van Griensven Johan, De Naeyer Ludwig, Uwera Jeanine, Asiimwe Anita, Gazille Claire, Reid Tony
Médecins Sans Frontières, Kigali, Rwanda.
BMC Pediatr. 2008 Oct 2;8:39. doi: 10.1186/1471-2431-8-39.
Although a number of studies have shown good results in treating children with antiretroviral drugs (ARVs) in hospital settings, there is limited published information on results in pediatric programs that are nurse-centered and based in health centers, in particular on the psychosocial aspects of care.
Program treatment and outcome data were reported from two government-run health centers that were supported by Médecins Sans Frontières (MSF) in Kigali, Rwanda between October 2003 and June 2007. Interviews were held with health center staff and MSF program records were reviewed to describe the organization of the program. Important aspects included adequate training and supervision of nurses to manage ARV treatment. The program also emphasized family-centered care addressing the psychosocial needs of both caregivers and children to encourage early diagnosis, good adherence and follow-up.
A total of 315 children (< 15 years) were started on ARVs, at a median age of 7.2 years (range: 0.7-14.9). Sixty percent were in WHO clinical stage I/II, with a median CD4% of 14%. Eighty-nine percent (n = 281) started a stavudine-containing regimen, mainly using the adult fixed-dose combination. The median follow-up time after ARV initiation was 2 years (interquartile range 1.2-2.6). Eighty-four percent (n = 265) of children were still on treatment in the program. Thirty (9.5%) were transferred out, eight (2.6%) died and 12 (3.8%) were lost to follow-up. An important feature of the study was that viral loads were done at a median time period of 18 months after starting ARVs and were available for 87% of the children. Of the 174 samples, VL was < 400 copies/ml in 82.8% (n = 144). Two children were started on second-line ARVs. Treatment was changed due to toxicity for 26 children (8.3%), mainly related to nevirapine.
This report suggests that providing ARVs to children in a health center/nurse-based program is both feasible and very effective. Adequate numbers and training of nursing staff and an emphasis on the psychosocial needs of caregivers and children have been key elements for the successful scaling-up of ARVs at this level of the health system.
尽管多项研究表明，在医院环境中使用抗逆转录病毒药物（ARV）治疗儿童取得了良好效果，但关于以护士为中心、设在健康中心的儿科项目的成果，尤其是护理方面的社会心理状况，公开信息有限。
报告了2003年10月至2007年6月期间，在卢旺达基加利由无国界医生组织（MSF）支持的两家政府运营的健康中心的项目治疗及结果数据。与健康中心工作人员进行了访谈，并查阅了MSF项目记录以描述项目的组织情况。重要方面包括对护士进行充分培训和监督以管理ARV治疗。该项目还强调以家庭为中心的护理，满足照顾者和儿童的社会心理需求，以鼓励早期诊断、良好的依从性和随访。
共有315名15岁以下儿童开始接受ARV治疗，中位年龄为7.2岁（范围：0.7 - 14.9岁）。60%处于世界卫生组织临床I/II期，CD4%中位数为14%。89%（n = 281）开始使用含司他夫定的治疗方案，主要采用成人固定剂量组合。开始ARV治疗后的中位随访时间为2年（四分位间距1.2 - 2.6年）。84%（n = 265）的儿童仍在该项目中接受治疗。30名（9.5%）被转出，8名（2.6%）死亡，12名（3.8%）失访。该研究的一个重要特点是，在开始ARV治疗后的中位18个月时进行了病毒载量检测，87%的儿童有检测结果。在174份样本中，82.8%（n = 144）的病毒载量<400拷贝/ml。两名儿童开始接受二线ARV治疗。26名儿童（8.3%）因毒性反应而更换治疗方案，主要与奈韦拉平有关。
本报告表明，在健康中心/以护士为基础的项目中为儿童提供ARV治疗既可行又非常有效。充足数量且经过培训的护理人员以及对照顾者和儿童社会心理需求的重视，是在这一卫生系统层面成功扩大ARV治疗规模的关键因素。
