到達和超越90-90-90目標的城市

資料來源：刺胳針愛滋病毒醫學雜誌，www.thelancet.com/hiv Vol 6 October 2019；財團法人台灣紅絲帶基金會編譯

城市對愛滋病毒/愛滋病的反應對於在2030年終結愛滋病毒/愛滋病的流行至關重要。體認到這一點，因此於2014年世界愛滋病日那一天，來自26個城市的領導人與民間社會和國際組織發起巴黎快速通道城市宣言，並作出到2020年要實現90-90-90目標的承諾。5年以內，已有300多個市和城市加入，美國的查爾斯頓(Charleston)和吉爾吉斯的奧什(Osh)，是最近的簽署者。

世界人口的城市化相對而言是最近的現象，截至2007年世界上有50％的人口居住在城市地區，而城市人口增長繼續加快。在2015年，聯合國愛滋病規劃署估計，大約25％的愛滋病毒感染者生活在200個城市當中，而其中的156個城市更是位於有90％新感染愛滋病毒的人居住的國家。隨著城市人口的增長，疾病流行潛力不斷擴大。針對普遍大流行城市的努力會嚴重影響國家整體的成果。城市往往有易受愛滋病毒影響的許多關鍵人群而成為人們關注的焦點。相較於農村地區，城市擁有更好的基礎設施、資源、和衛生服務。此外，城市往往有良好的社區網絡可鏈接到衛生服務提供者（公共和私人兩者均是）、公民社會組織和非政府組織。

9月9日至11日，由國際愛滋病照護提供者協會(Care)在英國倫敦召開了快速通道城市會議，這個首次舉辦的國際會議，展示宣傳了成員城市在對抗愛滋病毒挑戰上的成功並分享最佳成果之實踐。倫敦是第一個超過95-95-95目標的城市，其最新數字為95-98-97。阿姆斯特丹、布萊頓、霍夫，以及曼徹斯特也達到或超越了90-90-90的目標。在61個有數據的城市中，14個城市超過了最前一個90，16個已經超過了第二個90，而23個已超過第三個90。

倫敦很好地反映了所倡議的社會思潮，在所有利害相關者的共同努力下有助於超越目標。對於這個國家來說，這也是一個好消息，因為在英國多達38％的愛滋病毒感染者居住在倫敦。但是，及時診斷仍然是個問題，有37％的患者被延誤診斷。其他挑戰仍然保持不變，包括有限的推出暴露前預防（PrEP），以及如何達到剩餘高危人群。倫敦的成功與挑戰亦被其他許多城市的經驗所反映。

儘管城市可能面臨類似的挑戰，解決方案並非一成不變。在整個照護過程中成功結果的關鍵是創新方法和社區參與。例如，紐約立場中立的照護方法是解決愛滋病污名的開創性方法。城市的多面向的手法，其中還包括HIV分子學上之監測，PrEP的社會行銷，以及針對女同性戀、男同性戀、雙性戀和跨性別青年的反歧視計劃幫助他們超越第一個和第三個90的目慄。

快速通道城市方法之所以可能特別有效，是因為地方政府對對當地問題有所了解，其回應比國家努力更有效，有時甚至違反國家立法機構之規章限制或保守的價值觀。在東南亞菲律賓是愛滋病流行最快的國家之一，主要集中在城市地區與男男間性行為者族群和跨性別者。奎松市地方政府體認到問題的嚴重程度，並很大程度上被中央政府所忽視，他們現在提供免除恥辱的愛滋病服務。奎松市的經驗啟發了其他菲律賓城市的效仿跟隨其領導。俄羅斯的聖彼得堡雖然不是快速通道城市該網絡的成員，是另一個與國家趨勢和態度抗衡的城市，並且採取積極的行動以應對主要人群中迅速發展的流行。

然而，污名和歧視仍然存在，而不僅僅是存在民間社會中，也在醫療保健服務和提供者當中。的確，英國顯示，即使在已達到90-90-90目標的城市中，污名和歧視仍然有很大問題。基於人的性取向、性別、監禁、吸毒或HIV之狀態而加以歧視是不能被接受的。快速城市必須遊說各國政府廢除存在歧視的立法。

各國政府可以借鏡於城市的經驗並適當調整其國家愛滋病毒計畫。隨著快速通道城市網絡的不斷發展，以及對城市地區愛滋病問題的複雜性有了更好地理解，在這個日益城市化時代，城市將可引領潮流。 ■刺胳針愛滋病毒

Cities getting to 90-90-90 and beyond

The urban response to HIV/AIDS is crucial to ending the epidemic by 2030. In recognition of this, on World AIDS Day 2014, city leaders from 26 cities joined with civil society and international organisations to launch the Paris Declaration on Fast-Track Cities, with a commitment to achieve the 90-90-90 targets by 2020. In less than 5 years, more than 300 cities and municipalities have joined, with Charleston in the USA and Osh in Kyrgyzstan, among the most recent signatories.

The urbanisation of the world’s population is a relatively recent phenomenon, but as of 2007 more than 50% of the world’s population lives in urban areas, and urban population growth continues apace. In 2015, UNAIDS estimated that around 25% of people with HIV live in 200 cities, and 156 of these cities are in countries where 90% of people newly infected with HIV reside. As urban populations expand, there is the potential for an expanding epidemic. Targeting efforts in cities with generalised large epidemics can significantly affect national outcomes. Cities tend to be focal points for many of the key populations affected by HIV. Relative to rural areas, cities have better infrastructure, resources, and health services. Also, cities tend to have good community networks that link to health providers (both public and private), civil society organisations, and nongovernmental organisations.

On Sept 9–11 in London, Fast-Track Cities, convened by the International Association of Providers of AIDS Care, had its first international conference showcasing the successes across the member cities and sharing best practice and the challenges faced in their fight against HIV/AIDS. London was the first city to surpass 95-95-95 targets, with its latest figures at 95-98-97. Amsterdam, Brighton and Hove, and Manchester have also reached or surpassed the 90-90-90 target. Of 61 cities with data, 14 have surpassed the first 90, 16 have surpassed the second 90, and 23 have surpassed the third 90.

London reflects well the ethos of the initiative where the concerted effort of all stakeholders helped to exceed the target. This is also great news for the country as a whole since as much as 38% of people with HIV in the UK reside in London. However, timely diagnosis remains a problem with 37% being late diagnoses. Other challenges remain too, including the limited roll-out of pre-exposure prophylaxis (PrEP), and how to reach the remaining at-risk populations. London’s successes and challenges are reflected by many other cities’ experiences.

Although cities can face similar challenges, one solution does not fit all. Innovative approaches and community engagement are key to successful outcomes across the care continuum. For example, New York’s status neutral approach to care is a groundbreaking way to tackle HIV stigma. The city’s multifaceted approach, which also includes molecular HIV surveillance, social marketing for PrEP, and antistigma programmes aimed at lesbian, gay, bisexual, and transgender youth has helped it exceed the first and third 90s.

The Fast-Track Cities approach can be particularly effective because local governments have an understanding of the local issues and can respond better than national efforts, sometimes contrary to the strictures of national legislature or conservative values. The Philippines has one of the fastest growing HIV epidemics in southeast Asia, which is mainly concentrated in urban areas and populations of men who have sex with men and transgender people. Local government in Quezon City recognised the extent of the problem, which had largely gone ignored by national government, and now provides stigma-free HIV services. Quezon City’s experience has inspired other Filipino cities to follow its lead. Although not a member of the network, St Petersburg in Russia is another city that countered national trends and attitudes and took positive action to tackle its burgeoning epidemic among key populations.

However, stigma and discrimination remain, not just among civil society but also among health-care services and providers. Indeed, the Positive Voices survey in the UK showed that, even among cities achieving 90-90-90 targets, stigma and discrimination are still substantial problems. Discriminating against people on the basis of sexual orientation, gender, incarceration, drug use, or HIV status is unacceptable. Fast-track cities must lobby their national governments to repeal discriminatory legislation where it exists.

National governments can learn from cities’ experience and align their national HIV programmes appropriately. As the Fast-Track Cities network continues to grow and the complexity of the HIV problem in urban areas is better understood, cities can lead the way in this era of increasing urbanisation.

■ The Lancet HIV

www.thelancet.com/hiv Vol 6 October 2019