TB fast track: effect of a point-of-care TB test-and-treat algorithm on early mortality in people with HIV accessing ART

艾滋病毒治疗（抗逆转录病毒疗法）大大降低了全世界艾滋病毒感染者的死亡率。然而，在资源匮乏的环境中，即使是接受抗逆转录病毒治疗的人，特别是在治疗的头几个月，死亡率仍然很高。结核病是这些早期死亡的最重要原因，建议即将开始抗逆转录病毒治疗的人首先接受结核病筛查。然而，结核病很难诊断，因为最广泛使用的检测方法对艾滋病毒感染者不起作用。因此，艾滋病毒感染者可能不得不进行大量的结核病检测，从而推迟了结核病治疗的开始；它还推迟了抗逆转录病毒治疗的开始。这两种延误都增加了患者死亡的风险。我们提议进行一项研究，试图降低这种高死亡率。在南非的20个初级保健诊所，我们将招募已经开始抗逆转录病毒治疗的晚期艾滋病毒感染者参加我们的研究。在随机选择的10个诊所（干预）中，我们将使用简单、廉价的检查（一种新的结核病、体重和身高尿液检查，以及贫血血液检查），这些检查可以在现场进行，并立即产生结果，以确定那些患结核病和早期死亡风险最高的患者。高风险人群应立即开始结核病治疗，然后尽快进行抗逆转录病毒治疗；结核病风险较低的人将立即开始抗逆转录病毒治疗。中等结核病风险的患者将在进行胸部x光检查和痰液（唾液）检测结核病的同时给予抗生素，并将在一周后回来决定是否应开始结核病治疗并随后进行抗逆转录病毒治疗，还是仅开始抗逆转录病毒治疗。在其他10家（对照）诊所，患者将按照国家指导方针以正常方式得到照顾。我们将对所有患者进行为期6个月的随访。我们将使用我们的新方法比较10个干预诊所6个月时的死亡率与10个对照诊所使用常规方法的死亡率。如果我们的新方法能降低死亡率，那么资源匮乏地区的诊所就可以使用这种低成本策略来挽救艾滋病毒感染者的生命。

Treatment for HIV (antiretroviral therapy, or ART), has greatly reduced death rates among people with HIV worldwide. However in low-resource settings, death rates continue to be high even for people taking ART, particularly in the first few months on treatment. Tuberculosis (TB) is the most important cause of these early deaths, and people who are due to start ART are recommended to be screened for TB first. However, TB is hard to diagnose because the tests which are most widely available do not work well for people with HIV. As a result, people with HIV may have to go through lots of tests for TB, which delays the start of TB treatment; it also delays the start of ART. Both of these delays increase the risk that the patient dies. We propose a study to try to reduce this high death rate. In 20 primary care clinics in South Africa, we will enrol people with advanced HIV who have come to start ART to our study. In 10 of the clinics (intervention), selected at random, we will use simple, inexpensive tests (a new urine test for TB, weight and height, and a blood test for anaemia) which can be done on site with immediate results, to identify those patients who are at highest risk of having TB, and of dying early. People who are high risk will start TB treatment straight away, then ART as soon as possible afterwards; people who are low TB risk will start ART straight away. People with medium TB risk will be given antibiotics while a chest X-ray and sputum (spit) test for TB are done, and will come back after a week to decide if they should start TB treatment followed by ART, or just start ART. At the other 10 (control) clinics, patients will be looked after in the normal way, following national guidelines. We will follow all patients up for 6 months. We will compare the death rate at 6 months in the 10 intervention clinics, using our new approach, to death rates in the 10 control clinics, using the routine approach. If our new approach reduces the death rate, clinics throughout low resource settings could use this low-cost strategy to save lives among people with HIV.