Sustainable HIV treatment in Africa through viral-load-informed differentiated care.
Sustainable HIV treatment in Africa through viral-load-informed differentiated care.
复制标题
DOI：
10.1038/nature16046
复制
发表时间：
2015-12-03
期刊：
影响因子：
64.8
通讯作者：
Revill P
中科院分区：
文献类型：
--
作者：
Working Group on Modelling of Antiretroviral Therapy Monitoring Strategies in Sub-Saharan Africa;Phillips A;Shroufi A;Vojnov L;Cohn J;Roberts T;Ellman T;Bonner K;Rousseau C;Garnett G;Cambiano V;Nakagawa F;Ford D;Bansi-Matharu L;Miners A;Lundgren JD;Eaton JW;Parkes-Ratanshi R;Katz Z;Maman D;Ford N;Vitoria M;Doherty M;Dowdy D;Nichols B;Murtagh M;Wareham M;Palamountain KM;Chakanyuka Musanhu C;Stevens W;Katzenstein D;Ciaranello A;Barnabas R;Braithwaite RS;Bendavid E;Nathoo KJ;van de Vijver D;Wilson DP;Holmes C;Bershteyn A;Walker S;Raizes E;Jani I;Nelson LJ;Peeling R;Terris-Prestholt F;Murungu J;Mutasa-Apollo T;Hallett TB;Revill P
目前在撒哈拉以南非洲地区监测接受抗逆转录病毒治疗 (ART) 的患者的方法效率低下。患者通常每 1-3 个月去一次诊所进行临床评估，诊所费用与药物本身的费用相当，每 6 个月测量一次 CD4 计数，但患者很少转向二线治疗。为了确保治疗计划的可持续性，需要过渡到更具成本效益的抗逆转录病毒疗法。与 CD4 计数相反，血浆中 HIV RNA 水平（“病毒载量”）的测量可直接测量当前治疗效果。病毒载量知情的差异化护理是一种定制护理的方法，病毒载量受到抑制的患者临床就诊频率较低，而病毒载量未受抑制的患者则受到关注，以促进依从性并及时切换到二线治疗方案。在许多国家，测量病毒载量最可行的方法是收集干血斑 (DBS) 样本以在区域实验室进行检测，尽管人们对 DBS 定义治疗失败的敏感性/特异性以及接收结果的延迟存在担忧。我们使用建模来综合现有证据并评估病毒载量信息差异化护理的成本效益，并考虑 DBS 的局限性。我们发现，使用 DBS 进行基于病毒载量的差异化护理预计具有成本效益，并被推荐作为患者监测策略，尽管随着该方法的推出，进一步的经验证据将很有价值。我们还探讨了未来即时护理 (POC) 病毒载量测试的潜在好处。
There are inefficiencies in current approaches to monitoring patients on antiretroviral therapy (ART) in sub-Saharan Africa. Patients typically attend clinics every 1–3 months for clinical assessment, with clinic costs being comparable with costs of drugs themselves, CD4 counts are measured every 6 months, yet patients are rarely switched to second-line therapies. To ensure sustainability of treatment programmes a transition to more cost-effective ART deliver is needed. In contrast to the CD4 count, measurement of the level of HIV RNA in plasma (“viral load”) provides a direct measure of current treatment effect. Viral load informed differentiated care is a means of tailoring care whereby those with suppressed viral load have less frequent clinical visits and attention is paid to those with unsuppressed viral load to promote adherence and timely switching to a second-line regimen. The most feasible approach in many countries to measure viral load is by collecting dried blood spot (DBS) samples for testing in regional laboratories, although there have been concerns over the sensitivity/specificity of DBS to define treatment failure and the delay in receiving results. We use modelling to synthesize available evidence and evaluate the cost-effectiveness of viral load-informed differentiated care, account for limitations of DBS. We find that viral load-informed differentiated care using DBS is expected to be cost-effective and is recommended as the strategy for patient monitoring, although further empirical evidence as the approach is rolled out would be of value. We also explore the potential benefits of future availability of point-of-care (POC) viral load tests.