Venter Willem D F, Majam Mohammed, Akpomiemie Godspower, Arulappan Natasha, Moorhouse Michelle, Mashabane Nonkululeko, Chersich Matthew F
Wits Reproductive Health and HIV Institute (WRHI), Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.
BMC Public Health. 2017 Jul 4;17(Suppl 3):445. doi: 10.1186/s12889-017-4353-1.
Screening for renal, hepatic and haematological disorders complicates the initiation of current first-line antiretroviral therapy (ART). Each additional test done adds substantial costs, both through direct laboratory expenses, but also by increasing the burden on health workers and patients. Evaluating the prevalence of clinically relevant abnormalities in different population groups could guide decisions about what tests to recommend in national guidelines, or in local adaptations of these.
As part of enrolment procedures in a clinical trial, 771 HIV-positive adults, predominantly from inner-city primary health care clinics, underwent laboratory screening prior to ART. Participants had to be eligible for ART, based on the then CD4 eligibility threshold of 350 cells/μL, antiretroviral naïve and have no symptoms of peripheral neuropathy.
Participants were mostly female (57%) and a mean 34 years old. Creatinine clearance rates were almost all above 50 mL/min (99%), although 5% had microalbuminuria. Hepatitis B antigenaemia was common (8% of participants), of whom 40% had a raised AST/ALT, though only 2 had transaminase levels above 200 IU/L. Only 2% of participants had severe anaemia (haemoglobin <8 g/dl) and 1% neutropaenia (neutrophils <0.75 × 10^9/L). Costs per case detected of hepatitis B infection was USD135, but more than USD800 for a raised creatinine.
Hepatitis B continues to be a common co-infection in HIV-infected adults, and adds complexity to management of ART switches involving tenofovir. Routine renal and haematological screening prior to ART detected few abnormalities. The use of these screening tests should be assessed among patients with higher CD4 counts, who may even have fewer abnormalities. Formal evaluation of cost-effectiveness of laboratory screening prior to ART is warranted.
对肾脏、肝脏和血液系统疾病进行筛查会使当前一线抗逆转录病毒疗法（ART）的启动变得复杂。每增加一项检测都会增加大量成本，这不仅体现在直接的实验室费用上，还体现在增加医护人员和患者的负担上。评估不同人群中临床相关异常的患病率可为国家指南或其地方适应性版本中推荐何种检测提供决策依据。
作为一项临床试验入组程序的一部分，771名HIV阳性成年人（主要来自市中心的初级卫生保健诊所）在接受ART之前接受了实验室筛查。参与者必须符合ART的条件，当时的CD4细胞计数合格阈值为350个细胞/微升，未曾接受过抗逆转录病毒治疗，且没有周围神经病变的症状。
参与者大多为女性（57%），平均年龄34岁。肌酐清除率几乎都高于50毫升/分钟（99%），不过5%的人有微量白蛋白尿。乙肝抗原血症很常见（8%的参与者），其中40%的人AST/ALT升高，不过只有2人的转氨酶水平高于200国际单位/升。只有2%的参与者有严重贫血（血红蛋白<8克/分升），1%的人有中性粒细胞减少症（中性粒细胞<0.75×10⁹/升）。检测出一例乙肝感染的成本为135美元，但肌酐升高的检测成本超过800美元。
乙肝仍然是HIV感染成年人中常见的合并感染，并且增加了涉及替诺福韦的ART转换管理的复杂性。ART前的常规肾脏和血液学筛查发现的异常很少。对于CD4细胞计数较高的患者，这些筛查检测的使用情况应进行评估，这类患者可能异常情况更少。有必要对ART前实验室筛查的成本效益进行正式评估。
