Antiretroviral therapy and the control of HIV-associated tuberculosis. Will ART do it?
Antiretroviral therapy and the control of HIV-associated tuberculosis. Will ART do it?
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DOI：
10.5588/ijtld.10.0483
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发表时间：
2011-05
期刊：
影响因子：
--
通讯作者：
Wood R
中科院分区：
文献类型：
--
作者：
Lawn SD;Harries AD;Williams BG;Chaisson RE;Losina E;De Cock KM;Wood R
与人类免疫缺陷病毒（HIV）相关的结核病（TB）流行仍然是HIV高流行率国家结核病控制面临的巨大挑战。在他们1999年题为“DOTS会成功吗？”的文章中，De Cock和Chaisson质疑世界卫生组织的DOTS战略是否可以控制这种流行病。过去10年的数据清楚地表明，在这种情况下，直接观察下的短程化疗作为单一的结核病控制干预措施是不够的，因为它没有解决结核病和艾滋病毒之间基本的流行病学相互作用。免疫缺陷是这一流行病的主要根源，因此，解决办法必须包括利用抗逆转录病毒疗法恢复免疫。因此，在全球ART规模扩大的时代，我们现在问的问题是，“ART能做到吗？”抗逆转录病毒治疗可使结核病风险降低67%（95%CI 61-73），结核病复发率减半，队列死亡率降低64-95%，艾滋病相关耐药结核病患者生存率提高。然而，结核病在艾滋病毒感染者的累积终生风险是一个函数的时间花费在各种CD 4-定义的风险水平，之前和期间的ART。目前开始ART在低CD 4细胞计数（此时许多艾滋病毒相关的结核病已经发生）和低有效覆盖率大大削弱了ART在人口水平上的潜在影响。因此，虽然抗逆转录病毒疗法已被证明是艾滋病毒相关结核病病例管理的关键干预措施，但其在结核病控制方面的大部分预防潜力目前正在被浪费。如果抗逆转录病毒疗法要对结核病的发病率产生实质性影响，就需要更早开始高覆盖率的抗逆转录病毒疗法。
The human immunodeficiency virus (HIV) associated tuberculosis (TB) epidemic remains an enormous challenge to TB control in countries with a high prevalence of HIV. In their 1999 article entitled ‘Will DOTS do it?’, De Cock and Chaisson questioned whether the World Health Organization’s DOTS Strategy could control this epidemic. Data over the past 10 years have clearly shown that DOTS is insufficient as a single TB control intervention in such settings because it does not address the fundamental epidemiological interactions between TB and HIV. Immunodeficiency is a principal river of this epidemic, and the solution must therefore include immune recovery using antiretroviral therapy (ART). Thus, in the era of global ART scale-up, we now ask the question, ‘Will ART do it?’ ART reduces the risk of TB by 67% (95%CI 61–73), halves TB recurrence rates, reduces mortality risk by 64–95% in cohorts and prolongs survival in patients with HIV-associated drug-resistant TB. However, the cumulative lifetime risk of TB in HIV infected individuals is a function of time spent at various CD4-defined levels of risk, both before and during ART. Current initiation of ART at low CD4 cell counts (by which time much HIV-associated TB has already occurred) and low effective coverage greatly undermine the potential impact of ART at a population level. Thus, while ART has proven a critical intervention for case management of HIV-associated TB, much of its preventive potential for TB control is currently being squandered. Much earlier ART initiation with high coverage is required if ART is to substantially influence the incidence of TB.
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