【作者】 赖钰基；

【导师】 汪宁；

【作者基本信息】 中国疾病预防控制中心 ， 流行病与卫生统计学， 2011， 博士

【摘要】 背景：结核病是艾滋病病毒感染者和艾滋病(HIV/AIDS)患者最常见的机会性感染,也是最常见的死亡原因。世界卫生组织(WHO)提出双向筛查策略(向所有结核病人提供HIV检测和在HIV/AIDS患者中筛查结核病)并向筛查发现的艾滋病合并结核病(TB/HIV)病人提供相应治疗关怀。鉴于我国结核病高疫情、艾滋病处于全国低流行、局部地区和特定人群高流行的特点,有必要探讨适合我国国情的TB/HIV病人发现策略。目的：(1)从疫情和成本效果角度,探讨需要在结核病人中常规开展HV检测的地区和结核病人类型；(2)从成本效果角度,提高结核病可疑症状问卷在HIV/AIDS患者中筛查结核病的效率；(3)从TB/HIV病人发现数量和抗结核治疗效果角度,探讨双向筛查中的重点筛查方向。方法：(1)于2007年9月1日-12月31日和2008年9月1日-12月31日期间分两个阶段,在全国31省333个县(市、区)对结核病防治机构新登记结核病人开展HIV感染状况横断面调查,研究现场覆盖了艾滋病高、中、低流行地区和不同传播途径地区。(2)对2006年9月-2007年8月TB/HIV防治试点研究期间HIV/AIDS患者筛查结核病的个案数据深入挖掘,简化结核病可疑症状筛查问卷。(3)选择常规开展TB/HIV防治工作的6省14个艾滋病高疫情县(市),对2007年9月1日-2009年8月31日期间登记开始抗结核治疗的肺结核病人建立治疗随访队列,比较结防机构发现TB/HIV病人与艾防机构发现TB/HIV病人的抗结核治疗效果。(4)采用非条件单变量logistic回归及多变量logistic回归分析结核病人HIV检出率的影响因素、结核病人HIV检测接受率的影响因素和TB/HIV病人抗结核治疗期间死亡的影响因素。结果：(1)调查45675例结核病人中,152例在就诊时已知HIV阳性,1525例拒绝HIV检测,新检出HIV阳性133例,HIV检出率为0.30%,HIV感染率为0.65%。总计支出调查经费5,733,625元,检出1例HIV阳性平均花费66,670元。策略1(在西南9省县级累计报告HIV/AIDS数50例以上的县、中原7省县级累计报告HIV/AIDS数200例以上的县,向所有结核病人提供HIV检测),支出16%的调查经费,发现67%的病人,发现1例HIV阳性的平均成本为15622元。策略2(在西南9省县级累计报告HIV/AIDS数>50例且结核病登记报告率>70/10万的县、中原7省累计报告HIV/AIDS数>200例且结核病登记报告率>70/10万的县,向所有结核病人提供HIV检测),支出9%的调查经费,发现56%的病人,发现1例HIV阳性的平均成本为10715元。(2)以7个症状组成的结核病筛查问卷为参照,单独使用咳嗽咳痰症状对HIV/AIDS患者进行筛查,能够发现92%的结核病人,节约25%病人进一步结核病检查的费用,阳性预测值为12.3%。单独使用咳嗽咳痰症状对CD4<200的HIV/AIDS患者进行筛查,能够发现96%的结核病人,节约19%的费用,阳性预测值为12.0%。(3)19103例有痰涂片结果和HIV检测结果的肺结核病人中,925例HIV阳性,其中72.8%来源于艾防机构在HIV/AIDS中筛查结核病后转诊,27.2%来源于结防机构在结核病人中开展HIV筛查。HIV阴性肺结核病人的治疗成功率为95.0%、病死率为1.3%、不良反应发生率为1.7%。与艾防机构发现的TB/HIV病人相比,结防机构发现的TB/HIV病人治疗成功率相对较低(73.2%vs76.9%)、病死率相对较高(13.4%vs7.5%)。在既往采供血为主要传播途径的地区,结防机构与艾防机构发现的TB/HIV病人治疗成功率比为(82.1%vs90.6%)、非结核原因病死率比为(15.5%vs6.6%)；在吸毒和性为主要传播途径的地区,结防机构与艾防机构发现的TB/HIV病人治疗成功率比为(68.5%vs60.5%)、不良反应发生率比为(13.6%vs24.6%)。结论：艾滋病防治机构在已掌握的HIV/AIDS中主动开展结核病筛查,能够发现较多TB/HIV病人,提高抗结核治疗效果、降低病死率。咳嗽咳痰持续超过2周用于HIV/AIDS中筛查结核病有较好的成本效果。中原既往采供血传播艾滋病地区在累计报告HIV/AIDS大于200例的县、其他地区在累计报告HIV/AIDS大于50例的县向所有结核病人提供HIV检测具有较好的成本效果。更多还原

【Abstract】 Background Tuberculosis (TB) is the most common opportunistic infection and the leading cause of death among HIV seropositive patients (HIV/AIDS). The World Health Organization initiated an interim policy on collaborative TB/HIV activities which included providing HIV testing for all TB patients, intensifying TB screening in HIV/AIDS and providing treatment and care for TB/HIV patients. As one of the high burden countries in TB control in the world, China still remains one of low HIV prevalence overall with pockets of high infection among specific sub-populations and sub-region. The policy needs to adapt to this situation.Objective (1) Improve HIV screening in TB patients with cost-effectiveness. (2) Improve the efficiency of TB symptom screening in HIV/AIDS. (3) Compare anti-TB treatment outcome of TB/HIV patients who come from HIV and TB clinics.Methods (1) A cross-sectional survey of HIV testing for all TB patients was conducted in 333 counties which covered different prevalence of HIV infection during September 1 to December 31 in 2007 and 2008 separately. (2) Four counties with high HIV prevalence implemented a TB symptom questionnaire screening in HIV/AIDS during September 2006 to February 2007. (3) A cohort of anti-TB treatment was established in 14 counties, which enrolled TB patients registered during September 1, 2007 to August 31,2009 and who were followed for half a year. (4) Binary Logistic Regression was used to analyze related-factors of HIV infection, uptake of HIV testing, and mortality during anti-TB treatment.Results(1) There were 45,675 TB cases enrolled with 152 cases known to be HIV-positive. 1,525 cases refused HIV testing.133 new HIV-positive cases were detected from 43,998 cases. The new detection rate of HIV-positive is 0.30% and the prevalence of HIV infection in TB patients is 0.65%. The survey expended $882,096 in total with an average of $10,257 for detecting a new HIV-positive case.(2) If all TB patients were offered HIV testing in counties with cumulatively reporting of more than 200 cases of HIV/AIDS in seven provinces in central China and cumulatively reporting of more than 50 cases of HIV/AIDS in nine provinces in southern and western China, it would cost 16% of expenditure of this survey, and detect 67% new HIV-positive TB cases with an average of $2,403 per one case detection.(3) If all TB patients were offered HIV testing in countries with cumulatively reporting of more than 200 cases of HIV/AIDS and with a TB registry rate of more than 70/100,000 in seven provinces in central China, and cumulatively reporting of more than 50 cases of HIV/AIDS and TB registry rate of more than 70/100,000 in nine provinces in southern and western China, it would cost 9% of expenditure of this survey, and detect 56% new HIV-positive TB cases with an average of $1,648 per one case detection.(4) Compared to the questionnaire using a combination of seven symptoms and sign to screen TB in HIV/AIDS cases, a consistent cough for more than two weeks alone can detect 92% of TB patients, save 25% of the costs for further TB examinations, and the positive predictive value is 12.3%.(5) There were 19,103 pulmonary TB patients in the treatment cohort.925 cases were HIV-positive,72.8% of which came from TB screening in HIV/AIDS and the remaining 27.2% came from HIV testing in TB patients.(6) HIV-positive TB patients who came from HIV testing in TB patients had a higher mortality rate (13.4% vs.7.5%), and a lower treatment success rate (73.2% vs. 76.9%) than those who came from TB screening in HIV/AIDS cases.Conclusion Most HIV-positive TB patients come from TB screening in HIV/AIDS cases and have a better TB treatment outcome and a lower mortality rate relatively. Using a consistent cough more than two weeks to screen TB in HIV/AIDS cases is cost-effective. Offering HIV testing for all TB patients is cost-effective in counties reporting more than 200 cases of HIV/AIDS in central China where former illegal commercial plasma donation is the main route of HIV transmission, and in counties reporting more than 50 cases of HIV/AIDS in other areas of China where drug use and sexual contact are the main route of HIV transmission.更多还原