千年宣言后结核、疟疾和艾滋病发病率降低

临床医师

自从2000年确定千年发展目标6（MDG6）以来，结核、艾滋病和疟疾的发病率和死亡率均显著下降。

对全球疾病负担研究2013数据的分析显示，每年死于结核的HIV阴性者从1990年的180万人减少至2013年的130万人，减少了1.4%；全球疟疾发病例数在2003年达到峰值2320万，之后逐渐降至2013年的1650万，减少了29%。

本项研究发表在7月21日出版的《美国医学会杂志》上，第20届国际艾滋病大会于这一天在澳大利亚墨尔本开幕。7月22日在线发表于《柳叶刀》的数据显示，诸如预防母婴传播、抗逆转录病毒治疗（ART）等干预措施，已使艾滋病死亡例数由2005年的170万减少至2013年的130万，减少了3.1%，意味着挽救了1910万生命-年。艾滋病死亡例数的减少主要发生在发展中国家。然而，2013年时HIV阳性者已增至2920万人，比2000年时增加了1.2%（Lancet 2014 July 22 [doi: 10.1016/ S0140-6736(14)60844-8]）。

华盛顿大学卫生测量研究所主任Christopher J. L. Murray博士指出：“这3种疾病在各国的流行水平和趋势都有明显的差异。艾滋病和疟疾的发病和死亡均集中于撒哈拉以南非洲，而结核负担分布更广，但在南亚和东南亚最为突出。”

作者们指出，与UNAIDS对2012年的估计值相比，他们对HIV阳性存活者数量的估计值少18.7%，对艾滋病死亡例数的估计值少14.5%。他们认为这一差异可能是由于对集中流行国家（如巴拿马、哥伦比亚和俄罗斯）的死亡例数估计较低。

全球疾病负担研究还选择了与患病率数据、全因死亡率数据，以及用和不用ART的生存率数据相符合的流行病学曲线，作者们称这样得出的中位生存率较高。“例如，在南非，25~34岁年龄段不用ART的中位生存时间从10.5年延长至11.5年。”

与此相似的是，作者们发现他们与世界卫生组织的估计值有明显差异。基本上，他们估计的死亡率更高、患病率和发病率更低，与HIV感染相关的结核所占比例更低。

本项研究显示，儿童HIV感染与2002年峰值相比减少了62.4%，但是成年人新发感染仍高达每年170万例，提醒我们千年发展目标还远未实现。

“全球卫生领域在减少HIV/AIDS、结核和疟疾方面的努力，并不只适用于2000年发表千年宣言之时，而是变得越来越重要。还有很多事情要做。尽管现有证据显示干预措施已开始显现出效果，但恐怕并不像以前广泛认为或希望的那样奏效。”

哈佛大学公共卫生学院的RifatAtun博士在随刊述评中呼吁革新全球卫生数据的报告方式，采用新标准生成可供所有人使用的数据、方法和模式，提高全球卫生研究的透明度和责任性。

全球疾病负担研究是由比尔与梅琳达·盖茨基金会资助的。部分作者披露与公共资助者和私人企业有利益关系。述评作者声称无利益冲突。

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By: BIANCA NOGRADY, Internal Medicine News Digital Network

Tuberculosis, HIV, and malaria incidence and mortality have all declined significantly since the formulation of Millennium Development Goal 6 in 2000, which focused global attention on these three diseases and made them a priority.

Analysis of data from the Global Burden of Disease Study 2013 showed that annual deaths from tuberculosis among HIV-negative individuals decreased 1.4% from 1.8 million in 1990 to 1.3 million in 2013, while the global incidence of malaria appears to have peaked at 232 million in 2003 and since dropped 29% to 165 million new cases in 2013.

The study was published July 21 in JAMA coincident with the start of the 20th International AIDS Conference in Melbourne.Interventions such as prevention of mother-to-child transmission, and antiretroviral therapy (ART), have seen HIV deaths fall from 1.7 million in 2005 to 1.3 million in 2013 – a decline of 3.1% – representing 19.1 million life-years saved, mostly in developing countries, according to data published online July 22 in the Lancet.

However the prevalence of HIV-positive individuals has risen to 29.2 million in 2013, having increased at a rate of 1.2% per year since 2000 (Lancet 2014 July 22 [doi: 10.1016/ S0140-6736(14)60844-8]).

"There is substantial variation both in levels and trends for all three diseases across countries," wrote Dr. Christopher J. L. Murray, the director of the Institute for Health Metrics and Evaluation and professor of global health at the University of Washington, Seattle, and his associates.

"HIV and malaria incidence and death are concentrated in sub-Saharan Africa, whereas tuberculosis burden is more widespread but most pronounced in south and southeast Asia."

The authors pointed out that their estimates of the number of people living with HIV were 18.7% smaller and estimates for HIV mortality were 14.5% smaller than UNAIDS’s estimates for 2012.

"Revisions of the global epidemiology of HIV of this magnitude – in view of the weakness of direct measurement of incidence and death – should not be surprising," the authors wrote.

They suggested that the differences between their figures and those from UNAIDS could be partly attributed to their significantly lower estimates of mortality from concentrated epidemics such as those in Panama, Colombia, and Russia.

The Global Burden of Disease Study also selected epidemic curves for large generalized epidemics that were consistent with prevalence data, all-cause mortality, and data on survival with and without ART, which the authors said had shifted median survival up.

"For example, in southern Africa, median survival off ART for the age-group 25-34 years increased from 10.5 years to 11.5 years."

Similarly, the authors noted significant differences between their estimates and those from the World Health Organization in the prevalence of tuberculosis, commenting that in general they estimated higher mortality, lower prevalence and incidence, and a smaller fraction of tuberculosis related to HIV infection.

The study showed that HIV infections in children have declined by 62.4% since their peak in 2002; however, the authors said the continued 1.7 million new infections in adults each year were a stark reminder that the Millennium Development Goal’s work was far from done.

"The focus of the global health community on action to reduce HIV/AIDS, tuberculosis, and malaria, enshrined in MDG6 [Millennium Development Goal 6], was not only appropriate in 2000 at the Millennium Declaration, but is increasingly relevant now in view of the slow but important progress that disease control strategies have yielded, particularly since 2005.

"Much remains to be done, however: although evidence now exists that the implementation of known interventions is beginning to have an effect, it is probably less than is widely believed, or hoped."

In an accompanying editorial, Dr. RifatAtun, professor of global health systems and director of the global health systems cluster at Harvard University’s School of Public Health, Boston, called for a revolution in the reporting of global health data, with new standards to make data, methods, and models available for all, enabling greater transparency, scrutiny, and accountability in global health research.

Describing the paper as "a bold and welcome action" in its efforts to clarify the reasons for differences in estimates between the global burden of disease data, and data from UNAIDS and WHO, Dr. Atun said that global health studies should strive for rigor of data, methods, and results.

"By providing detailed information on key data sources, key adjustments to data, modeling strategies, and uncertainty analyses, Murray and colleagues have pushed the boundaries of reporting in global health to levels expected of other disciplines and areas of health research – an important step in the right direction," Dr. Atun wrote.

The Global Burden of Disease Study is funded by the Bill & Melinda Gates Foundation. Some authors declared consultancies, lecture fees, honoraria, and grants from public funding sources and private industry. The editorial author declared no conflicts of interest.