Prevention, Care and Treatment Department, FHI 360 (Family Health International), Abuja, Nigeria.
Institute of Tropical Medicine (ITM), Antwerp, Belgium.
J Int AIDS Soc. 2018 Apr;21(4):e25108. doi: 10.1002/jia2.25108.
Significant gaps persist in providing HIV treatment to all who are in need. Restricting care delivery to healthcare facilities will continue to perpetuate this gap in limited resource settings. We assessed a large-scale community-based programme for effectiveness in identifying people living with HIV and linking them to antiretroviral treatment.
A retrospective secular trend study of 14 high burden local government areas of Nigeria was conducted in which two models of community antiretroviral treatment delivery were implemented: Model A (on-site initiation) and Model B (immediate referral) clusters. Model A cluster offered services within communities, from HIV diagnosis to immediate antiretroviral therapy initiation and some follow-up. Model B cluster offered services for HIV diagnosis up to baseline evaluation and provided referral for antiretroviral therapy initiation to nearest health facility providing HIV services. For controls, we selected and cluster-matched 34 local government areas where community antiretroviral treatment delivery was not implemented. Outcomes of interest were: the number of people identified as HIV positive and the number of HIV-positive individuals started on antiretroviral treatment; from June 2014 to May 2016. We used interrupted time-series analysis to estimate outcome levels and trends across the pre-and post-intervention periods.
Before community antiretrovial treatment introduction, Model A cluster identified, per 100,000 catchment population, 500 HIV-positives (95% CI: 399.66 to 601.41) and initiated 216 HIV-positives on antiretroviral treatment (95% CI: 152.72 to 280.10). Model B cluster identified 32 HIV-positives (95% CI: 25.00 to 40.51) and initiated 8 HIV-positives on antiretroviral treatment (95% CI: 5.54 to 10.33). After commART introduction, Model A cluster showed an immediate significant increase in 744 HIV-positive persons (p = 0.00, 95% CI: 360.35 to 1127.77) and 560 HIV-positives initiated on treatment (p = 0.00, 95% CI: 260.56 to 859.64). Model B cluster showed an immediate significant increase in 30 HIV-positive persons identified (p = 0.01, 95% CI: 8.38 to 51.93) but not in the number of HIV-positives initiated on treatment. Model B cluster showed increased month-on-month trends of both outcomes of interest (3.4, p = 0.02, 95% CI: 0.44 to 6.38).
Both community-models had similar population-level effectiveness for rapidly identifying people living with HIV but differed in effectively transitioning them to treatment. Comprehensiveness, integration and attention to barriers to care are important in the design of community antiretroviral treatment delivery.
为所有有需要的人提供艾滋病毒治疗仍然存在很大差距。将护理服务仅限于医疗机构将继续使资源有限的环境中的这一差距长期存在。我们评估了一项大规模的社区为基础的方案，以评估其在识别艾滋病毒感染者并将其与抗逆转录病毒治疗联系起来方面的有效性。
对尼日利亚 14 个高负担地方政府区进行了回顾性时间序列研究，其中实施了两种社区抗逆转录病毒治疗提供模式：模式 A（现场启动）和模式 B（立即转诊）群。模式 A 群在社区内提供服务，从艾滋病毒诊断到立即开始抗逆转录病毒治疗和一些随访。模式 B 群提供艾滋病毒诊断服务，直至基线评估，并为最近提供艾滋病毒服务的卫生机构提供抗逆转录病毒治疗启动转诊。对于对照组，我们选择并按群匹配了 34 个未实施社区抗逆转录病毒治疗的地方政府区。感兴趣的结果是：确定为艾滋病毒阳性的人数和开始接受抗逆转录病毒治疗的艾滋病毒阳性人数；从 2014 年 6 月至 2016 年 5 月。我们使用中断时间序列分析来估计干预前后各期的结果水平和趋势。
在引入社区抗逆转录病毒治疗之前，模式 A 群每 10 万收容人口中发现 500 名艾滋病毒阳性者（95%CI：399.66 至 601.41），并开始为 216 名艾滋病毒阳性者提供抗逆转录病毒治疗（95%CI：152.72 至 280.10）。模式 B 群发现 32 名艾滋病毒阳性者（95%CI：25.00 至 40.51），并开始为 8 名艾滋病毒阳性者提供抗逆转录病毒治疗（95%CI：5.54 至 10.33）。在 commART 引入后，模式 A 群立即显著增加了 744 名艾滋病毒阳性者（p=0.00，95%CI：360.35 至 1127.77）和 560 名开始接受治疗的艾滋病毒阳性者（p=0.00，95%CI：260.56 至 859.64）。模式 B 群发现识别出的 30 名艾滋病毒阳性者立即显著增加（p=0.01，95%CI：8.38 至 51.93），但开始接受治疗的艾滋病毒阳性者人数并未增加。模式 B 群显示出对这两个感兴趣的结果的逐月趋势增加（3.4，p=0.02，95%CI：0.44 至 6.38）。
两种社区模式在快速识别艾滋病毒感染者方面都具有相似的人群有效性，但在有效将他们过渡到治疗方面存在差异。全面性、整合性和关注护理障碍是社区抗逆转录病毒治疗提供设计的重要因素。
