIV-infected persons who have no viral load test results in the past two years, and whose self-reported or epidemiological information shows that they have engaged in high-risk behavior in the past six months, or whose genotypic resistance test shows drug resistance in the past year.

[0077] The information system query condition template includes: case information of HIV-infected persons who have not been followed up, case information of HIV-infected persons who have not been treated during follow-up, case information of HIV-infected persons who have been treated but have not had their viral load tested, case information of HIV-infected persons whose viral load has been tested and is >50 copies / ml, case information of HIV-infected persons who have interrupted treatment, case information of HIV-infected persons whose spouses or regular sexual partners have not been tested, case information of HIV-infected persons who have not been screened for tuberculosis, case information of HIV-infected persons who have not been treated within 30 days of being newly diagnosed, case information of HIV-infected persons who have not received their first CD4+T lymphocyte test, case information of HIV-infected persons who need to receive a baseline viral load test for treatment, and case information of HIV-infected persons who have not received a viral load test after 6 months of treatment.

[0078] The case information includes comprehensive information on the diagnosis and treatment services received by HIV-infected persons, such as follow-up or loss of follow-up time, time of acceptance or withdrawal of antiviral treatment, and treatment plan; sociological information, such as age, gender, marital status, educational level, etc.; behavioral information, such as condom use and sexual behavior; biological information, such as CD4+T lymphocyte detection time and results, viral load detection time and results, etc.; as well as cardiovascular disease, chronic tumors, viral hepatitis, tuberculosis, and sexually transmitted diseases.

[0079] The intervention measures for very low-risk HIV-infected people are health education and routine diagnosis and treatment services for infected people, including health guidance and behavioral intervention, medical consultation, CD4+T lymphocyte testing, viral load testing, compliance assessment and safety assessment, as follows:

[0080] The health guidance and behavior intervention mentioned above refer to: introducing relevant policies on AIDS prevention and treatment, such as the free provision of antiviral drugs, free provision of mother-to-child transmission prevention drugs, regular follow-up consultation, free CD4 cell testing, regular free HIV antibody testing for spouses / regular sexual partners, etc., as well as the legal liability for intentional transmission of AIDS; according to national requirements, understanding the high-risk behaviors of infected persons, inquiring about the history of high-risk behaviors, judging the possible route of infection, time and place of infection, and whether it is possible to spread to others; inquiring about the marital status, sexual partners and sexual behaviors, condom use, and injection drug use of infected persons; guiding infected persons to adopt safe sex and, if necessary, demonstrating the correct use of condoms; recommending spouses, sexual partners, and injection drug users to undergo HIV testing; also understanding the living habits of infected persons, such as living, eating, hygiene, production labor, exercise, and sleep, and discussing with them the importance of establishing healthy living habits that suit them for improving their own health and living conditions, introducing knowledge about nutrition, hygiene, and life, guiding infected persons to improve their self-care skills, and encouraging them to actively seek relevant support services, etc.;

[0081] The medical consultation means: understanding the physical condition of the infected person and informing them of the possible clinical symptoms of HIV infection, conducting tuberculosis questionnaire screening, and helping the infected person to be referred to relevant medical institutions for tuberculosis examination; helping the infected person to be referred to antiviral treatment medical institutions based on their clinical symptoms; understanding the infected person's reproductive desire and needs, introducing mother-to-child transmission prevention policies and strategies to those infected who have reproductive desires and are already pregnant, providing basic mother-to-child transmission information consultation, and further referring them to maternal and child health institutions;

[0082] The CD4+T lymphocyte test is performed 3 months before antiviral treatment, 3 months after the first antiviral treatment, and every 3-6 months within 2 years after antiviral treatment. If the baseline CD4+T lymphocyte count is between 200-350 cells / ul, it is recommended to test once every 3 months; if it is ≥350 cells / ul, it is recommended to test once every 6 months; after 2 years of antiviral treatment, if the viral load of HIV-infected patients is <50 copies / ml and the CD4+T lymphocyte count is between 350-500 cells / ul, it is recommended to test once a year. If the CD4+T lymphocyte count is ≥500 cells / ul, the infected person can choose the time for testing;

[0083] Viral load test: test once before antiviral treatment and 4-8 weeks after the first antiviral treatment, and then test once every 8-12 weeks until the infected person's viral load is <50 copies / ml. Then, HIV-infected people who have been on antiviral treatment for 2 years should be tested once every 3-4 months, and after 2 years of antiviral treatment, test once every 6 months. If antiviral treatment fails, test once 4-8 weeks after adjusting the treatment regimen, and the rest is the same as above. For those with viral load <50 copies / ml due to drug toxicity or simplified drug regimen, test once 4-8 weeks after adjusting the treatment regimen, and then test once every 3 months.

[0084] The compliance assessment is to help HIV-infected people find motivation factors for compliance medication, emphasize personal benefits, such as virus control and improved health, discuss and formulate medication regimens and plans, inform HIV-infected people of ways to improve compliance, such as alarm reminders, medicine boxes, etc., and understand the standardization, accuracy and timeliness of medication taken by HIV-infected people during each follow-up visit;

[0085] The safety assessment means that the infected person's blood sugar, blood lipids, liver and kidney function and bone density are tested at least once a year, the impact of antiviral treatment drugs is evaluated, and comorbid diseases are regularly screened, diagnosed and treated.

[0086] Intervention measures for low-risk HIV-infected people are to strengthen health guidance and behavioral intervention on the basis of health education and routine diagnosis and treatment services, urge them to change their behavior, eliminate high-risk behaviors, and reduce the risk of transmission and reinfection.

[0087] The intervention measures for medium-risk HIV-infected people are to test the viral load once every 3 months on the basis of health education and routine diagnosis and treatment services, re-determine the risk level based on the test results, and adopt targeted diagnosis and treatment services:

[0088] If the viral load test result is <50 copies / ml and there is no information indicating that the person has engaged in high-risk behavior, he or she will be defined as a very low-risk HIV-infected person and appropriate intervention measures will be taken;

[0089] If the viral load test result is <50 copies / ml, and self-report or epidemiological survey information shows high-risk behavior in the past six months, the individual is defined as a low-risk HIV-infected person and corresponding intervention measures are taken;

[0090] If the viral load test result is >50 copies / ml and there is no information indicating that the person has engaged in high-risk behavior, he or she will be defined as a high-risk HIV infected person and appropriate intervention measures will be taken;

[0091] If the viral load test result is >50 copies / ml, and self-reported or epidemiological information shows high-risk behavior in the past six months, the individual is defined as an extremely high-risk HIV-infected person and corresponding intervention measures are taken.

[0092] Interventions for people at high risk of HIV infection include:

[0093] For HIV-infected individuals whose most recent viral load test result is >50 copies / ml in the past two years, we analyze the reasons why their virus is not completely suppressed, and provide symptomatic treatment for HIV-infected individuals whose compliance is poor due to adverse drug reactions but who are not yet drug-resistant, and change treatment plans when necessary; for cases with poor compliance due to other reasons, we conduct compliance reinforcement education, and after compliance improves, we select appropriate treatment plans based on drug resistance test results; at the same time, we conduct viral load tests every 3 months to monitor the occurrence of high-risk behaviors, further re-determine the risk level based on the test and monitoring results, and take targeted diagnosis and treatment services;

[0094] For HIV-infected persons who have no viral load test results in the past two years, analyze the reasons for not testing their viral load and take targeted measures; if it is due to the mobility of HIV-infected persons, strengthen the connection with the diagnosis and treatment service institutions in the place of residence, and have the diagnosis and treatment service institutions in the place of residence provide viral testing; if it is due to HIV-infected persons' limited mobility or transportation, provide door-to-door services and other means to mobilize them to carry out viral load testing. At the same time, carry out viral load testing every 3 months, further re-determine the risk level based on the test monitoring results, and take targeted diagnosis and treatment services.

[0095] Specific interventions for people at very high risk of HIV infection include:

[0096] For HIV-infected persons who have been lost for follow-up: The CDC will work with government departments to search for HIV-infected persons based on their registered residence, current address, or reporting location through telephone, mobile phone, WeChat, and the Internet, etc., under the premise of keeping it confidential; mobilize them to receive diagnosis and treatment services, pay special attention to their mobility and compliance, strengthen referral and compliance education, and monitor treatment effectiveness. For HIV-infected persons who have been lost for follow-up for more than one year, verification can be carried out through information systems such as death cause reports.

[0097] For HIV-infected people who have not received antiviral treatment: The CDC will work with medical staff of designated hospitals for antiviral treatment, volunteers from social organizations, etc. to jointly analyze and sort out the reasons for non-treatment, conduct physiological, psychological, treatment cognition, treatment willingness and compliance assessments, and adopt targeted mobilization treatment strategies based on the reasons for non-treatment. For those who refuse treatment, one strategy is given to each person. Based on the fundamental needs of the patient, education is provided from the aspects of personal health, quality of life, protection of family members, and fulfillment of legal obligations; on the premise of protecting their privacy, psychological counselors are invited to intervene to increase the treatment participation rate and shorten the treatment hesitation period; for those who are still unwilling to receive treatment after repeated mobilization for three times, follow-up should be conducted every 6 months to closely observe the progression of the disease and reduce loss of follow-up. When necessary, the police will work together to carry out mobilization and referral.

[0098] For those who interrupt antiviral treatment: The CDC will collaborate with medical staff of designated hospitals, volunteers from social organizations, etc. to analyze the reasons for dropout or interruption of treatment, and recall HIV-infected people who have interrupted treatment by contacting them and their families, providing home diagnosis and treatment services, etc., and collaborate with the public security department to carry out this work when necessary.

[0099] For those whose most recent viral load test result is >50 copies / ml within the past two years:

[0100] ① If the information shows that there have been high-risk behaviors in the past six months, legal education should be carried out in coordination with the public security, judicial and other departments, emphasizing family responsibilities, social responsibilities and the legal liability for intentionally spreading the HIV virus, and urging them to change risky behaviors and reduce transmission.

[0101] ② The CDC will work with designated hospitals for antiviral treatment to analyze the reasons why the virus is not completely suppressed, and provide symptomatic treatment for HIV-infected patients who have poor compliance due to adverse drug reactions but have not yet developed drug resistance. If necessary, consider changing the treatment plan. For cases with poor compliance due to other reasons, conduct compliance reinforcement education. For patients with drug-resistant HIV, analyze the reasons for drug resistance and optimize the antiviral treatment plan in a timely manner.

[0102] ③ Provide face-to-face health education at least twice a year to remind HIV-infected people to cooperate with treatment and avoid high-risk behaviors, and closely monitor the effectiveness of intervention; if drug resistance testing has not been conducted, a genotype drug resistance test should be completed within 6 months; and a viral load test should be conducted every 3 months until the viral load test result is <50 copies / ml.

[0103] ④ Further comprehensive assessment will be conducted based on the results of viral load, drug resistance testing and behavioral monitoring, and risk levels will be adjusted, and targeted diagnosis and treatment services will be provided.

[0104] The method of the present invention is applied, and the specific classification results of HIV infected persons are as follows: Figure 2 As shown, according to the classification results, for HIV-infected persons with card number 370102037-2020-00002, routine health education and diagnosis and treatment services should continue to be carried out; for HIV-infected persons with card number 370202001-2022-00561, health education and behavioral intervention should be strengthened, especially the publicity of the "Law of the People's Republic of China on the Prevention and Control of Infectious Diseases" and the "Regulations on the Prevention and Control of AIDS", so that they can understand the law and clearly understand the hazards behind the behavior, reduce the number of sexual partners, and correctly use qualified condoms throughout sexual intercourse; for HIV-infected persons with card number 370690001-2021-00005, the viral load should be tested once in January 2025, and the risk level should be re-evaluated based on the test results and the behavioral information obtained from the epidemiological survey results to determine further diagnosis and treatment measures; for HIV-infected persons with card number 370724003-2021-00009, follow-up personnel of the CDC and antiviral Medical staff in designated medical institutions for treatment should analyze the reasons why their antiviral treatment is not effective. If HIV-infected patients have poor medication compliance and do not take medication on time and in the prescribed dosage, they need to be assisted in developing measures to improve medication compliance, such as alarm reminders and family reminders. For HIV-infected patients with card numbers 371602004-2024-00268, in addition to analyzing the reasons for the poor treatment effect, they should also cooperate with the public security and judicial departments to strengthen legal publicity and health education, reduce unsafe sexual behavior, and avoid HIV transmission. For HIV-infected patients with card numbers 370602037-2020-00007, follow-up personnel of the CDC need to cooperate with the public security, civil affairs and other departments to search for them through telephone, mobile phones, WeChat, the Internet and other means, under the premise of confidentiality, based on the information such as the registered residence, current address or reporting place of the HIV-infected person; find and mobilize them to receive diagnosis and treatment services, pay special attention to their mobility and compliance, strengthen referral and compliance education, and monitor treatment effects.

Claims

1. A method for accurate follow-up of HIV-infected persons, characterized in that: The method comprises: S1. Collect basic data from the Chinese Disease Prevention and Control Information System, and import the basic data into the information system after governance; the governed data contains detailed information on the patients' medical services, biological information, sociological information, and behavioral information; S2. Based on the diagnosis and treatment service information, sociological information, behavioral information and biological information of HIV-infected persons, a grading standard is established for HIV-infected persons, which are divided into five levels: very low-risk HIV-infected persons, low-risk HIV-infected persons, medium-risk HIV-infected persons, high-risk HIV-infected persons and very high-risk HIV-infected persons; S3, querying the case information of HIV infected persons according to the information system query condition template, determining whether the current HIV infected person case belongs to the level in the classification standard, and marking the level; The case information includes comprehensive HIV-infected person's diagnosis and treatment service information, sociological information, behavioral information, biological information, and cardiovascular disease, chronic tumors, viral hepatitis, tuberculosis, and sexually transmitted diseases comorbidity; S4. Develop corresponding intervention measures for people with very low risk of HIV infection, low risk of HIV infection, medium risk of HIV infection, high risk of HIV infection and very high risk of HIV infection; S5. Grassroots staff conduct precise follow-up work on HIV-infected people according to the grading labels and corresponding intervention measures.

2. A method for accurate follow-up of HIV-infected persons according to claim 1, characterized in that: The basic data includes a medical record table Card, a basic treatment table, a treatment follow-up table and a treatment detection information table; the basic data is managed and imported into the system, which includes the following steps: S11, using the ID number and name of the HIV-infected person as the link variable, merge the Card database with the treatment database, generate a new medical record database and import it into the system to achieve the association between the patient's basic information and the treatment code ptid; S12, using the ID number, name and treatment code ptid of HIV-infected persons as link variables, merge the new medical record database with the treatment follow-up database, generate a new treatment database and import it into the system; S13. Using the treatment code ptid of HIV-infected patients as the link variable, merge the new treatment database with the follow-up database, generate a new database and import it into the information system, while screening out useless follow-up data.

3. A method for accurate follow-up of HIV-infected persons according to claim 1, characterized in that: The extremely low-risk HIV-infected persons in the classification standard are those who are on follow-up antiviral treatment, have two consecutive viral load test results of <50 copies / ml in the past two years, the interval between viral load tests is 3-18 months, and there is no information indicating that they have engaged in high-risk behavior; Low-risk HIV-infected people refer to those who are on follow-up antiretroviral treatment, have two consecutive viral load test results <50 copies / ml in the past two years, but have self-reported or epidemiological survey information showing high-risk behavior in the past six months; Medium-risk HIV-infected people are those who are on follow-up antiretroviral treatment, whose most recent viral load test result in the past two years is less than 50 copies / ml, but who do not meet the requirement of two consecutive viral load test results less than 50 copies / ml in the past two years; High-risk HIV-infected persons refer to those who are on follow-up antiretroviral treatment, whose most recent viral load test result in the past two years is >50 copies / ml, and who have no information indicating that they have engaged in high-risk behavior or whose genotype resistance test shows that they are not resistant; or those who have no viral load test results in the past two years, and who have no information indicating that they have engaged in high-risk behavior or whose genotype resistance test shows that they are not resistant; Extremely high-risk HIV-infected persons refer to: HIV-infected persons who have not received antiviral treatment, whose antiviral treatment has been interrupted or who have not been followed up; or HIV-infected persons who are undergoing antiviral treatment follow-up, whose most recent viral load test result in the past two years is >50 copies / ml, and whose self-reported or epidemiological information shows that they have engaged in high-risk behavior in the past six months, or whose genotypic resistance test shows drug resistance in the past year; or HIV-infected persons who have no viral load test results in the past two years, and whose self-reported or epidemiological information shows that they have engaged in high-risk behavior in the past six months, or whose genotypic resistance test shows drug resistance in the past year.

4. A method for accurate follow-up of HIV-infected patients according to claim 1, characterized in that: The information system query condition template includes: case information of HIV-infected persons who have not been followed up, case information of HIV-infected persons who have not been treated during follow-up, case information of HIV-infected persons who have been treated but have not had their viral load tested, case information of HIV-infected persons whose viral load has been tested and is >50 copies / ml, case information of HIV-infected persons who have interrupted treatment, case information of HIV-infected persons whose spouses or regular sexual partners have not been tested, case information of HIV-infected persons who have not been screened for tuberculosis, case information of HIV-infected persons who have not been treated within 30 days of being newly diagnosed, case information of HIV-infected persons who have not received their first CD4+T lymphocyte test, case information of HIV-infected persons who need to receive a baseline viral load test for treatment, and case information of HIV-infected persons who have not received a viral load test after 6 months of treatment.

5. A method for accurate follow-up of HIV-infected patients according to claim 1, characterized in that: The intervention measures for very low-risk HIV-infected people are health education and routine diagnosis and treatment services for infected people, including health guidance and behavioral intervention, medical consultation, CD4+T lymphocyte testing, viral load testing, compliance assessment and safety assessment, as follows: The health guidance and behavior intervention mentioned above refer to: introducing the relevant policies on AIDS prevention and control and the legal responsibilities for intentionally spreading AIDS; in accordance with national requirements, asking the infected person about their high-risk behaviors, judging their possible infection routes, time and place of infection, and whether they are likely to spread the disease to others; asking the infected person about their marital status, sexual partners and sexual behaviors, condom use, and injection drug use, and guiding the infected person to adopt safe sex; recommending spouses, sexual partners, and injection drug users to undergo HIV testing; and understanding the living habits of the infected person, discussing with them the importance of establishing healthy living habits, introducing health knowledge, guiding the infected person to improve their self-care skills, and encouraging the infected person to actively seek relevant support services; The medical consultation means: understanding the physical condition of the infected person and informing them of the possible clinical symptoms of HIV infection, conducting tuberculosis questionnaire screening, and helping the infected person to be referred to relevant medical institutions for tuberculosis examination; helping the infected person to be referred to antiviral treatment medical institutions based on their clinical symptoms; understanding the infected person's reproductive desire and needs, introducing mother-to-child transmission prevention policies and strategies to those infected who have reproductive desires and are already pregnant, providing basic mother-to-child transmission information consultation, and further referring them to maternal and child health institutions; The CD4+T lymphocyte test is performed 3 months before antiviral treatment, 3 months after the first antiviral treatment, and every 3-6 months within 2 years after antiviral treatment. After 2 years of antiviral treatment, if the viral load of HIV-infected patients is <50 copies / ml and the CD4+T lymphocyte count is between 350-500 cells / ul, it is recommended to test once a year. If the CD4+T lymphocyte count is ≥500 cells / ul, the infected person can choose the time for testing. The viral load test is conducted before antiviral treatment and 4-8 weeks after the first antiviral treatment, and then every 8-12 weeks until the viral load of the infected person is less than 50 copies / ml. After that, HIV-infected people who have been on antiviral treatment for 2 years should be tested every 3-4 months, and after 2 years of antiviral treatment, every 6 months. If antiviral treatment fails, the treatment regimen should be adjusted and tested once 4-8 weeks later, and the rest is the same as above. For those with viral load less than 50 copies / ml due to drug toxicity or simplified drug regimen, the treatment regimen should be adjusted and tested once 4-8 weeks later, and then every 3 months. The compliance assessment refers to: helping HIV-infected people find the motivation factors for compliance medication, emphasizing personal benefits, discussing and formulating medication regimens and plans, informing HIV-infected people of ways to improve compliance, and understanding the standardization, accuracy and timeliness of medication taken by HIV-infected people during each follow-up visit; The safety assessment means that the infected person's blood sugar, blood lipids, liver and kidney function and bone density are tested at least once a year, the impact of antiviral treatment drugs is evaluated, and comorbid diseases are regularly screened, diagnosed and treated.

6. A method for accurate follow-up of HIV-infected persons according to claim 5, characterized in that: Intervention measures for low-risk HIV-infected people are to strengthen health guidance and behavioral intervention on the basis of health education and routine diagnosis and treatment services, urge them to change their behavior, eliminate high-risk behaviors, and reduce the risk of transmission and reinfection.

7. A method for accurate follow-up of HIV-infected persons according to claim 6, characterized in that: The intervention measures for medium-risk HIV-infected people are to test the viral load once every 3 months on the basis of health education and routine diagnosis and treatment services, re-determine the risk level based on the test results, and adopt targeted diagnosis and treatment services: If the viral load test result is <50 copies / ml and there is no information indicating that the person has engaged in high-risk behavior, he or she will be defined as a very low-risk HIV-infected person and appropriate intervention measures will be taken; If the viral load test result is <50 copies / ml, and self-report or epidemiological survey information shows high-risk behavior in the past six months, the individual is defined as a low-risk HIV-infected person and corresponding intervention measures are taken; If the viral load test result is >50 copies / ml and there is no information indicating that the person has engaged in high-risk behavior, he or she will be defined as a high-risk HIV infected person and appropriate intervention measures will be taken; If the viral load test result is >50 copies / ml, and self-reported or epidemiological information shows high-risk behavior in the past six months, the individual is defined as an extremely high-risk HIV-infected person and corresponding intervention measures are taken.

8. A method for accurate follow-up of HIV-infected persons according to claim 7, characterized in that: Interventions for people at high risk of HIV infection include: For HIV-infected individuals whose most recent viral load test result is >50 copies / ml in the past two years, we analyze the reasons why their virus is not completely suppressed, and provide symptomatic treatment for HIV-infected individuals whose compliance is poor due to adverse drug reactions but who are not yet drug-resistant, and change treatment plans when necessary; for cases with poor compliance due to other reasons, we conduct compliance reinforcement education, and after compliance improves, we select appropriate treatment plans based on drug resistance test results; at the same time, we conduct viral load tests every 3 months to monitor the occurrence of high-risk behaviors, further re-determine the risk level based on the test and monitoring results, and take targeted diagnosis and treatment services; For HIV-infected individuals who have no viral load test results in the past two years, we analyze the reasons why their viral load was not tested and take targeted measures. At the same time, we conduct viral load tests every three months, further determine the risk level based on the test monitoring results, and provide targeted diagnosis and treatment services.

9. A method for accurate follow-up of HIV-infected persons according to claim 8, characterized in that: Specific interventions for people at very high risk of HIV infection include: For HIV-infected persons who have been lost to follow-up: The CDC will work with government departments to search for HIV-infected persons based on their personal information, while maintaining confidentiality; once found, they will be mobilized to receive diagnosis and treatment services, with special attention paid to their mobility and compliance, and monitoring will be strengthened; for HIV-infected persons who have been lost to follow-up for more than one year, their death will be verified; For HIV-infected people who have not received antiviral treatment: The CDC will work with professionals to analyze and sort out the reasons for not receiving treatment, conduct physiological, psychological, treatment cognition, treatment willingness and compliance assessments, and adopt targeted mobilization treatment strategies based on the reasons for not receiving treatment; for those who refuse treatment, adopt a one-person-one-strategy based on the fundamental needs of the infected person; on the premise of protecting their privacy, ask psychological counselors to intervene; for those who are still unwilling to receive treatment after repeated mobilization three times, follow up every 6 months to closely observe the progression of the disease, and cooperate with the public security to carry out mobilization referrals when necessary; For those who interrupt antiviral treatment: The CDC will work with professionals to analyze the reasons for dropout or interruption of treatment, and recall HIV-infected people who have interrupted treatment by contacting them and their families and providing home diagnosis and treatment services. If necessary, it will work with the public security department to carry out this task; For those whose most recent viral load test result is >50 copies / ml within the past two years: If the individual case information shows that there has been high-risk behavior in the past six months, the government should work together to carry out legal education for the individual, emphasizing family responsibility, social responsibility and the legal liability for intentionally spreading HIV; The CDC will work with designated hospitals for antiviral treatment to analyze the reasons why the virus is not completely suppressed, and provide symptomatic treatment for HIV-infected patients whose compliance is poor due to adverse drug reactions but who are not yet drug-resistant. If necessary, they will consider changing the treatment plan. For cases with poor compliance due to other reasons, they will carry out compliance reinforcement education. For those with drug-resistant HIV, they will analyze the reasons for drug resistance and optimize the antiviral treatment plan in a timely manner. Face-to-face health education should be provided at least twice a year to remind HIV-infected people to cooperate with treatment and avoid high-risk behaviors, and the intervention effect should be closely monitored; if drug resistance testing has not been carried out, a genotype drug resistance test should be completed within 6 months; at the same time, viral load testing should be carried out every 3 months until the viral load test result is <50 copies / ml; Based on the results of viral load, drug resistance testing and behavioral monitoring, further comprehensive assessments will be conducted, risk levels will be adjusted, and targeted diagnosis and treatment services will be provided.

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