在世界大部分地區，老年人的HIV延遲診斷是一個日益嚴重的問題

資料來源：羅傑·佩博迪 / 2022 年 3 月 15 日/ aidsmap news

圖片：Shutterstock Studios HIV in View gallery

50 歲以上被診斷出HIV的人群中，晚期診斷出來的比例高於年輕人。耶魯大學艾米·賈斯蒂斯(Amy Justice)教授在《刺胳針HIV》雜誌上檢視幾乎全球所有地區後表示。儘管近年來許多地區年輕人的晚期診斷率有所下降，但老年人的進展卻較少。

數據來自國際愛滋病流行病學評估資料庫 (IeDEA) 聯盟，該聯盟將七個大型HIV感染者群體聚集在一起。分析了自 2000 年以後的數據，尤其特別關注最新的可用數據（2017 年至 2019 年，取決於地區）。其中 CD4 細胞計數低於 350 的人（亦即需要立即開始治療不能拖延時）被認為延遲診斷。

最近的調查數據顯示，很大一部分人在被診斷出感染 HIV 時超過 50 歲：北美佔 24%、西非 19%、亞太地區 15%、中非 13%、東非12 % 、拉丁美洲和加勒比地區11%，以及8% 在南部非洲。

在非洲世代之人群中，50 歲以上被診斷出HIV的男性多於女性，而在美洲，情況正好相反。

在所有世代中，50 歲以下人群的延遲診斷很常見，但 50-64 歲人群的延遲診斷率更高。這種差異最引人注目的地區在東非（54% 的 50 歲以下的人診斷較晚，而 50 歲以上的人為 67%）、拉丁美洲和加勒比地區（49% 對 61%）和亞太地區（69% 對81%）。 ［（而分析中唯一沒有遵循這種模式的地區是西非（63% 對 62%）］。

更重要的是，這些地區的年輕人和老年人之間的差距越來越大。在東非和拉丁美洲，直到 2004 年左右，年輕人和老年人在確診時的平均 CD4 計數非常相似，但從那時起，年輕人的平均 CD4 計數增長速度更快。在亞太地區，這一差距在 2008 年之後開始顯現。

作者認為這可能是因為測試和治療之策略通常針對年輕人。 「現在是時候去調整溝通之語言和媒介，以便透過 HIV 預防、診斷和治療介入等措施能更有效地觸及老年人」，Justice 及其同事說。

他們建議擴大普遍的HIV篩檢計畫，在該計畫中，所有患者——而不是具有特定風險因素的患者——都應接受HIV檢測。作者說：「在許多國家，醫療保健提供者不認為老年人有感染HIV的風險，老年人他們自己也不認為有感染HIV的風險」。普遍篩查不會那麼污名化，但一些指引仍有年齡的限制（例如，在美國疾病控制和預防中心指引中僅包括 13 至 64 歲的人）。

針對可能與 HIV 相關的「指示條件」之檢測還更應擴大。一個挑戰是，其中一些情況在老年人中是更為常見，因此可能不會像在年輕人中那樣被提示去進行 HIV 檢測。由於透用普遍性檢測和指標條件式檢測都要求臨床醫生不要集中在HIV時僅考慮 HIV 感染的可能性，因此電子健康記錄中的自動提醒應提示他們去進行檢測。也更應該推廣 HIV 自我檢測——這可能對那些關心隱私的人特別有益，例如面臨年齡和性少數地位之雙重污名的人。

作者建議應常規性地與患者就性健康和成癮物質使用等進行臨床討論。對於有感染 HIV 風險的人，應該討論暴露前預防投藥(PrEP)，認知其於預防上之益處以及對腎臟健康和多重藥物上的擔憂。

「是時候將減少延遲診斷的目標一起納入聯合國愛滋病規劃署 2030 年的 95-95-95 目標了嗎？」伴隨著《刺胳針HIV》上的分析該期刊社論問道。「要確保取得進展，需要在預防和檢測上針對有延遲診斷風險的人群，其中老年人基本上佔很大比例。每個感染HIV的人都會從及時的診斷和治療中受益——針對老年人先入為主的觀念不應成為照護上的障礙」。”

Late HIV diagnosis of older people is an increasing problem, in most parts of the world

Roger Pebody 15 March 2022

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Among people diagnosed with HIV over the age of 50, the proportion diagnosed at a late stage is higher than among younger people, in almost all global regions examined by Professor Amy Justice of Yale University in The Lancet HIV. While rates of late diagnosis have fallen among younger people in many regions in recent years, there has been less progress for older people.

Data come from the International Epidemiology Databases to Evaluate AIDS (IeDEA) consortium, which groups together seven large cohorts of people living with HIV. Data from the year 2000 onwards were analysed, with a particular focus on the most recent available data (2017 to 2019, depending on the region). People with a CD4 cell count below 350 (when treatment needs to be started without delay) were considered to be diagnosed late.

Data from the most recent surveys show that a significant proportion of people were over 50 years when they are diagnosed with HIV: 24% in North America, 19% in west Africa, 15% in Asia-Pacific, 13% in central Africa, 12% in east Africa, 11% in Latin America and the Caribbean and 8% in southern Africa.

In the African cohorts, more men than women were diagnosed over the age of 50, whereas in the Americas, it was the other way round.

Late diagnosis was common among people under the age of 50 in all the cohorts, but rates were higher in people aged 50-64 years. The differences were most striking in east Africa (54% of those under 50 were diagnosed late, versus 67% of those over 50), Latin America and the Caribbean (49% vs 61%) and the Asia-Pacific region (69% vs 81%). (The only region included in the analysis which did not follow this pattern was west Africa (63% vs 62%)).

What’s more, disparities between younger and older people are getting worse in those regions. In east Africa and Latin America, up to around 2004, average CD4 count at diagnosis was pretty similar for younger and older people, but has increased more rapidly for the younger age group since then. In Asia-Pacific, the gap started to appear after 2008.

The authors suggest this may be because test-and-treat strategies are often targeted towards younger adults. “It is time to tailor language and mediums of communication to reach older individuals more effectively with HIV prevention, diagnosis, and treatment interventions,” say Justice and colleagues.

They recommend an expansion of universal HIV screening programmes in which all patients – rather than those with particular risk factors – are offered HIV tests. “In many countries, older individuals are not viewed by health-care providers, nor do they see themselves, as at risk for HIV,” the authors say. Universal screening would be less stigmatising, but some guidelines have age restrictions (for example, the US Centers for Disease Control and Prevention guideline which only includes people aged 13 to 64).

Testing in response to ‘indicator conditions’ that may be linked to HIV should also be scaled up. One challenge is that some of these conditions are more common in older people anyway and therefore might not prompt HIV testing as they would do in younger people. As both universal testing and indicator condition testing require clinicians who are not focused on HIV to consider the possibility of HIV infection, automatic reminders in electronic health records should prompt them to order a test. HIV self-testing should be promoted – it may be especially beneficial for people who are concerned about privacy, such as people facing the double stigma of age and sexual minority status.

The authors recommend routine clinical discussion of sexual health and substance use with patients. For those at risk of HIV, PrEP should be discussed, acknowledging both its prevention benefits and concerns with kidney health and polypharmacy.

“Is it time to include targets for reducing late diagnoses alongside the UNAIDS 95-95-95 targets for 2030?,” asks a Lancet HIV editorial that accompanies the analysis. “Ensuring progress will require targeted HIV prevention and testing in those at risk of late diagnosis, among whom older people are a substantial proportion. Everyone who acquires HIV would benefit from prompt diagnosis and treatment initiation – preconceived ideas about older adults should not be a barrier to care.”

References

Justice AC et al. Delayed presentation of HIV among older individuals: a growing problem. The Lancet HIV, published online 23 February 2022.

DOI: https://doi.org/10.1016/S2352-3018(22)00003-0

Editorial: Time to tackle late diagnosis. The Lancet HIV 9: E139, 2022.

DOI: https://doi.org/10.1016/S2352-3018(22)00040-6