Decentralisation, integration, and task-shifting in hepatitis C virus infection testing and treatment: a global systematic review and meta-analysis.
Decentralisation, integration, and task-shifting in hepatitis C virus infection testing and treatment: a global systematic review and meta-analysis.
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DOI：
10.1016/s2214-109x(20)30505-2
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发表时间：
2021-04
期刊：
影响因子：
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通讯作者：
Easterbrook P
中科院分区：
文献类型：
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作者：
Oru E;Trickey A;Shirali R;Kanters S;Easterbrook P
增加获得丙型肝炎病毒（HCV）护理和治疗将需要简化服务提供模式。我们的目的是评估检测、护理和治疗与减少危害和其他服务的分散和整合，以及向非专业人员转移任务对整个HCV护理连续体结果的影响。在这项系统评价和荟萃分析中，我们检索了PubMed、Embase、WHO全球医学索引和会议摘要，检索了2008年1月1日至2018年2月20日期间发表的研究，这些研究评估了注射吸毒者、监狱服刑人员、艾滋病毒感染者和一般人群中HCV检测的接受情况、与护理的联系、治疗、治愈评估和12周持续病毒学反应（SVR12）。随机对照试验、非随机研究和观察性研究均符合纳入条件。排除了最大分母为10或更少样本量的研究。根据分散程度对研究进行分类：全面（在同一地点进行检测和治疗），部分（在分散地点进行检测并转诊到其他地方进行治疗）或没有。任务转移分为专家治疗和非专家治疗。使用随机效应荟萃分析汇总了整个HCV治疗连续体的结局数据（与治疗、治疗吸收和SVR12的联系）。我们检索了8050篇报道，其中132篇符合入选标准，另外10篇报道来自参考文献和灰色文献。因此，最终的综合纳入了来自34个国家的142项研究（20项[14%]研究来自低收入和中等收入国家），共计48996例患者（239 446例[49%]来自低收入和中等收入国家）。在注射吸毒者中，与部分或没有权力下放相比，完全权力下放与护理的联系率更高（完全72% [95% CI 57-85] vs部分53% [38-67]vs没有47%[11-84]），在监狱中（完全94% [79-100]vs部分50%[29-71]），尽管注射吸毒者的CI重叠。同样，完全权力下放与部分或不权力下放相比，治疗接受度更高（注射吸毒者：完全73% [65-80]vs部分66% [55-77]vs不35%[23-48]；监狱囚犯：完全72% [48-91]vs部分39%[17-63]），尽管完全权力下放与部分权力下放的ci重叠。一般人群研究的结果则更加不同。在所有人群中，不同分散程度的SVR12率都很高（≥90%）。将护理和治疗任务转移给非专科医生的SVR12率与专科医生提供的治疗相似。46%的研究存在严重或严重的偏倚风险，研究之间的异质性往往非常高（i2bb090%）。将丙型肝炎病毒护理分散和整合到减少危害的地点或初级保健中心，有证据表明，检测的可及性、与护理和治疗的联系有所改善，在一系列人群和环境中，将护理和治疗的任务转移到非专业人员身上，与专业人员提供的护理相比，治愈率同样高。这些发现为在国家HCV规划中采用权力下放和将任务转移给非专业人员提供了支持。国际药品采购机制。
Increasing access to hepatitis C virus (HCV) care and treatment will require simplified service delivery models. We aimed to evaluate the effects of decentralisation and integration of testing, care, and treatment with harm-reduction and other services, and task-shifting to non-specialists on outcomes across the HCV care continuum. For this systematic review and meta-analysis, we searched PubMed, Embase, WHO Global Index Medicus, and conference abstracts for studies published between Jan 1, 2008, and Feb 20, 2018, that evaluated uptake of HCV testing, linkage to care, treatment, cure assessment, and sustained virological response at 12 weeks (SVR12) in people who inject drugs, people in prisons, people living with HIV, and the general population. Randomised controlled trials, non-randomised studies, and observational studies were eligible for inclusion. Studies with a sample size of ten or less for the largest denominator were excluded. Studies were categorised according to the level of decentralisation: full (testing and treatment at same site), partial (testing at decentralised site and referral elsewhere for treatment), or none. Task-shifting was categorised as treatment by specialists or non-specialists. Data on outcomes across the HCV care continuum (linkage to care, treatment uptake, and SVR12) were pooled using random-effects meta-analysis. Our search identified 8050 reports, of which 132 met the eligibility criteria, and an additional ten reports were identified from reference citations and grey literature. Therefore, the final synthesis included 142 studies from 34 countries (20 [14%] studies from low-income and middle-income countries) and a total of 489 996 patients (239 446 [49%] from low-income and middle-income countries). Rates of linkage to care were higher with full decentralisation compared with partial or no decentralisation among people who inject drugs (full 72% [95% CI 57–85] vs partial 53% [38–67] vs none 47% [11–84]) and among people in prisons (full 94% [79–100] vs partial 50% [29–71]), although the CIs overlap for people who inject drugs. Similarly, treatment uptake was higher with full decentralisation compared with partial or no decentralisation (people who inject drugs: full 73% [65–80] vs partial 66% [55–77] vs none 35% [23–48]; people in prisons: full 72% [48–91] vs partial 39% [17–63]), although CIs overlap for full versus partial decentralisation. The results in the general population studies were more heterogeneous. SVR12 rates were high (≥90%) across different levels of decentralisation in all populations. Task-shifting of care and treatment to a non-specialist was associated with similar SVR12 rates to treatment delivered by specialists. There was a severe or critical risk of bias for 46% of studies, and heterogeneity across studies tended to be very high (I2>90%). Decentralisation and integration of HCV care to harm-reduction sites or primary care showed some evidence of improved access to testing, linkage to care, and treatment, and task-shifting of care and treatment to non-specialists was associated with similarly high cure rates to care delivered by specialists, across a range of populations and settings. These findings provide support for the adoption of decentralisation and task-shifting to non-specialists in national HCV programmes. Unitaid.