Division of Allergy and Infectious Diseases, Department of Medicine, University of Washington, Seattle, Washington, USA.
Department of Industrial and Systems Engineering, University of Washington, Seattle, Washington, USA.
J Int AIDS Soc. 2024 Jun;27(6):e26272. doi: 10.1002/jia2.26272.
INTRODUCTION: Antiretroviral therapy (ART) and tuberculosis preventive treatment (TPT) both prevent tuberculosis (TB) disease and deaths among people living with HIV. Differentiated care models, including community-based care, can increase the uptake of ART and TPT to prevent TB in settings with a high burden of HIV-associated TB, particularly among men. METHODS: We developed a gender-stratified dynamic model of TB and HIV transmission and disease progression among 100,000 adults ages 15-59 in KwaZulu-Natal, South Africa. We drew model parameters from a community-based ART initiation and resupply trial in sub-Saharan Africa (Delivery Optimization for Antiretroviral Therapy, DO ART) and other scientific literature. We simulated the impacts of community-based ART and TPT care programmes during 2018-2027, assuming that community-based ART and TPT care were scaled up to similar levels as in the DO ART trial (i.e. ART coverage increasing from 49% to 82% among men and from 69% to 83% among women) and sustained for 10 years. We projected the number of TB cases, deaths and disability-adjusted life years (DALYs) averted relative to standard, clinic-based care. We calculated programme costs and incremental cost-effectiveness ratios from the provider perspective. RESULTS: If community-based ART care could be implemented with similar effectiveness to the DO ART trial, increased ART coverage could reduce TB incidence by 27.0% (range 21.3%-34.1%) and TB mortality by 34.6% (range 24.8%-42.2%) after 10 years. Increasing both ART and TPT uptake through community-based ART with TPT care could reduce TB incidence by 29.7% (range 23.9%-36.0%) and TB mortality by 36.0% (range 26.9%-43.8%). Community-based ART with TPT care reduced gender disparities in TB mortality rates, with a projected 54 more deaths annually among men than women (range 11-103) after 10 years of community-based care versus 109 (range 41-182) in standard care. Over 10 years, the mean cost per DALY averted by community-based ART with TPT care was $846 USD (range $709-$1012). CONCLUSIONS: By substantially increasing coverage of ART and TPT, community-based care for people living with HIV could reduce TB incidence and mortality in settings with high burdens of HIV-associated TB and reduce TB gender disparities.
引言：抗逆转录病毒疗法（ART）和结核预防治疗（TPT）均可预防艾滋病毒感染者的结核病（TB）发病和死亡。在艾滋病毒相关结核负担高的地区，包括社区为基础的护理在内的差异化护理模式可以提高 ART 和 TPT 的覆盖率，以预防结核，尤其是在男性中。
方法：我们在南非夸祖鲁-纳塔尔省开发了一个 10 万名 15-59 岁成年人的结核和艾滋病毒传播及疾病进展的性别分层动态模型。我们从撒哈拉以南非洲的社区为基础的抗逆转录病毒治疗启动和供应试验（Delivery Optimization for Antiretroviral Therapy，DO ART）和其他科学文献中提取模型参数。我们模拟了在 2018-2027 年期间社区为基础的 ART 和 TPT 护理方案的影响，假设社区为基础的 ART 和 TPT 护理的覆盖范围扩大到与 DO ART 试验相似的水平（即男性中的 ART 覆盖率从 49%增加到 82%，女性中的 ART 覆盖率从 69%增加到 83%），并持续 10 年。我们预测了与标准的以诊所为基础的护理相比，相对应的结核病例、死亡和残疾调整生命年（DALYs）的数量。我们从提供者的角度计算了方案成本和增量成本效益比。
结果：如果社区为基础的 ART 护理能够以与 DO ART 试验相似的效果实施，增加 ART 的覆盖率可以在 10 年内降低 27.0%（范围为 21.3%-34.1%）的结核发病率和 34.6%（范围为 24.8%-42.2%）的结核死亡率。通过社区为基础的 ART 与 TPT 护理同时增加 ART 和 TPT 的覆盖率，可以降低 29.7%（范围为 23.9%-36.0%）的结核发病率和 36.0%（范围为 26.9%-43.8%）的结核死亡率。社区为基础的 ART 与 TPT 护理降低了结核死亡率的性别差距，在 10 年的社区护理后，预计男性每年比女性多 54 例死亡（范围为 11-103），而在标准护理中则为 109 例（范围为 41-182）。在 10 年期间，社区为基础的 ART 与 TPT 护理每避免一个 DALY 的平均成本为 846 美元（范围为 709-1012 美元）。
结论：通过大幅提高 ART 和 TPT 的覆盖率，针对艾滋病毒感染者的社区护理可以降低艾滋病毒相关结核负担高的地区的结核发病率和死亡率，并减少结核的性别差距。
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