Hanrahan Colleen F, Van Rie Annelies
Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.
Epidemiology for Global Health Institute, University of Antwerp, Antwerp, Belgium.
J Int AIDS Soc. 2017 Apr 20;20(1):21375. doi: 10.7448/IAS.20.01.21375.
The rapid and accurate diagnosis of HIV-associated tuberculosis (TB), timely initiation of curative or preventative treatment and assurance of favourable treatment outcomes is a complex process. The current system of monitoring and reporting TB diagnosis and treatment does not include several key aspects of the care cascade, and may obscure systematic bottlenecks, inefficiencies or sources of sub-optimal care.
We critically reviewed the current World Health Organizations recommended system of monitoring and reporting, and identified the following key deficiencies that could limit the ability of healthcare workers to identify structural problems in the provision of TB/HIV care.
We identified the following key deficiencies in the current monitoring and evaluation system: (1) an emphasis on national-level reporting and programmatic analysis results in a loss of granularity; (2) the absence of a general framework to anchor indicators in relation to one another as well as the overall goals for TB/HIV collaborative activities; (3) de-linking of TB treatment indicators from those for screening and diagnosis; (4) few indicators are tied to suggested times for completion of an activity. We defined three distinct stages comprising the cascade of HIV-associated TB diagnosis and treatment: (1) Screening & Diagnosis, (2) Treatment and (3) Preventive Therapy. We detailed major steps within each stage, described potential sources of variability, and proposed data elements, process indicators, main outcomes, and retention calculations for each stage.
This proposed framework of monitoring is novel in its focus on a cohort experience through the entire scope of the care cascade from screening and TB diagnosis through curative or preventive treatment. This approach can be applied to all settings at clinic, district or national level, and used to identify crucial areas for improvement in order to maximize health outcomes for all those affected by the dual epidemics of TB and HIV.
快速准确地诊断艾滋病毒相关结核病（TB）、及时启动治疗或预防治疗并确保良好的治疗效果是一个复杂的过程。当前监测和报告结核病诊断与治疗的系统并未涵盖照护流程中的几个关键方面，可能会掩盖系统性瓶颈、效率低下或次优照护的来源。
我们严格审查了世界卫生组织目前推荐的监测和报告系统，确定了以下可能限制医护人员识别结核病/艾滋病毒照护提供中结构问题能力的关键缺陷。
我们在当前监测和评估系统中发现了以下关键缺陷：（1）对国家级报告和项目分析的强调导致细节信息丢失；（2）缺乏一个通用框架来将指标相互关联以及与结核病/艾滋病毒协作活动的总体目标联系起来；（3）结核病治疗指标与筛查和诊断指标脱节；（4）很少有指标与活动建议完成时间相关联。我们定义了艾滋病毒相关结核病诊断和治疗流程的三个不同阶段：（1）筛查与诊断，（2）治疗，（3）预防性治疗。我们详细阐述了每个阶段的主要步骤，描述了潜在的变异来源，并针对每个阶段提出了数据元素、过程指标、主要结果和留存率计算方法。
这个提议的监测框架的新颖之处在于其关注从筛查和结核病诊断到治疗或预防性治疗的整个照护流程中的队列体验。这种方法可应用于诊所、地区或国家层面的所有环境，并用于识别关键的改进领域，以便为所有受结核病和艾滋病毒双重流行影响的人最大化健康结果。
