Bekker Linda-Gail, Myer Landon, Orrell Catherine, Lawn Steve, Wood Robin
Desmond Tutu HIV Centre, Institute for Infectious Disease and Molecular Medicine, University of Cape Town.
S Afr Med J. 2006 Apr;96(4):315-20.
Despite rapid expansion of antiretroviral therapy (ART) in sub-Saharan Africa there are few longitudinal data describing programme performance during rapid scale-up.
We compared mortality, viral suppression and programme retention in 3 consecutive years of a public sector community-based ART clinic in a South African township. Data were collected prospectively from establishment of services in October 2002 to the censoring date in September 2005. Viral load and CD4 counts were monitored at 4-monthly intervals. Community-based counsellors provided adherence and programme support.
During the study period 1139 ART-naïve patients received ART (161, 280 and 698 in the 1st, 2nd and 3rd years respectively). The median CD4 cell counts were 84 cells/microl (interquartile range (IQR) 42-139), 89 cells/microl (IQR 490-149), and 110 cells/microl (IQR 55-172), and the proportions of patients with World Health Organization (WHO) clinical stages 3 and 4 were 90%, 79% and 76% in each sequential year respectively. The number of counsellors increased from 6 to 28 and the median number of clients allocated to each counsellor increased from 13 to 33. The overall loss to follow-up was .9%. At the date of censoring, the Kaplan-Meier estimates of the proportion of patients still on the programme were 82%, 86% and 91%, and the proportion who were virally suppressed (< 400 copies/ml) were 100%, 92% and 98% for the 2002, 2003 and 2004 cohorts respectively.
While further operational research is required into optimal models of care in different populations across sub-Saharan Africa, these results demonstrate that a single community-based public sector ART clinic can extend care to over 1000 patients in an urban setting without compromising programme performance.
尽管撒哈拉以南非洲地区抗逆转录病毒疗法（ART）迅速推广，但在快速扩大规模期间，描述项目实施情况的纵向数据却很少。
我们比较了南非一个城镇一家基于社区的公共部门抗逆转录病毒治疗诊所连续三年的死亡率、病毒抑制情况和项目留存率。数据从2002年10月服务建立时前瞻性收集至2005年9月审查日期。每4个月监测一次病毒载量和CD4细胞计数。社区咨询员提供依从性和项目支持。
在研究期间，1139名未接受过抗逆转录病毒治疗的患者接受了治疗（第一年、第二年和第三年分别为161例、280例和698例）。CD4细胞计数中位数分别为84个/微升（四分位间距（IQR）42 - 139）、89个/微升（IQR 49 - 149）和110个/微升（IQR 55 - 172），世界卫生组织（WHO）临床3期和4期患者比例在连续各年分别为90%、79%和76%。咨询员数量从6名增加到28名，分配给每位咨询员的客户中位数从13名增加到33名。总体失访率为9%。在审查日期，2002年、2003年和2004年队列中仍在接受该项目治疗的患者比例的Kaplan - Meier估计值分别为82%、86%和91%，病毒被抑制（<400拷贝/毫升）的比例分别为100%、92%和98%。
虽然需要对撒哈拉以南非洲不同人群的最佳护理模式进行进一步的行动研究，但这些结果表明，一家基于社区的单一公共部门抗逆转录病毒治疗诊所在不影响项目实施效果的情况下，能够在城市环境中将护理服务扩展到1000多名患者。
