ISGlobal, Hospital Clínic-Universitat de Barcelona, Barcelona, Spain.
Centro de Investigação em Saude de Manhiça (CISM), Manhiça, Mozambique.
J Int AIDS Soc. 2021 Aug;24(8):e25775. doi: 10.1002/jia2.25775.
AIDS-mortality remains unacceptably high in sub-Saharan Africa, largely driven by advanced HIV disease (AHD). We nested a study in an existing tuberculosis (TB) contact-tracing intervention (Xpatial-TB). The aim was to assess the burden of AHD among high-risk people living with HIV (PLHIV) identified and to evaluate the provision of the WHO-recommended package of care to this population.
All PLHIV ≥14 years old identified between June and December 2018 in Manhiça District by Xpatial-TB were offered to participate in the study if ART naïve or had suboptimal ART adherence. Consenting individuals were screened for AHD. Patients with AHD (CD4 < 200 cells/μL or WHO stage 3 or 4) were offered a package of interventions in a single visit, including testing for cryptococcal antigen (CrAg) and TB-lipoarabinomannan (TB-LAM), prophylaxis and treatment for opportunistic infections, adherence support or accelerated ART initiation. We collected information on follow-up visits carried out under routine programmatic conditions for six months.
A total of 2881 adults were identified in the Xpatial TB-contact intervention. Overall, 23% (673/2881) were HIV positive, including 351 TB index (64.2%) and 322 TB contacts (13.8%). Overall, 159/673 PLHIV (24%) were ART naïve or had suboptimal ART adherence, of whom 155 (97%, 124 TB index and 31 TB-contacts) consented to the study and were screened for AHD. Seventy percent of TB index-patients (87/124) and 16% of TB contacts (5/31) had CD4 < 200 cells/µL. Four (13%) of the TB contacts had TB, giving an overall AHD prevalence among TB contacts of 29% (9/31). Serum-CrAg was positive in 4.6% (4/87) of TB-index patients and in zero TB contacts. All ART naïve TB contacts without TB initiated ART within 48 hours of HIV diagnosis. Among TB cases, ART timing was tailored to the presence of TB and cryptococcosis. Six-month mortality was 21% among TB-index cases and zero in TB contacts.
A TB contact-tracing outreach intervention identified undiagnosed HIV and AHD in TB patients and their contacts, undiagnosed cryptococcosis among TB patients, and resulted in an adequate provision of the WHO-recommended package of care in this rural Mozambican population. Same-day and accelerated ART initiation was feasible and safe in this population including among those with AHD.
引言：在撒哈拉以南非洲地区，艾滋病导致的死亡率仍然居高不下，这主要是由于艾滋病患者的病情较为严重（AHD）。本研究在现有的结核病（TB）接触者追踪干预（Xpatial-TB）中进行了嵌套研究。目的是评估在 Xpatial-TB 中发现的 HIV 感染者（PLHIV）中 AHD 的负担，并评估向这一人群提供世卫组织推荐的护理套餐的情况。
方法：2018 年 6 月至 12 月期间，通过 Xpatial-TB 在马希齐区发现的所有年龄在 14 岁及以上的 PLHIV，如果是初治或 ART 依从性差，均被邀请参加研究。同意的参与者接受 AHD 筛查。患有 AHD（CD4<200 个细胞/μL 或世卫组织 3 或 4 期）的患者在一次就诊中提供了一整套干预措施，包括检测隐球菌抗原（CrAg）和结核分枝杆菌脂阿拉伯甘露聚糖（TB-LAM）、机会性感染的预防和治疗、依从性支持或加速 ART 启动。我们收集了在常规规划条件下进行的为期六个月的随访信息。
结果：Xpatial TB 接触干预共发现 2881 名成年人。总体而言，23%（673/2881）为 HIV 阳性，包括 351 例结核病指标（64.2%）和 322 例结核病接触者（13.8%）。总体而言，673 例 PLHIV 中有 159 例（24%）为初治或 ART 依从性差，其中 155 例（97%，124 例结核病指标和 31 例结核病接触者）同意参加研究并接受了 AHD 筛查。70%的结核病指标患者（87/124）和 16%的结核病接触者（5/31）的 CD4<200 个细胞/µL。4 例（13%）结核病接触者患有结核病，结核病接触者的总体 AHD 患病率为 29%（9/31）。4 例结核病指标患者（87/124）和零例结核病接触者的血清 CrAg 呈阳性。所有未经治疗的结核病接触者在 HIV 诊断后 48 小时内均开始接受 ART。在结核病病例中，ART 的时机取决于结核病和隐球菌病的存在。结核病指标病例的 6 个月死亡率为 21%，而结核病接触者的死亡率为零。
结论：结核病接触者追踪外展干预在结核病患者及其接触者中发现了未确诊的 HIV 和 AHD，在结核病患者中发现了未确诊的隐球菌病，并在这个农村莫桑比克人群中提供了足够的世卫组织推荐的护理套餐。在包括 AHD 患者在内的人群中，当天和加速的 ART 启动是可行和安全的。
Zotero 插件