Impact of Decentralized Care and the Xpert MTB/RIF Test on Rifampicin-Resistant Tuberculosis Treatment Initiation in Khayelitsha, South Africa
Impact of Decentralized Care and the Xpert MTB/RIF Test on Rifampicin-Resistant Tuberculosis Treatment Initiation in Khayelitsha, South Africa
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DOI：
10.1093/ofid/ofv014
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发表时间：
2015-12-01
影响因子：
4.2
通讯作者：
Hughes, Jennifer
中科院分区：
文献类型：
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作者：
Cox, Helen S.;Daniels, Johnny F.;Hughes, Jennifer
背景。在全球范围内，耐利福平结核病（RR-TB）的病例发现和治疗可及性较差。 Xpert MTB/RIF 测试有可能提高检测率并缩短治疗时间 (TTT)。然而，这些益处取决于卫生系统提供治疗方法的能力。我们使用常规规划数据回顾性评估了 Xpert 在开普敦 Khayelitsha 分散式 RR-TB 护理背景下对治疗开始和 TTT 的影响。从2008年开始逐步引入社区治疗。2007年之前，诊断依赖于表型耐药性（培养）。 20072008 年，引入了线性探针检测 (LPA)，随后于 2012 年引入了 Xpert。结果。权力下放之前（2003-2006 年），TTT 中位数为 71 天（四分位距 [IQR]，49-134；n = 158）。 2007-2008 年期间 LPA 的引入与中位 TTT 从 76 天减少到 50 天相关（P < .0001，n = 257）。 2009 年 1 月至 2013 年 6 月期间，诊断出 938 例 RR-TB 病例（74% 感染人类免疫缺陷病毒 [HIV]）。 2008-2011 年期间的权力下放与 TTT 下降有关（P < .0001，趋势检验），2011 年下降至 28 天（IQR，16-40；n = 173）。 Xpert 与 2013 年进一步减少至 8 天相关（IQR，5-25；n = 89；P < .0001）。 Xpert 的治疗起始时间保持不变，并且 HIV 感染者的治疗起始时间较低（2010-2013 年）； 87.9%（506 人中的 445 人）与未感染 HIV 的患者（P < .0001）的 96.9%（194 人中的 188 人）相比。结论。需要改进病例检测并快速开始治疗，以阻断传播并降低死亡率。在这种情况下，权力下放与较高的治疗起始时间和减少的 TTT 相关。 Xpert 的实施显着减少了 TTT，并有可能减少传播。
Background. Globally, case detection and treatment access are poor for rifampicin-resistant tuberculosis (RR-TB). The Xpert MTB/RIF test has the potential to increase detection and reduce time to treatment (TTT). However, these benefits are dependent on health system capacity to provide treatment.Methods. We retrospectively assessed the impact of Xpert on treatment initiation and TTT in the context of decentralized RR-TB care in Khayelitsha, Cape Town, using routine programmatic data. Community-based treatment was introduced progressively from 2008. Before 2007, diagnosis relied on phenotypic resistance (culture). During 20072008, the line probe assay (LPA) was introduced, followed by Xpert in 2012.Results. Before decentralization (2003-2006), median TTT was 71 days (interquartile range [IQR], 49-134; n = 158). The LPA introduction during 2007-2008 was associated with reduced median TTT from 76 to 50 days (P < .0001, n = 257). Between January 2009 and June 2013, 938 RR-TB cases were diagnosed (74% human immunodeficiency virus [HIV]-infected). Decentralization during 2008-2011 was associated with declining TTT (P < .0001, test for trend), a decline to 28 days in 2011 (IQR, 16-40; n = 173). Xpert was associated with a further reduction to 8 days in 2013 (IQR, 5-25; n = 89; P < .0001). Treatment initiation remained unchanged with Xpert and was lower among HIV-infected (2010-2013); 87.9% (445 of 506) compared with 96.9% (188 of 194) for HIV-uninfected (P < .0001) patients.Conclusions. Improved case detection and rapid treatment initiation are required to interrupt transmission and reduce mortality. In this setting, decentralization was associated with high treatment initiation and reduced TTT. Xpert implementation significantly enhanced the reduction in TTT and has the potential to reduce transmission.