在南非，檢測不到 HIV 的人的健康年數幾乎與 HIV 陰性的人一樣多
資料來源：Alain Volny-Anne / 2022 年 11 月 21 日 / Aidsmap/財團法人台灣紅絲帶基金會編譯
盧西安·科曼/Shutterstock.com。 圖片僅供參考。
在抗反轉錄病毒療法下實現病毒抑制的愛滋病毒感染者的預期壽命和無殘疾預期壽命幾乎與南非的愛滋病毒陰性人群相似。 與在接受治療時未達到病毒抑制的 HIV 感染者相比，他們還有更大的機會過上更長壽、更健康的生活。 這是南非最近發表在《刺胳針愛滋病毒》上的一項研究的發現。 作者說，這項研究首次揭示了 HIV 病毒抑制與撒哈拉以南非洲 HIV 感染者無殘疾壽命之間的關聯。
在撒哈拉以南非洲地區大規模推廣抗反轉錄病毒療法已經延長了愛滋病毒感染者的預期壽命，其中大多數人現在正在老齡化。 然而，在抗反轉錄病毒療法的益處可能分佈不均的情況下，有一個懸而未決的問題是這些益處在多大程度上出現在未實現病毒抑制的個體中。
這種知識差距帶來了由澳大利亞國立大學的 Collin Payne 博士領導的國際研究人員合作夥伴關係，以研究在南非HIV 和病毒抑制如何導致 HIV 感染者的預期壽命和無殘疾預期壽命的差異。
研究人員使用了來自非洲健康和老齡化的數據：INDEPTH (HAALSI) 社區的縱向研究，這是一項主要的基於人口的世代研究，正在南非姆普馬蘭加省的農村地區進行，那裡的愛滋病毒盛行率可能高達 15%。 更準確地說，Payne 及其同事分析了在 HAALSI 研究的基準線（2014-2015 年）和追蹤2018-2019 年）接受採訪或在這兩個調查期間死亡的 40 歲以上人群的數據，以比較預期壽命，還有感染或未感染 HIV 的人的無殘疾預期壽命。
殘疾的主要衡量標準是基於受訪者自我報告的日常生活活動 (ADL)，這是獨立照顧自己所需的基本技能。六項技能（吃飯、洗澡、行動等）中的任何一項有困難的人都被視為殘疾人。
結果
總共有 4,322 人符合研究條件：54% 為女性，46% 為男性。 在整個世代中，23% 的人是 HIV 陽性。平均而言，感染 HIV 的受訪者比 HIV 陰性的受訪者更年輕，報告殘疾的可能性也略低。在感染 HIV 的受訪者中，59% 的病毒受到抑制，41% 的沒有（即病毒載量至少為 200 拷貝）。
該研究發現，在 45 歲時，愛滋病毒陰性的男性預計可以活到 72 歲，這意味著比愛滋病毒感染者的預期壽命長近七年。 然而，在僅按 HIV 狀態進行分組的背後，對病毒抑制的分析揭示了其他現實：
• 如果病毒載量受到抑制，一名感染 HIV 的 45 歲男性可能會活到 69 歲，也就是說，比 HIV 陰性男性預期的 72 歲少三年。
• 相比之下，一名病毒載量未被抑制的 45 歲 HIV 陽性男性預計只能活到 62 歲，也就是說，比同齡的 HIV 陰性男性少將近十年。
• 一名感染愛滋病毒且病毒載量受到抑制的 45 歲女性預計可以活到 77 歲，僅比愛滋病毒呈陰性的女性少一歲。
• 與同齡的HIV 陰性對照者相比，未受到病毒抑制的HIV 感染女性的預期壽命要少近七年。
對於女性和男性而言，65 歲時按 HIV 狀態和病毒載量劃分的預期壽命趨勢相似，但由於該年齡段的總體剩餘預期壽命較低，差異幅度較小。
關於無殘疾預期壽命的估計，將日常生活活動考慮在內，Payne 及其同事發現感染 HIV 的受訪者與 HIV 陰性的受訪者之間存在顯著差異：
• 一名感染 HIV 且病毒載量受到抑制的 45 歲男性有望活到 66 歲而不會出現殘疾，而沒有受到病毒抑制的男性則只能活到 60 歲。
• 對於活到 65 歲的人來說，如果病毒載量得到抑制，感染 HIV 的男性有望活到 76 歲而不致殘疾——類似於 HIV 陰性的男性。然而，如果沒有抑制病毒載量，這一預期下降到 73。
• 在女性中觀察到相同的趨勢，儘管差異幅度較小。
鑑於這些重大差異，研究人員進一步探討了健康預期壽命。當透過身體測試（步態速度和握力）而不是日常生活活動來評估身體機能時，健康預期壽命的差異與上述發現相似。
這項研究的第一個重要信息是，抗反轉錄病毒療法下的 HIV 病毒抑制是延長南非生命的關鍵。
第二個是愛滋病毒感染者控制他們的病毒載量對以後的健康和福祉有很大的積極影響。在社會和衛生服務極其薄弱的非洲背景下，這可能會產生重大的積極影響。
然而，與該研究一起發表的評論呼籲謹慎，不要暗示 HIV 病毒抑制患者的預期壽命和無殘疾預期壽命與 HIV 陰性個體相同。Jepchirchir Kiplagat 博士和 Amy Justice 教授指出，美國之前的一項研究顯示，一些 HIV 感染者的預期壽命與普通人群相似，但在更年輕的時候出現了主要的合併症。
他們還強調，南非的研究是在該國 HIV 照護存留率低和病毒抑制率最低的人群中進行的，並且研究樣本的預期壽命低於南非平均水平。因此，那些病毒受到抑制的受訪者「可能是非常健康的人：比那些檢測到病毒的人（甚至可能比那些沒有感染愛滋病毒的人）擁有更多的社會經濟資源、更好的營養、更少的酒精消耗和更少的結核病。該研究可能將部分由於這些共病因素導致的生存率和無殘疾生存率的差異歸因於可檢測病毒與不可檢測病毒」。
這並不是要低估這項研究的重要性。正如 Payne 及其同事所說：「這些結果凸顯了 ART 在 HIV 高流行情況下對人口健康的巨大好處，並強調了繼續努力使老齡人口獲得 ART 治療的必要性」。
參考文獻：
1.Payne CF et al. Differences in healthy longevity by HIV status and viral load among older South African adults: an observational cohort modelling study. The Lancet HIV 9: e709-e716, 2022.
DOI: https://doi.org/10.1016/S2352-3018(22)00198-9
2.Kiplagat J & Justice A. HIV viral suppression is key to healthy longevity. The Lancet HIV 9: e672-e673, 2022. DOI: https://doi.org/10.1016/S2352-3018(22)00227-2
Almost as many healthy years for people with undetectable HIV as HIV-negative people in South Africa
Alain Volny-Anne / 21 November 2022 / Aidsmap
Lucian Coman/Shutterstock.com. Image is for illustrative purposes only.
People with HIV who achieve viral suppression under antiretroviral therapy have a life expectancy and a disability-free life expectancy almost similar to those of HIV-negative people in South Africa. They also have a greater chance of living a longer and healthier life than people with HIV not reaching viral suppression while on treatment. This is what a recent study from South Africa, published in The Lancet HIV, has found. The authors say that this study is the first to reveal an association between HIV viral suppression and years lived without disability among people with HIV in sub-Saharan Africa.
The large-scale roll-out of antiretroviral therapy in sub-Saharan Africa has led to a longer life expectancy among people with HIV, most of whom are now ageing. However, one of the unanswered questions, in a context where the benefits of antiretroviral therapy might be unevenly distributed, is the extent to which these benefits are seen in individuals not achieving viral suppression.
This knowledge gap brought an international partnership of researchers, led by Dr Collin Payne from the Australian National University, to examine how both HIV and viral suppression lead to differences in life expectancy and in disability-free life expectancy among people who are ageing with HIV in South Africa.
The investigators used data from The Health and Ageing in Africa: a Longitudinal Study of an INDEPTH (HAALSI) community, a major population-based cohort study which is ongoing in rural parts of the Mpumalanga province of South Africa, where HIV prevalence can be as high as 15%. More precisely, Payne and colleagues analysed data from people aged over 40 who were interviewed at baseline (2014-2015) and follow-up (2018-2019) of the HAALSI study, or had died between these two survey periods, to compare life expectancy, but also life expectancy without disability in people who had or did not have HIV.
The primary measure of disability was based on respondents’ self-reported Activities of Daily Living (ADL) which are fundamental skills required to independently care for oneself. People who have difficulty with any one of the six skills (eating, bathing, mobility, etc.) are considered disabled.
Results
In total, 4,322 individuals were eligible for the study: 54% were women and 46% were men. Of the entire cohort, 23% were HIV-positive. On average, respondents with HIV were younger and slightly less likely to report disability than their HIV-negative counterparts. Of the respondents with HIV, 59% were virally suppressed and 41% were not (i.e a viral load of at least 200 copies).
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The study found that at age 45, an HIV-negative man could expect to live to the age of 72, which translates into almost seven years longer than the life expectancy of a man with HIV. However, behind this grouping by HIV status alone, analysis of viral suppression revealed other realities:
•With a suppressed viral load, a 45-year-old man with HIV might reach age 69, that is, three years less than the 72 years expected for an HIV-negative man.
•By contrast, a 45-year-old HIV-positive man with an unsuppressed viral load could expect to live to only 62, that is, nearly a decade less than an HIV-negative man the same age.
•A 45-year-old woman with HIV and a suppressed viral load could expect to reach age 77, just one year less than an HIV-negative woman.
•Compared with their HIV-negative counterparts the same age, women with HIV who were not virally suppressed were expected to live nearly seven years less.
For both women and men, the trends in life expectancy by HIV status and viral load at age 65 were similar, but due to the overall lower remaining life expectancy at that age, the magnitude of differences was smaller.
Turning to estimates of disability-free life expectancy, taking into account Activities of Daily Living, Payne and colleagues found substantial differences between respondents living with HIV and HIV-negative counterparts:
•A 45-year-old man with HIV and a suppressed viral load could expect to reach age 66 without disability, compared with only age 60 for a man who was not virally suppressed.
•For those alive at age 65, a man with HIV could expect to live to age 76 without disability – similar to an HIV-negative man – if his viral load was suppressed. However, without a suppressed viral load, this expectation dropped to 73.
•The same trends were observed for women, although the differences were smaller in magnitude.
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Given these substantial differences, the researchers further explored healthy life expectancy. When physical function was assessed through physical tests (gait speed and grip strength) rather than the Activities of Daily Living, the differences in healthy life expectancy were similar to the findings above.
The first take-home message from this study is that HIV viral suppression under antiretroviral therapy is key to prolonging life in South Africa.
The second is that people with HIV’s control over their viral load has a substantial positive impact on health and wellbeing later in life. In an African context where social and health services are extremely weak, this may have significant positive implications.
However, a commentary published alongside the study calls for caution so as to not suggest that people with HIV viral suppression have a life expectancy and a disability-free life expectancy equal to those in HIV-negative individuals. Dr Jepchirchir Kiplagat and Professor Amy Justice point to a previous US study in which some people with HIV had a similar life expectancy to the general population, but major co-morbidities at a much younger age.
They also highlight that the South African study was done in a population with low HIV care retention rates and the lowest viral suppression rates in the country, and that life expectancy in the study sample was lower than the South African average. Therefore, those respondents with viral suppression “might be exceptionally healthy individuals: with more socio-economic resources, better nutrition, lower alcohol consumption and less tuberculosis than those with detectable virus (and, possibly, even than those without HIV). The study might be attributing differences in survival and disability-free survival partly due to these comorbid factors to detectable virus versus undetectable virus.”
This is not to underestimate the significance of the study. As Payne and colleagues say: “These results highlight the tremendous benefits of ART for population health in high-HIV-prevalence contexts and reinforce the need for continued work in making ART treatment accessible to ageing populations.”
References
Payne CF et al. Differences in healthy longevity by HIV status and viral load among older South African adults: an observational cohort modelling study. The Lancet HIV 9: e709-e716, 2022.
DOI: https://doi.org/10.1016/S2352-3018(22)00198-9
Kiplagat J & Justice A. HIV viral suppression is key to healthy longevity. The Lancet HIV 9: e672-e673, 2022.
DOI: https://doi.org/10.1016/S2352-3018(22)00227-2