背景:艾滋病毒仍然是撒哈拉以南非洲死亡率高的主要决定因素,大量患者是晚期HIV患者。因此,晚期HIV患者的临床管理是复杂的,需要严格遵守更新,经验和简化指南。本研究调查了实施新的临床指南对金沙萨晚期艾滋病毒管理的影响,刚果民主共和国(DRC)。
方法:对晚期HIV患者的常规临床资料进行回顾性分析;2016年2月至2017年3月,在实施新指南之前,2017年11月至2018年7月,新准则实施后。合格的患者是CD4<200细胞/μl并且呈现4种机会性感染中的至少1种的患者。患者档案由医生和其他3名医生组成的委员会进行了审查,以确保一致性。统计显著性设定为0.05%。
结果:在实施新指南之前和之后,分别有两百四十三例患者符合纳入条件。这两个时期的性别和年龄分布相似,和中位数CD436和52细胞/μl,新准则实施前后,分别。40.7%的患者在新指南之前至少有1次漏诊/不正确的诊断,而新指南之后为30%。p<0.05。实施新指南后,结核病和弓形虫病的临床诊断也有了很大改善。此外,只有63%的患者在新指南之前有CD4计数检测结果,而99%的患者在新指南之后有CD4计数检测结果.在包括患者CD4计数和其他10个协变量的多元回归模型中,新指南实施后的死亡几率显着低于新指南之前,p<0.05。
结论:简化和实施新的和改进的HIV临床指南,再加上实验室设备和护理点测试的安装,可能有助于减少不正确的诊断,并改善晚期HIV患者的临床结局。监管当局应考虑制定简化版本的指南,然后向医疗中心提供基本诊断设备。
BACKGROUND: HIV continues to be the main determinant morbidity with high mortality rates in Sub-Saharan Africa, with a high number of patients being late presenters with advanced HIV. Clinical management of advanced HIV patients is thus complex and requires strict adherence to updated, empirical and simplified guidelines. The current study investigated the impact of the implementation of a new clinical
guideline on the management of advanced HIV in Kinshasa, Democratic Republic of Congo (DRC).
METHODS: A retrospective analysis of routine clinical data of advanced HIV patients was conducted for the periods; February 2016 to March 2017, before implementation of new guidelines, and November 2017 to July 2018, after the implementation of new guidelines. Eligible patients were patients with CD4 < 200 cell/μl and presenting with at least 1 of 4 opportunistic infections. Patient files were reviewed by a medical doctor and a committee of 3 other doctors for congruence. Statistical significance was set at 0.05%.
RESULTS: Two hundred four and Two hundred thirty-one patients were eligible for inclusion before and after the implementation of new guidelines respectively. Sex and age distributions were similar for both periods, and median CD4 were 36 & 52 cell/μl, before and after the new guidelines implementation, respectively. 40.7% of patients had at least 1 missed/incorrect diagnosis before the new guidelines compared to 30% after new guidelines, p < 0.05. Clinical diagnosis for TB and
toxoplasmosis were also much improved after the implementation of new
guidelines. In addition, only 63% of patients had CD4 count test results before the new guidelines compared to 99% of patients after new
guidelines. Death odds after the implementation of new
guidelines were significantly lower than before new
guidelines in a multivariate regression model that included patients CD4 count and 10 other covariates, p < 0.05.
CONCLUSIONS: Simplification and implementation of a new and improved HIV clinical
guideline coupled with the installation of laboratory equipment and point of care tests potentially helped reduce incorrect diagnosis and improve clinical outcomes of patients with advanced HIV. Regulating authorities should consider developing simplified versions of guidelines followed by the provision of basic diagnostic equipment to health centers.