Clouse Kate, Blevins Meridith, Lindegren Mary Lou, Yotebieng Marcel, Nguyen Dung Thi, Omondi Alfred, Michael Denna, Zannou Djimon Marcel, Carriquiry Gabriela, Pettit April
Vanderbilt Institute for Global Health, Nashville, Tennessee, United States of America.
Vanderbilt University Medical Center, Nashville, Tennessee, United States of America.
PLoS One. 2017 Feb 9;12(2):e0171384. doi: 10.1371/journal.pone.0171384. eCollection 2017.
Xpert MTB/RIF is recommended by the World Health Organization (WHO) as the initial tuberculosis (TB) diagnostic test in individuals suspected of HIV-associated TB. We sought to evaluate field implementation of Xpert among a cohort of HIV/TB co-infected individuals, including availability, utilization and outcomes.
Observational cohort study (patient-level data) and cross-sectional study (site-level Xpert availability data).
Data were collected at 30 participating International epidemiologic Databases to Evaluate AIDS (IeDEA) sites in 18 countries from January 2012-January 2016. All patients were HIV-infected and diagnosed with TB, either bacteriologically or clinically, and followed until a determination of TB treatment outcome. We used multivariable modified Poisson regression to estimate adjusted relative risk (RR) and 95% confidence intervals for unfavorable TB treatment outcomes.
Most sites (63%) had access to Xpert, either in the clinic (13%), in the same facility (20%) or offsite (30%). Among 2722 HIV/TB patients included, median age was 35.4 years and 41% were female; BMI and CD4 count were low. Overall, most patients (76%) received at least one TB test; 45% were positive. Only 4% of all patients were tested using Xpert: 64% were Xpert-positive, 13% showed rifampicin (RIF) resistance and 30% were extrapulmonary (EPTB) or both pulmonary-EPTB. Treatment outcomes were mostly favorable (77%) and we found little association between Xpert use and an unfavorable TB treatment outcome (RR 1.25, 95%CI: 0.83, 1.90).
In this cohort, Xpert utilization was low even though the majority of sites had access to the test. Our findings show the need for expanded implementation and further research exploring barriers to use in low-resource settings.
世界卫生组织（WHO）推荐使用Xpert MTB/RIF对疑似合并HIV感染的结核病（TB）患者进行初始结核病诊断检测。我们试图评估Xpert在一组HIV/TB合并感染患者中的现场实施情况，包括可及性、使用情况和结果。
观察性队列研究（患者层面数据）和横断面研究（机构层面Xpert可及性数据）。
2012年1月至2016年1月期间，在18个国家的30个参与国际流行病学数据库以评估艾滋病（IeDEA）的机构收集数据。所有患者均为HIV感染者，经细菌学或临床诊断为结核病，并随访至确定结核病治疗结果。我们使用多变量修正泊松回归来估计不良结核病治疗结果的调整相对风险（RR）和95%置信区间。
大多数机构（63%）可以使用Xpert，要么在诊所（13%），要么在同一机构内（20%），要么在机构外（30%）。在纳入的2722例HIV/TB患者中，中位年龄为35.4岁，41%为女性；体重指数和CD4细胞计数较低。总体而言，大多数患者（76%）接受了至少一次结核病检测；45%检测结果为阳性。所有患者中只有4%使用Xpert进行检测：64%的Xpert检测结果为阳性，13%显示利福平（RIF）耐药，以及30%为肺外结核（EPTB）或同时合并肺内和肺外结核。治疗结果大多良好（77%），并且我们发现使用Xpert与不良结核病治疗结果之间几乎没有关联（RR 1.25，95%CI：0.83，1.90）。
在该队列中，尽管大多数机构可以使用该检测，但Xpert的使用率较低。我们的研究结果表明，需要扩大实施范围，并进一步研究低资源环境下使用该检测的障碍。
