The where, when, and how of community-based versus clinic-based ART delivery in South Africa and Uganda.
The where, when, and how of community-based versus clinic-based ART delivery in South Africa and Uganda.
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DOI：
10.1016/s2214-109x(20)30385-5
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发表时间：
2020-10
期刊：
影响因子：
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通讯作者：
Geng EH
中科院分区：
文献类型：
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作者：
Nachega JB;Fatti G;Zumla A;Geng EH
抗逆转录病毒治疗（ART）可以抑制HIV血浆RNA浓度和病毒的有害影响。然而，目前只有约60%的艾滋病毒感染者的病毒得到抑制。因此，全球公共卫生规划迫切需要创新方法，以提高患者参与治疗的速度和持久性。在这一期的《柳叶刀全球健康》杂志上，Ruanne Barnabas及其同事报告了抗逆转录病毒治疗交付优化（DO-ART）研究的结果，这是一项多中心随机试验，比较了基于社区的抗逆转录病毒治疗启动、监测和再补给与使用混合方法（在诊所启动抗逆转录病毒治疗，社区监测和再补给）以及在南非和乌干达可检测到艾滋病毒载量的个体中基于诊所的标准抗逆转录病毒治疗。研究人员假设，以社区为基础的抗逆转录病毒治疗可以克服后勤障碍，简化监测和抗逆转录病毒治疗的再供应，并提高病毒抑制率，特别是在男性中，足以使以社区为基础的干预措施具有成本效益。他们发现，与标准的临床治疗相比，以社区为基础的开始和治疗显著提高了所有参与者的病毒抑制率，从63.1%提高到73.9%，男性从54.3%提高到73.2%。混合方法取得了较小但相似的效果。DO-ART研究的报告为越来越多的文献做出了贡献，这些文献表明，与以诊所为基础的ART提供相比，以社区为基础的干预措施可以产生类似或改善的患者结果。在莱索托进行的一项试验中，以家庭为基础的当日抗逆转录病毒治疗与社区艾滋病毒检测相结合，改善了12个月后的病毒抑制。5采用差异化服务提供模式的社区艾滋病毒护理，包括以社区为基础的数月抗逆转录病毒治疗分发，已被证明具有良好的结果6，并为患者和提供者节省了成本。然而，大多数以社区为基础的ART提供差异化服务模式是为已经稳定抗逆转录病毒治疗的患者开发的，Barnabas及其同事的研究最重要的贡献是，在病毒载量升高的个体中，以社区为基础的当日ART启动是安全的，并且在12个月后病毒抑制得到改善，特别是在男性中。有了这些有希望的结果，接下来的问题是全球公共执行者是否、在何处、何时以及如何扩大DO-ART方法，特别是在男性中。然而，答案不仅取决于研究的严谨性或内部有效性（研究者应该为此鼓掌），还取决于外部有效性，因此一些额外的信息将是有用的。实施研究中的新兴观点可以帮助研究人员定位，提供在其他实施环境中最大限度地解释的发现，这些实施环境因地理（城市与农村）、经济（肯尼亚与莫桑比克）和社会因素而不同——这些观点对旨在影响艾滋病毒应对执行的未来研究有什么建议？
Antiretroviral therapy (ART) can suppress HIV plasma RNA concentrations and harmful effects of the virus. However, at present, only about 60% of people living with HIV are virally suppressed. 1 Therefore, global public health programmes urgently need innovative approaches to improve the rapidity and durability of engaging patients in treatment. In this issue of The Lancet Global Health, Ruanne Barnabas and colleagues report results of the Delivery Optimization of Antiretroviral Therapy (DO-ART) study, a multicentre, randomised trial comparing community-based ART initiation, monitoring, and resupply with use of a hybrid approach (ART initiation at the clinic with community monitoring and resupply), and with standard clinicbased ART delivery among individuals from South Africa and Uganda with detectable HIV viral load. 2 The investigators hypothesised that community-based ART could overcome logistical barriers, simplify monitoring and ART resupply, and increase viral suppression rates, especially among men, enough to make communitybased interventions cost-effective. They found that community-based initiation and treatment significantly increased viral suppression compared with standard clinic-based care among all participants from 63· 1% to 73· 9%, and among men from 54· 3% to 73· 2%. The hybrid approach registered smaller but similar effects. The report of the DO-ART study contributes to a growing body of literature showing that communitybased interventions result in similar or improved patient outcomes compared with clinic-based ART delivery. 3, 4 Home-based, same-day ART initiation integrated with community-based HIV testing improved viral suppression at 12 months in a trial in Lesotho. 5 Community-based HIV care using differentiated service delivery models, including community-based multimonth ART dispensing, have been shown to have favourable outcomes6 and result in cost savings to both patients and providers. 7 However, most communitybased differentiated service delivery models for ART delivery have been developed for patients who are already stable on ART, and the most important contribution of the study by Barnabas and colleagues is that community-based, same-day ART initiation in individuals with elevated viral load was safe and resulted in improved viral suppression after 12 months, particularly among men.With these promising results, the next questions are whether, where, when, and how global public implementers should scale up the DO-ART approach, particularly among men. The answers, however, depend not only on the rigour or internal validity of the study (for which the investigators should be applauded) but also on the external validity, for which some additional information would be useful. Emerging perspectives in implementation research can help position researchers to offer findings that are maximally interpretable in other implementing contexts that differ by geographical (urban vs rural), economic (Kenya vs Mozambique), and social factors—what do these perspectives suggest for future research that aims to influence execution of the HIV response?