Maphosa Thulani, Denoeud-Ndam Lise, Chilikutali Lloyd, Matiya Eddie, Wilson Bilaal, Nyirenda Rose, Mayi Allan, Machekano Rhoderick, Tiam Appolinaire
Elizabeth Glaser Pediatric AIDS Foundation, Lilongwe, Lilongwe, Malawi.
Elizabeth Glaser Pediatric AIDS Foundation, Geneva, Switzerland.
BMC Public Health. 2025 Aug 16;25(1):2802. doi: 10.1186/s12889-025-24157-2.
Despite significant advances in HIV diagnosis and access to ART, many patients still present with advanced HIV disease (AHD). We assessed the effect of an optimized AHD care package on the screening and diagnosis of opportunistic diseases among clients enrolled in AHD care.
This non-randomized cluster design was conducted using a hub-and-spoke model. Twenty-two health facilities, including hub facilities (eight hub sites) and their associated spoke facilities (14 spoke sites), were purposively selected as intervention sites (IS) across three districts in Malawi. The optimized AHD package implemented in these IS included enhanced CD4 testing, tuberculosis (TB) and cryptococcal antigen (CrAg) screening, and appropriate treatment of opportunistic diseases delivered through a hub-and-spoke model. Thirteen non-intervention sites (NIS) (five hub and eight spoke sites) were chosen from four districts that did not implement the intervention and were matched with the IS based on rural/urban settings and health facility types. We abstracted individual-level data from routine clinical records of clients meeting the World Health Organization's definition of AHD between June and December 2021.
Of 963 patients with AHD, 57.4% were seen at IS, and 42.6% at NIS. The IS showed higher proportions of AHD clients identified at (44.3% vs. 36.8%, p = 0.020) and increased screening of children under five years old (7.1% vs. 2.7%, p = 0.004). Additionally, IS diagnosed more cases of WHO stage 3 or 4 disease (47.6% vs. 40.5%, P = 0.029). Patients seen at IS were significantly more likely to receive TB symptom screening (Adjusted Relative Risk [ARR]: 1.13, 95% Confidence Interval [CI]: 1.06-1.21), urine lateral flow lipoarabinomannan test administration (ARR: 1.94, 95% CI: 1.18-3.20), and TB diagnosis (ARR: 2.64, 95% CI: 1.47-4.75). Screening for neurological signs in IS was also improved (ARR: 1.07, 95% CI: 1.02-1.13), as was the diagnosis of cryptococcal meningitis (ARR: 4.28, 95% CI: 1.58-11.70), compared to NIS. There was no difference in retention and mortality in the care of patients after twelve months of follow-up between IS and NIS.
Our study underscores the vital role of improving screening and diagnostic efforts for advanced HIV disease (AHD), notably targeting AHD-related opportunistic infections, including TB and Cryptococcal diseases. Word count: 4,832 words, excluding references.
尽管在艾滋病毒诊断和获得抗逆转录病毒治疗方面取得了重大进展，但许多患者仍表现为晚期艾滋病毒疾病（AHD）。我们评估了优化的AHD护理方案对参加AHD护理的患者中机会性疾病筛查和诊断的影响。
本非随机整群设计采用中心辐射模型进行。在马拉维的三个地区，有目的地选择了22个卫生设施作为干预地点（IS），包括中心设施（8个中心站点）及其相关的分支设施（14个分支站点）。在这些干预地点实施的优化AHD方案包括强化CD4检测、结核病（TB）和隐球菌抗原（CrAg）筛查，以及通过中心辐射模型提供的机会性疾病的适当治疗。从四个未实施干预的地区选择了13个非干预地点（NIS）（5个中心和8个分支站点），并根据农村/城市环境和卫生设施类型与干预地点进行匹配。我们从2021年6月至12月期间符合世界卫生组织AHD定义的患者的常规临床记录中提取了个体水平的数据。
在963例AHD患者中，57.4%在干预地点接受治疗，42.6%在非干预地点接受治疗。干预地点在AHD患者中识别出的比例更高（44.3%对36.8%，p = 0.020），五岁以下儿童的筛查增加（7.1%对2.7%，p = 0.004）。此外，干预地点诊断出的世卫组织3期或4期疾病病例更多（47.6%对40.5%，P = 0.029）。在干预地点接受治疗的患者更有可能接受结核病症状筛查（调整相对风险[ARR]：1.13，95%置信区间[CI]：1.06 - 1.21）、尿液侧向流动脂阿拉伯甘露聚糖检测（ARR：1.94，95% CI：1.18 - 3.20）和结核病诊断（ARR：2.64，95% CI：1.47 - 4.75）。与非干预地点相比，干预地点的神经体征筛查也有所改善（ARR：1.07，95% CI：1.02 - 1.13），隐球菌性脑膜炎的诊断也是如此（ARR：4.28，95% CI：1.58 - 11.70）。在随访十二个月后，干预地点和非干预地点在患者护理中的留存率和死亡率没有差异。
我们的研究强调了改善晚期艾滋病毒疾病（AHD）筛查和诊断工作的重要作用，特别是针对与AHD相关的机会性感染，包括结核病和隐球菌病。字数：4832字，不包括参考文献。
