Global Tuberculosis Prevention and Control Branch, U.S. Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America.
Center for Global Health, U.S. Centers for Disease Control and Prevention, Lilongwe, Malawi.
PLoS One. 2021 Apr 1;16(4):e0248115. doi: 10.1371/journal.pone.0248115. eCollection 2021.
Isoniazid preventive therapy (IPT) against tuberculosis (TB) is a life-saving intervention for people living with HIV (PLHIV). In September 2017, Malawi began programmatic scale-up of IPT to eligible PLHIV in five districts with high HIV and TB burden. We measured the frequency and timeliness of early-phase IPT implementation to inform quality-improvement processes.
We applied a two-stage cluster design with systematic, probability-proportional-to-size sampling of six U.S. Centers for Disease Control and Prevention (CDC)-affiliated antiretroviral therapy (ART) centers operating in the urban areas of Lilongwe and Blantyre, Malawi (November 2017). ART clinic patient volume determined cluster size. Within each cluster, we sequentially sampled approximately 50 PLHIV newly enrolled in ART care. We described a quality-of-care cascade for intensive TB case finding (ICF) and IPT in PLHIV. PLHIV newly enrolled in ART care were eligibility-screened for hepatitis and peripheral neuropathy, as well as for TB disease using a standardized four-symptom screening tool. Among eligible PLHIV, the overall weighted IPT initiation rate was 70% (95% CI: 46%-86%). Weighted IPT initiation among persons aged <15 years (30% [95% CI: 12%-55%]) was significantly lower than among persons aged ≥15 years (72% [95% CI: 47%-89%]; Rao-Scott chi-square P = 0.03). HIV-positive children aged <5 years had a weighted initiation rate of only 13% (95% CI: 1%-79%). For pregnant women, the weighted initiation rate was 67% (95% CI: 32%-90%), similar to non-pregnant women aged ≥15 years (72% [95% CI: 49%-87%]). Lastly, 95% (95% CI: 92%-97%) of eligible PLHIV started ART within one week of HIV diagnosis, and 92% (95% CI: 73%-98%) of patients receiving IPT began on the same day as ART.
Early-phase IPT uptake among adults at ART centers in Malawi was high. Child uptake needed improvement. National programs could adapt this framework to evaluate their ICF-IPT care cascades.
异烟肼预防治疗（IPT）是挽救生命的干预措施，适用于艾滋病毒（HIV）感染者（PLHIV）。2017 年 9 月，马拉维开始在五个 HIV 和结核病负担较高的地区扩大 IPT 规划，为符合条件的 PLHIV 提供 IPT。我们测量了早期 IPT 实施的频率和及时性，以告知质量改进过程。
我们应用了两阶段聚类设计，对美国疾病控制与预防中心（CDC）附属的六个抗逆转录病毒治疗（ART）中心在马拉维利隆圭和布兰太尔市区运营的情况进行了系统的、按大小比例概率抽样（2017 年 11 月）。ART 诊所的患者量决定了集群的大小。在每个集群中，我们按顺序抽取大约 50 名新入组 ART 护理的 PLHIV。我们描述了密集型结核病病例发现（ICF）和 PLHIV 中 IPT 的护理质量级联。新入组 ART 护理的 PLHIV 接受了乙型肝炎和周围神经病变的资格筛查，以及使用标准化的四项症状筛查工具进行结核病疾病筛查。在符合条件的 PLHIV 中，IPT 起始率加权值为 70%（95%CI：46%-86%）。年龄<15 岁的人群中，IPT 起始率加权值为 30%（95%CI：12%-55%），明显低于年龄≥15 岁的人群（72%[95%CI：47%-89%]；Rao-Scott 卡方 P=0.03）。年龄<5 岁的 HIV 阳性儿童 IPT 起始率仅为 13%（95%CI：1%-79%）。对于孕妇，IPT 起始率为 67%（95%CI：32%-90%），与年龄≥15 岁的非孕妇相似（72%[95%CI：49%-87%]）。最后，95%（95%CI：92%-97%）的符合条件的 PLHIV 在 HIV 诊断后一周内开始接受 ART 治疗，92%（95%CI：73%-98%）接受 IPT 的患者在同一天开始接受 ART 治疗。
马拉维 ART 中心成人早期 IPT 接受率较高，但儿童接受率需要提高。国家方案可以采用这一框架来评估其 ICF-IPT 护理级联。
