Division of Global HIV/AIDS (DGHA), Center for Global Health (CGH), Centers for Disease Control and Prevention, Atlanta, Georgia, USA.
PLoS One. 2013;8(1):e54665. doi: 10.1371/journal.pone.0054665. Epub 2013 Jan 22.
In Mozambique, tuberculosis (TB) is thought to be the most common cause of death among antiretroviral therapy (ART) enrollees. Monitoring proportions of enrollees screened for TB, and incidence and determinants of TB during ART can help clinicians and program managers identify program improvement opportunities.
METHODOLOGY/PRINCIPAL FINDINGS: We conducted a retrospective cohort study among a nationally representative sample of the 79,500 adults (>14 years old) initiating ART during 2004-2007 to estimate clinician compliance with TB screening guidelines, factors associated with active TB at ART initiation, and incidence and predictors of documented TB during ART follow-up. Of 94 sites enrolling >50 adults on ART, 30 were selected using probability-proportional-to-size sampling; 2,596 medical records at these sites were randomly selected for abstraction and analysis. At ART initiation, median age of patients was 34, 62% were female, median baseline CD4(+) T-cell count was 153/µL, and 11% were taking TB treatment. Proportions of records with TB screening documentation before ART initiation improved from 31% to 66% during 2004-2007 (p<0.001). TB screening compliance varied widely by ART clinic [n = 30, 2%-98% (p<0.001)] and supporting non-Governmental Organization (NGO) [n = 7, 27%-83% (p<0.001)]. Receiving TB treatment at ART enrollment was associated with male sex (p<0.001), weight <45 kg (p<0.001) and CD4<50/µL (p = 0.001). Isoniazid preventive therapy (IPT) was prescribed to <1% of ART enrollees not taking TB treatment. TB incidence during ART was 2.32 cases per 100 person-years. Factors associated with TB incidence included adherence to ART <95% (AHR 2.06; 95% CI, 1.32-3.21).
Variations in TB screening by clinic and NGO may reflect differing investments in TB screening activities. Future scale-up should target under-performing clinics. Scale-up of TB screening at ART initiation, IPT, and ART adherence interventions could significantly reduce incident TB during ART.
在莫桑比克，结核病（TB）被认为是接受抗逆转录病毒治疗（ART）者的最常见死因。监测接受 TB 筛查者的比例，以及 ART 期间 TB 的发生率和决定因素，可以帮助临床医生和项目管理者发现项目改进的机会。
方法/主要发现：我们对 2004-2007 年间全国代表性的 79500 名开始接受 ART 的成年人（>14 岁）进行了回顾性队列研究，以估计临床医生对 TB 筛查指南的遵守情况、与 ART 开始时活动性 TB 相关的因素，以及在 ART 随访期间记录的 TB 发生率和预测因素。在纳入>50 名成人接受 ART 的 94 个地点中，使用概率比例抽样选择了 30 个；从这些地点中随机选择了 2596 份病历进行提取和分析。在开始 ART 时，患者的中位年龄为 34 岁，62%为女性，中位基线 CD4+T 细胞计数为 153/µL，11%正在接受 TB 治疗。2004-2007 年期间，开始 ART 前有 TB 筛查记录的病历比例从 31%提高到 66%（p<0.001）。ART 诊所[ n=30，2%-98%（p<0.001）]和支持非政府组织（NGO）[ n=7，27%-83%（p<0.001）]的 TB 筛查依从性差异很大。在 ART 登记时接受 TB 治疗与男性（p<0.001）、体重<45kg（p<0.001）和 CD4<50/µL（p=0.001）有关。未接受 TB 治疗的 ART 登记者中，<1%接受了异烟肼预防性治疗（IPT）。ART 期间的 TB 发病率为每 100 人年 2.32 例。与 TB 发病率相关的因素包括 ART 依从性<95%（AHR 2.06；95%CI，1.32-3.21）。
诊所和 NGO 之间的 TB 筛查差异可能反映了对 TB 筛查活动的不同投资。未来的扩大规模应针对表现不佳的诊所。在 ART 开始时扩大 TB 筛查、IPT 和 ART 依从性干预措施，可以显著降低 ART 期间的新发 TB 。
