The WHO public-health approach to antiretroviral treatment against HIV in resource-limited settings
The WHO public-health approach to antiretroviral treatment against HIV in resource-limited settings
复制标题
DOI：
10.1016/s0140-6736(06)69158-7
复制
发表时间：
2006-08-05
期刊：
影响因子：
168.9
通讯作者：
De Cock, Kevin
中科院分区：
文献类型：
--
作者：
Gilks, Charles F.;Crowley, Siobhan;De Cock, Kevin
世卫组织提出了一个抗逆转录病毒疗法的公共卫生方法，以扩大发展中国家艾滋病毒阳性者获得治疗的机会，认识到西方专家医生管理和先进实验室监测模式在资源贫乏的环境中不可行。在这种方法中，标准化的简化治疗方案和分散的服务提供使大量艾滋病毒阳性成人和儿童能够通过公共和私营部门获得治疗。简化临床决策的工具和方法，以“四个S”为中心-何时开始药物治疗;何时以毒性替代药物治疗;何时在治疗失败后转换药物治疗;何时停止-使较低级别的保健工作者能够提供保健服务。简单有限的处方集推动了成人一线治疗固定剂量复方制剂的大规模生产，并降低了价格，但为了确保最贫穷国家获得抗逆转录病毒疗法，在服务提供点应免费提供护理和药物。需要对获得性和传播性耐药性进行以人群为基础的监测，以解决以下问题：仅根据临床失败标准转换治疗方案可能导致耐药病毒株的广泛出现。成人或儿童疾病综合管理（IMAI/IMCI）有助于分散实施，并纳入现有的卫生系统。简化的操作指南、工具和培训材料使初级保健和二级设施的临床团队能够提供艾滋病毒预防、艾滋病毒护理和抗逆转录病毒治疗，并使用标准化的患者跟踪系统。
WHO has proposed a public-health approach to antiretroviral therapy (ART) to enable scaling-up access to treatment for HIV-positive people in developing countries, recognising that the western model of specialist physician management and advanced laboratory monitoring is not feasible in resource-poor settings. In this approach, standardised simplified treatment protocols and decentralised service delivery enable treatment to be delivered to large numbers of HIV-positive adults and children through the public and private sector. Simplified tools and approaches to clinical decision-making, centred on the "four Ss"-when to: start drug treatment; substitute for toxicity; switch after treatment failure; and stop-enable lower level health-care workers to deliver care. Simple limited formularies have driven large-scale production of fixed-dose combinations for first-line treatment for adults and lowered prices, but to ensure access to ART in the poorest countries, the care and drugs should be given free at point of service delivery. Population-based surveillance for acquired and transmitted resistance is needed to address concerns that switching regimens on the basis of clinical criteria for failure alone could lead to widespread emergence of drug-resistant virus strains. The integrated management of adult or childhood illness (IMAI/IMCI) facilitates decentralised implementation that is integrated within existing health systems. Simplified operational guidelines, tools, and training materials enable clinical teams in primary-care and second-level facilities to deliver HIV prevention, HIV care, and ART, and to use a standardised patient-tracking system.