優先為 HIV 感染者接種 COVID-19 疫苗
資料來源：www.thelancet.com/hiv Vol 8 November 2021；財團法人台灣紅絲帶基金會編譯
SARS-CoV-2 大流行已近 2 年，許多人開始享受放寬限制所帶來的自由。各國政府將疫苗的推出解釋為意味著關閉本國社會的災難性 COVID-19 浪潮已成為過去。於此同時，SARS-CoV-2 與 HIV 之間相互作用的證據也在增加，對臨床結果的更好瞭解也正在為保護 HIV 感染者所需的臨床管理和措施上提供清晰的信息。然而，新出現的證據顯示，新的 SARS-CoV-2 變異株的產生與免疫抑制和不受控制的 HIV 感染有關。
剌胳針愛滋病毒期刊最近的兩篇論文對 HIV 感染者其 COVID-19 臨床結果的證據進行了大量補充。 Yang 及其同事描述了來自美國國家 COVID 世代聯盟的數據，其中包括 1,436,622 名患有 COVID-19 的成年人，其中 13,170 人感染愛滋病毒。愛滋病毒感染者的 COVID-19 死亡和住院機率高於非愛滋病毒感染者。年齡較大的群體和男性、黑人或非裔美國人以及西班牙裔或拉丁裔成年人面臨的風險最大。 CD4 計數低於每微升 200 個細胞與 COVID-19 的不良結果相關。 Nomah 及其同事描述了西班牙 13,142 名 HIV 感染者世代中的 749 例 COVID-19 病例：高齡、非西班牙裔、神經精神疾病、自身免疫性疾病、呼吸系統疾病和代謝疾病增加了嚴重後果的風險。
在與這兩篇論文相關的評論中，Boffito 和 Waters 表示，這些研究「增加了越來越多的證據顯示 HIV 感染者的結局更糟，並支持早期指導，即 HIV 感染者，尤其是免疫抑制患者，應優先治療 COVID-19以降低風險，包括接種疫苗」。我們同意以下結論：全球所有 HIV 感染者都迫切需要接種 SARS-CoV-2 疫苗。
除了對 HIV 感染者來說有更糟糕的 COVID-19 結果之外，人們越來越擔心免疫功能低下人群的 SARS-CoV-2 病毒之進化可能會阻礙全球對冠狀病毒的反應。 9 月，在《新英格蘭醫學雜誌》上，Corey 及其同事總結了越來越多的證據，顥示免疫功能低下與持續性 SARS-CoV-2 感染和突變有關，這些突變可能會增加病毒的傳播能力或逃避疫苗保護。此外，在 6 月發表在 medRxiv 上的預印本中，Karim 及其同事描述了一個南非婦女的病例，她感染了不受控制的 HIV 病毒，其 SARS-CoV-2 病毒持續傳播 210 天，在此期間病毒發生了 30 次突變，所發生了變化包括與疫苗逃逸相關的突變和在相關變異中發現的突變。
考慮到這兩種大流行病毒之間的相互作用，對於愛滋病毒負擔最高的撒哈拉以南非洲地區，SARS-CoV-2 的疫苗覆蓋率非常低是一個很大的問題。世衛組織到 2021 年 9 月底，每個國家的疫苗接種覆蓋率目標為 10%，到年底達到 40%。然而，非洲的疫苗覆蓋率遠遠低於這些目標：在54 個國家當中僅有 15 個國家已為其 10% 的人口完全接種了疫苗，一些國家的疫苗接種率甚至不到人口的1%，而更甚者其他有些國家至在九月底尚未推出疫苗接種。在實現世衛組織 9 月目標所需的 2.7 億支疫苗中，僅收到了 2 億支。非洲的疫苗運動不僅受到供應的困擾，還受到越來越多對疫苗猶豫不決的困擾。 6 月和 7 月在南非進行的一項調查顯示，45% 的 18-24 歲成年人不願意接種疫苗——2021 年初進行的一項類似調查發現，該年齡組中 37% 的人對疫苗接種持懷疑態度。
隨著許多國家開始疫苗追加計劃，疫苗覆蓋率的全球差異變得更加明顯。儘管對免疫功能低下或其他易受傷害的個體追加劑量仍有強烈的爭論，但對一般人群進行追加免疫的科學證據則很差；而確保全球疫苗高覆蓋率的理由仍是無可辯駁的。
確保世界各地的 HIV 感染者優先接種 SARS-CoV-2 疫苗是迫切需要的。首先也是最重要的是在這些臨床上易受傷害的人群中挽救生命並預防疾病。但疫苗接種也可能阻止可能危及全球 COVID-19 反應的潛在變異泉源。此外，全球 COVID-19 復甦的教訓是明確的：必須優先治療愛滋病毒，以挽救現在的生命並在未來發生大流行時幫助保護每個人。
■ 剌胳針愛滋病毒
Prioritise people with HIV for COVID-19 vaccination
Almost 2 years into the SARS-CoV-2 pandemic, many people are starting to enjoy freedoms afforded by relaxation of restrictions. Governments are interpreting vaccine roll-out to mean that the catastrophic waves of COVID-19 that have shut own societies are a thing of the past. At the same time, evidence of the interaction between SARS-CoV-2 and HIV is also growing, and the better understanding of clinical outcomes is providing clarity on clinical management and measures needed to protect people with HIV. However, emerging evidence implicates immunosuppression and uncontrolled HIV infection in the generation of new SARS-CoV-2 variants.
Two papers in this issue provide substantial dditions to the evidence on clinical outcomes of COVID-19 in people with HIV. Yang and colleagues describe data from the US National COVID Cohort Collaboration, including 1436622 adults with COVID-19, of whom 13 170 have HIV. People with HIV had higher odds of COVID-19 death and hospitalisation than did people without HIV. Older age groups and male, Black or African American, and Hispanic or Latinx adults were most at risk. CD4 counts lower than 200 cells per μL were associated with adverse COVID-19 outcomes. Nomah and colleagues describe 749 COVID-19 cases in a Spanish cohort of 13 142 people with HIV: old age, non-Spanish origin, and neuropsychiatric illness, autoimmune disease, respiratory disease, and metabolic disease increased risks of severe outcome.
In a Comment linked to the two papers, Boffito and Waters say the studies “add to the accumulating evidence for worse outcomes for people with HIV and support early guidance that people with HIV, particularly those with immune suppression, should be prioritised for COVID-19 risk reduction, including vaccination”. We agree with the conclusion that there is an urgent need for vaccination against SARS-CoV-2 for all people with HIV globally.
In addition to worse COVID-19 outcomes for people with HIV, there are growing concerns that SARS-CoV-2 viral evolution in immunocompromised people could hinder the global coronavirus response. In September, in the New England Journal of Medicine, Corey and colleagues summarised the growing evidence that immunocompromise is associated with persistent SARS-CoV-2 infection and mutations that might increase virus transmissibility or enable escape from vaccine protection. Additionally, in a preprint published in medRxiv in June, Karim and colleagues describe a case of a South African woman with uncontrolled HIV who had persistent SARS-CoV-2 virus shedding for 210 days, during which time the virus mutated 30 times, with changes including mutations associated with accine escape and those found in variants of concern.
Given the interplay between the two pandemic viruses, it is a great concern that vaccine coverage
for SARS-CoV-2 is so low for sub-Saharan Africa, the region with the highest burden of HIV. WHO set
targets for vaccination coverage of 10% for each country by the end of September 2021, and 40% by the end of the year. However, vaccine coverage in Africa is woefully short of these targets: 15 of 54 countries have fully vaccinated 10% of their population, several have vaccinated fewer than 1% of the population, and others had not even begun their vaccine roll-out by the end of September. Of 270 million vaccines needed to reach WHO’s September target, only 200 million have been received. Vaccine campaigns in Africa are dogged not only by supply but also by growing vaccine hesitancy. A survey done in June and July in South Africa showed that 45% of adults age 18–24 years would be reluctant to take the vaccine—a similar survey done at the start of 2021 found that 37% in this age group were sceptical of the vaccine.
As numerous countries begin booster programmes, global disparities in vaccine coverage grow starker.
Although there is a strong argument for additional doses for immunocompromised or otherwise vulnerable individuals, the scientific basis for boosting in the general population is poor. The case for ensuring high coverage of vaccines worldwide is irrefutable.
There is an urgent case to ensure that people living with HIV around the world are prioritised for SARS-CoV-2 vaccination. First and foremost to save lives and prevent illness among this clinically vulnerable populations. But vaccination might also block a potential wellspring of variants that could jeopardise the global COVID-19 response. Moreover, the lesson for the global COVID-19 recovery is clear: treatment of HIV must be prioritised to save lives now and to help protect everyone in the event of future pandemics.
■ The Lancet HIV