HIV Testing and Treatment with the Use of a Community Health Approach in Rural Africa
HIV Testing and Treatment with the Use of a Community Health Approach in Rural Africa
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DOI：
10.1056/nejmoa1809866
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发表时间：
2019-07-18
影响因子：
158.5
通讯作者：
Petersen, Maya
中科院分区：
文献类型：
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作者：
Havlir, Diane V.;Balzer, Laura B.;Petersen, Maya
背景普遍抗逆转录病毒治疗（ART）、每年进行人群检测和以患者为中心的多疾病策略可以减少新的人类免疫缺陷病毒（HIV）感染并改善社区健康。方法：我们随机将乌干达和肯尼亚的32个农村社区分配到基线HIV和多种疾病检测和国家指南限制的ART（对照组）或基线检测加年度检测，普及ART的资格和以患者为中心的护理（干预组）。主要终点是3年时HIV感染的累积发生率。次要终点包括病毒抑制、死亡、结核病、高血压控制和HIV感染年发病率的变化（仅在干预组中进行评估）。结果共有150，395人被纳入分析。在15，399名HIV感染者中，基线时人群水平的病毒抑制率为42%，3年时干预组高于对照组（79% vs. 68%;相对患病率，1.15; 95%置信区间[CI]，1.11至1.20）。干预组的HIV感染年发病率在3年内下降了32%（从0.43例/100人-年下降到0.31例/100人-年;相对比率为0.68; 95%CI为0.56 ~ 0.84）。然而，干预组和对照组的3年累积发病率（704例HIV感染事件）无显著差异（分别为0.77%和0.81%;相对危险度为0.95; 95%CI为0.77 ~ 1.17）。在艾滋病毒感染者中，干预组第3年的死亡风险为3%，对照组为4%（每100人-年死亡0.99对1.29;相对风险为0.77; 95%CI为0.64至0.93）。在HIV感染者中，到第3年HIV相关结核病或死亡的风险在干预组中为4%，在对照组中为5%（1.19 vs. 1.50起事件/100人-年;相对风险为0.79; 95%CI为0.67 - 0.94）。在3年时，干预组中47%的高血压成人和对照组中37%的高血压得到控制（相对患病率，1.26; 95%CI，1.15 - 1.39）。结论：普及HIV治疗并没有导致HIV感染的发生率显著低于标准治疗，这可能是由于全面的基线HIV检测的可用性和对照组ART资格的快速扩展。（由美国国立卫生研究院和其他机构资助;网址：ClinicalTrials.gov编号：NCT 01864603）。在乌干达和肯尼亚农村，在对高血压和糖尿病等其他疾病进行健康评估的背景下，启动了艾滋病毒检测和治疗方案。在3年的艾滋病毒感染率没有发现显着低于测试和治疗的社区比在控制社区，这一发现可能与艾滋病毒治疗的规模，发生在全国范围内的试验期间。
Background Universal antiretroviral therapy (ART) with annual population testing and a multidisease, patient-centered strategy could reduce new human immunodeficiency virus (HIV) infections and improve community health. Methods We randomly assigned 32 rural communities in Uganda and Kenya to baseline HIV and multidisease testing and national guideline-restricted ART (control group) or to baseline testing plus annual testing, eligibility for universal ART, and patient-centered care (intervention group). The primary end point was the cumulative incidence of HIV infection at 3 years. Secondary end points included viral suppression, death, tuberculosis, hypertension control, and the change in the annual incidence of HIV infection (which was evaluated in the intervention group only). Results A total of 150,395 persons were included in the analyses. Population-level viral suppression among 15,399 HIV-infected persons was 42% at baseline and was higher in the intervention group than in the control group at 3 years (79% vs. 68%; relative prevalence, 1.15; 95% confidence interval [CI], 1.11 to 1.20). The annual incidence of HIV infection in the intervention group decreased by 32% over 3 years (from 0.43 to 0.31 cases per 100 person-years; relative rate, 0.68; 95% CI, 0.56 to 0.84). However, the 3-year cumulative incidence (704 incident HIV infections) did not differ significantly between the intervention group and the control group (0.77% and 0.81%, respectively; relative risk, 0.95; 95% CI, 0.77 to 1.17). Among HIV-infected persons, the risk of death by year 3 was 3% in the intervention group and 4% in the control group (0.99 vs. 1.29 deaths per 100 person-years; relative risk, 0.77; 95% CI, 0.64 to 0.93). The risk of HIV-associated tuberculosis or death by year 3 among HIV-infected persons was 4% in the intervention group and 5% in the control group (1.19 vs. 1.50 events per 100 person-years; relative risk, 0.79; 95% CI, 0.67 to 0.94). At 3 years, 47% of adults with hypertension in the intervention group and 37% in the control group had hypertension control (relative prevalence, 1.26; 95% CI, 1.15 to 1.39). Conclusions Universal HIV treatment did not result in a significantly lower incidence of HIV infection than standard care, probably owing to the availability of comprehensive baseline HIV testing and the rapid expansion of ART eligibility in the control group. (Funded by the National Institutes of Health and others; SEARCH ClinicalTrials.gov number, NCT01864603.).)An HIV testing and treatment program was initiated in the context of health assessments for other conditions, including hypertension and diabetes, in rural Uganda and Kenya. The incidence of HIV infection at 3 years was not found to be significantly lower in the test-and-treat communities than in the control communities, a finding that was probably related to the scale-up of HIV treatment that occurred countrywide during the trial period.