The Lancet HIV:该如何降低儿童HIV的患病率 ？

屈泰龙

     

人类免疫缺陷病毒（HIV）的母婴垂直传播是在资源匮乏，缺少医疗保障的农村地区存在的一个重要问题。但是最近一项研究发现，只要能够将整合的医疗服务执行到家庭层面，即使是在最贫困最糟糕的环境下也可以取得很大的改善。

这就是范德堡大学全球健康研究所的研究人员在尼日利亚的中北部农村地区进行的一项研究所得出的结论。相关研究结果发表在国际学术期刊The Lancet HIV上，这项研究将有助于燃起人们对于彻底消除HIV母婴垂直传播的希望。

尼日利亚的HIV感染和死亡率一直居高不下，同时尼日利亚还是新增儿童HIV感染病例数第二多的国家，仅次于南非。使用抗逆转录病毒疗法能够防止HIV病毒从母亲传递给婴儿，但是一些贫穷地区仍然缺少使用这种治疗方法的条件。在携带HIV病毒的尼日利亚当中，每10人中仅有2人能够得到这种治疗。

在这项研究中，研究人员对尼日利亚的12个农村地区进行了重点研究，他们随机安排了一些怀孕或刚生产过的女性接受一套特殊的医疗服务，而另外一组女性作为对照，接受标准的医疗护理。

在干预组中，研究人员鼓励男性参与妻子的护理，同时对于助产士以及社区健康志愿者等非医师健康护理人员进行服务培训，培训过程尽量做到经济有效。

除此之外，还提供CD4细胞计数检测，并在怀孕女性生产之后为母亲和婴儿提供整合服务。干预组和对照组中携带HIV的怀孕女性，母乳喂养的母亲以及生产过程中受到HIV暴露的婴儿都接受了抗逆转录病毒治疗。

经过一段时间之后，干预组内婴儿的HIV感染率仅为2.4%，而对照组内婴儿的感染率达到7.3%——经过特殊护理，婴儿的HIV感染率下降了74%。

这项研究表明通过医疗服务以及资源整合等措施能够有效预防HIV母婴垂直传播，贫穷地区的孩子需要得到更多的关注。

Integrated prevention of mother-to-child HIV transmission services, antiretroviral therapy initiation, and maternal and infant retention in care in rural north-central Nigeria: a cluster-randomised controlled trialSummaryBackground

Antiretroviral therapy (ART) and retention in care are essential for the prevention of mother-to-child HIV transmission (PMTCT). We aimed to assess the effect of a family-focused, integrated PMTCT care package.

Methods

In this parallel, cluster-randomised controlled trial, we pair-matched 12 primary and secondary level health-care facilities located in rural north-central Nigeria. Clinic pairs were randomly assigned to intervention or standard of care (control) by computer-generated sequence. HIV-infected women (and their infants) presenting for antenatal care or delivery were included if they had unknown HIV status at presentation (there was no age limit for the study, but the youngest participant was 16 years old); history of antiretroviral prophylaxis or treatment, but not receiving these at presentation; or known HIV status but had never received treatment. Standard of care included health information, opt-out HIV testing, infant feeding counselling, referral for CD4 cell counts and treatment, home-based services, antiretroviral prophylaxis, and early infant diagnosis. The intervention package added task shifting, point-of-care CD4 testing, integrated mother and infant service provision, and male partner and community engagement. The primary outcomes were the proportion of eligible women who initiated ART and the proportion of women and their infants retained in care at 6 weeks and 12 weeks post partum (assessed by generalised linear mixed effects model with random effects for matched clinic pairs). The trial is registered with ClinicalTrials.gov, number NCT01805752.

Findings

Between April 1, 2013, and March 31, 2014, we enrolled 369 eligible women (172 intervention, 197 control), similar across groups for marital status, duration of HIV diagnosis, and distance to facility. Median CD4 count was 424 cells per μL (IQR 268–606) in the intervention group and 314 cells per μL (245–406) in the control group (p<0·0001). Of the 369 women included in the study, 363 (98%) had WHO clinical stage 1 disease, 364 (99%) had high functional status, and 353 (96%) delivered vaginally. Mothers in the intervention group were more likely to initiate ART (166 [97%] vs 77 [39%]; adjusted relative risk 3·3, 95% CI 1·4–7·8). Mother and infant pairs in the intervention group were more likely to be retained in care at 6 weeks (125 [83%] of 150 vs 15 [9%] of 170; adjusted relative risk 9·1, 5·2–15·9) and 12 weeks (112 [75%] of 150 vs 11 [7%] of 168 pairs; 10·3, 5·4–19·7) post partum.

Interpretation

This integrated, family-focused PMTCT service package improved maternal ART initiation and mother and infant retention in care. An effective approach to improve the quality of PMTCT service delivery will positively affect global goals for the elimination of mother-to-child HIV transmission.

文献下载地址：http://www.sciencedirect.com/sci ... i/S2352301816000187

生物谷，The Lancet HIV