London School of Hygiene & Tropical Medicine, London, UK.
Int J Tuberc Lung Dis. 2013 Sep;17(9):1125-38. doi: 10.5588/ijtld.13.0117.
Twenty years of sky-high tuberculosis (TB) incidence rates and high TB mortality in high human immunodeficiency virus (HIV) prevalence countries have so far not been matched by the same magnitude or breadth of responses as seen in malaria or HIV programmes. Instead, recommendations have been narrowly focused on people presenting to health facilities for investigation of TB symptoms, or for HIV testing and care. However, despite the recent major investment and scale-up of TB and HIV services, undiagnosed TB remains highly prevalent at community level, implying that diagnosis of TB remains slow and incomplete. This maintains high transmission rates and exposes people living with HIV to high rates of morbidity and mortality. More intensive use of TB screening, with broader definitions of target populations, expanded indications for screening both inside and outside of health facilities, and appropriate selection of new diagnostic tools, offers the prospect of rapidly improving population-level control of TB. Diagnostic accuracy of suitable (high throughput) algorithms remains the major barrier to realising this goal. In the present study, we review the evidence available to guide expanded TB screening in HIV-prevalent settings, ideally through combined TB-HIV interventions that provide screening for both TB and HIV, and maximise entry to HIV and TB care and prevention. Ideally, we would systematically test, treat and prevent TB and HIV comprehensively, offering both TB and HIV screening to all health facility attendees, TB households and all adults in the highest risk communities. However, we are still held back by inadequate diagnostics, financing and paucity of population-impact data. Relevant contemporary research showing the high need for potential gains, and pitfalls from expanded and intensified TB screening in high HIV prevalence settings are discussed in this review.
二十年来，在人类免疫缺陷病毒（HIV）高发国家，结核病（TB）发病率和死亡率居高不下，但与疟疾或 HIV 规划相比，并未采取同等规模或范围的应对措施。相反，建议的重点狭窄地放在因 TB 症状到医疗机构就诊的人，或进行 HIV 检测和护理的人身上。然而，尽管最近在结核病和 HIV 服务方面进行了大量投资和扩大规模，但社区层面仍存在大量未确诊的结核病，这意味着结核病的诊断仍然缓慢且不完整。这维持了高传播率，并使 HIV 感染者面临高发病率和死亡率。更广泛地使用结核病筛查，扩大目标人群的定义，扩大卫生机构内外的筛查指征，并适当选择新的诊断工具，有望迅速改善人群层面的结核病控制。合适（高通量）算法的诊断准确性仍然是实现这一目标的主要障碍。在本研究中，我们回顾了现有的证据，以指导 HIV 高发环境中扩大结核病筛查，理想情况下通过结合结核病-艾滋病干预措施，同时为结核病和艾滋病提供筛查，并最大限度地为艾滋病和结核病的护理和预防提供入口。理想情况下，我们将全面系统地检测、治疗和预防结核病和艾滋病，为所有医疗机构就诊者、结核病家庭和最高危社区的所有成年人提供结核病和艾滋病筛查。然而，我们仍然受到诊断不足、资金短缺和缺乏人口影响数据的限制。本综述讨论了相关的当代研究，这些研究表明，在 HIV 高发环境中扩大和强化结核病筛查具有很高的需求，同时也存在潜在的风险。
