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將 U=U 納入全球 HIV 照護的挑戰

將 U=U 納入全球 HIV 照護的挑戰

Krishen Samuel / 2022 年 8 月 17 日 /aidsmap / 財團法人台灣紅絲帶基金會編譯

 

U=U 峰會的倡導者(從左到右:NAM aidsmap 的 Matthew Hodson、Fungai Murau、Franco Bova 博士、Jacquelyne Alessi 和 Judy-Ann Nugent)。圖片:byol kimura 2022 – U=U 2022 年全球峰會,加拿大蒙特婁

 

上個月在蒙特婁舉行的第 24 屆國際愛滋病大會(AIDS 2022)上,來自世界各地的倡導者齊聚一堂,分享全面整合「檢測不到 = 無法傳播」(U =U) 在全球不同的環境中傳遞信息的持續性阻礙。

中心的一個主題是結構性障礙——特別是貧困、獲得治療和病毒載量檢測的機會有限、污名化和普遍的不平等——繼續影響著健康結果。在許多情況下,愛滋病毒的刑事定罪也是一個巨大的障礙,倡導者討論了 U=U 在挑戰愛滋病毒刑法中的可能作用。

加勒比

來自牙買加血清學陽性網絡 (JN+) 的 Judy-Ann Nugent 談到了加勒比地區的挑戰,那裡的醫療保健提供者和愛滋病毒感染者的 U=U 支持有限。她強調了污名化、貧困、衛生系統薄弱和識字率低在限制治療接受和順從性方面的作用。

「簡單地說,如果人們沒有得到食物、報酬——沒有足夠的錢或食物——如果他們的基本需求得不到滿足,那麼服用愛滋病毒藥物就不會成為他們的優先事項」,她說。

整個 2022 年愛滋病大會在活動家 Michael Ighadoro 的帶領下,都支持 U=U。

然而,該地區仍取得了進展,到 2021 年,該地區 70% 的愛滋病毒感染者獲得治療且發生率繼續下降。根據聯合國愛滋病規劃署的最新數據,加勒比地區 84% 的愛滋病毒感染者知道自己的狀況,83% 正在接受治療,87% 的病毒受到抑制。

為了提高對 U=U 的廣泛認識,Nugent 建議將 U=U 信息嵌入美國總統愛滋病緊急救援計畫(PEPFAR) 和全球基金的資助協議中,以便各國必須採取積極措施將 U=U 納入國家計畫以獲得資助。 PEPFAR 更新的 2022 年國家指南就是這樣做的,它廣泛提到各國需要將 U=U 信息整合到 HIV 照護連續體中。

拉丁美洲

來自阿根廷組織 Asociación Ciclo Positivo 的 Franco Bova 博士分享說,在拉丁美洲,只有 60% 的接受治療的人受到病毒抑制,遠遠低於之前的 90%和目前的 95% 病毒抑制目標。它也是自 2020 年以來愛滋病毒發生率增加的地區之一。博瓦說,貧困和不平等使新感染持續存在,並且是阻礙愛滋病毒感染者實現病毒抑制的障礙。

各種方法已成功地在該地區建立 U=U 意識。在阿根廷,活動人士與社區組織、非政府組織、大學和地方政府合作,在 Pride 等同志大型公共活動和社交媒體上傳播 U=U 信息。 Bova 談到了其他拉丁美洲國家使用的一些成功策略,例如墨西哥的講故事、委內瑞拉的音樂視頻和音樂會以及巴西的官方政府活動。他還強調了重要的差距,這些差距使得談論 U=U 具有挑戰性。例如,在秘魯,衛生部不收集任何有關病毒抑制的數據。

Bova 的組織正在推廣一個名為 Indetectable LAC 的虛擬平台,以將拉丁美洲和加勒比地區的利益相關者聚集在一起,以共享信息並在這些地區建立更好的網絡。

中東和北非

從 2020 年到 2021 年,該地區的愛滋病毒感染人數增加了 33%。它是全球僅有的三個愛滋病毒仍在上升的地區之一,此外還有拉丁美洲、東歐和中亞。到 2021 年,只有 67% 的 HIV 感染者知道自己的感染狀況,50% 正在接受治療,44% 的人受到病毒抑制。

「中東和北非是國際 HIV 社區失敗的地區」,土耳其領先的 HIV 民間社會組織 Red Ribbon Istanbul 的創始人 Arda Karapinar 說。他強調了該地區獨特的背景挑戰。與愛滋病毒相關的污名,加上對性的保守宗教態度和有限的人權,在傳播 U=U 信息方面提出了巨大的挑戰。

然而,他也談到了熱情的地方激進主義如何能夠帶來改變和創造意識。「根據我在土耳其的親身經歷,我知道有時,一個國家或地區的一名活動家,致力於為所有人的利益創造社會變革,可能就足夠了。該地區有偉大的活動家在捍衛 U=U。儘管存在無數風險,但它們仍在繼續工作」。

Karapinar 認為,土耳其在歐洲和中東之間處於獨特的位置,對於那些希望在中東和北非地區改善愛滋病毒結果和 U=U 意識的人來說,它可以作為一個交匯點和安全港。

英國

活動家 Fungai Murau 談到了 U=U 意識仍然存在的差距,即使在英國也是如此。她分享了一位年輕女性垂直感染 HIV 並且從未聽說過 U=U 的故事。 「在英國垂直感染愛滋病毒的兒童正在從青少年診所轉移到成人診所,而沒有被告知 U=U」,她說。「因為我們假設兒科醫生不應該和年輕女孩談論性問題。這是不正確的。我們需要改變這一點。我們需要確保當他們轉移到成人診所時,我們已經縮小了這一差距」。

她主張整合英國不同的醫療保健服務。「我的 HIV 診所是我的理念擁護者,但我的全科醫生或牙醫可能不知道 U=U」。

美國的刑事定罪

美國是根據從保密到涉嫌傳播的法律將愛滋病毒感染者定為刑事犯罪的主要國家之一。根據這些法律定罪可能導致長期監禁並被登記為性犯罪者。

Krishen Samuel、Florence Anam 和 Linda-Gail Bekker 教授在我們的 aidsmap LIVE AIDS 2022 特刊中討論了 U=U。

雖然一些活動人士認為 U=U 應該作為非刑事化的基礎,但愛滋病法律和政策中心的創始人凱瑟琳·漢森斯談到了在倡導愛滋病非刑事化時過度依賴 U=U 的潛在陷阱,特別是因為在美國實現病毒抑制的結構性障礙。

漢森斯強調,代表個人的倡議與倡導公平的政策和法律改革有很大不同。雖然在個別情況下證明無法檢測(以及隨後不具愛滋病毒傳播的能力)肯定是有益的,但如果倡導者要求將無法檢測的狀態編入法律,則可能會產生意想不到的負面後果——尤其是對於最有可能感染愛滋病毒的群體。成為 HIV 刑事定罪的目標。

如果病毒載量是決定一個人是否有罪的一個因素,它可能會導致利用一個人未能留在醫療保健機構或實現病毒抑制作為有罪的證據。它還可能導致政策制定者和檢察官相信並爭辯說,那些並非無法檢測到的 HIV 感染者具有將傳染傳播給性伴侶的重大風險。 「目前的科學清楚地表明,愛滋病毒不容易傳播」,漢森斯說。「即使被傳播,通過適當的治療也很容易存活」。

她認為,改革愛滋病毒刑法的努力應該基於是否存在傷害意圖,以及愛滋病毒是一種可以控制的慢性疾病,經過適當的治療,而不是判處死刑。

 

參考文獻:

U=U 全球峰會。一場好的戰鬥:宣傳、政策和法律,第 5 場。第 24 屆國際愛滋病大會,蒙特婁,會前會議。

U=U 全球峰會。全球視野:挑戰與成功,第 6 場。第 24 屆國際愛滋病大會,蒙特婁,會前會議。

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

The challenges integrating U=U into HIV care around the world

Krishen Samuel / 17 August 2022 / aidsmap

 

Advocates at the U=U Summit (L-R: NAM aidsmap’s Matthew Hodson, Fungai Murau, Dr Franco Bova, Jacquelyne Alessi & Judy-Ann Nugent). Image: byol kimura 2022 – U=U Global Summit 2022, Montréal Canada

Advocates from around the world came together at the U=U Global Summit at the 24th International AIDS Conference (AIDS 2022) in Montreal last month to share successes and challenges that continue to hamper full-scale integration of the ‘Undetectable = Untransmittable’ (U=U) message in diverse global contexts.

A central theme was that structural barriers – especially poverty, limited access to treatment and viral load testing, stigma, and widespread inequalities – continue to shape health outcomes. HIV criminalisation is also a formidable barrier in many contexts, and advocates discussed the possible role of U=U in challenging HIV criminal laws.

The Caribbean

Judy-Ann Nugent, from the Jamaican Network of Seropositives (JN+), spoke about challenges in the Caribbean, where there has been limited U=U buy-in from healthcare providers and people living with HIV. She emphasised the role of stigma, poverty, weak health systems and low levels of literacy in limiting treatment uptake and adherence.

“Simply put, if people are not fed, paid – have enough money or food – if their basic needs are not met, taking HIV medication will not be a priority for them,” she said.

Led by activist Michael Ighadoro the entire AIDS 2022 conference stands up for U=U.

However, there has been progress, with 70% of all people living with HIV in the region accessing treatment in 2021 and incidence continuing to drop. According to the latest UNAIDS data, 84% of people living with HIV in the Caribbean know their status, 83% are on treatment and 87% are virally suppressed.

To promote more widespread awareness of U=U, Nugent recommended that U=U messaging is embedded in funding agreements with PEPFAR and the Global Fund so that countries are required to take proactive steps to integrate U=U into national programmes in order to receive funding. PEPFAR’s updated country guidance for 2022 does just this, making extensive mention of the need for countries to integrate U=U messaging along the HIV care continuum.

Latin America

Dr Franco Bova, from the Argentinian organisation Asociación Ciclo Positivo, shared that only 60% of those on treatment are virally suppressed in Latin America, falling far short of the previous 90 and the current 95 targets for viral suppression. It is also one of the regions where HIV incidence has increased since 2020. Bova said poverty and inequality perpetuate new infections and are barriers preventing people living with HIV from achieving viral suppression.

Various approaches have been successful at creating awareness of U=U in the region. In Argentina, activists have worked with community-based organisations, NGOs, universities, and local government to spread the U=U message at large public events, such as Pride, and through social media. Bova spoke about some successful strategies used in other Latin American countries, such as storytelling in Mexico, music videos and concerts in Venezuela and official government campaigns in Brazil. He also highlighted important gaps that make it challenging to speak about U=U at all. For instance, in Peru, the Ministry of Health does not collect any data on viral suppression.

Bova’s organisation is promoting a virtual platform, Indetectable LAC, to bring stakeholders in Latin America and the Caribbean together to share information and to enable better networking in the regions.

The Middle East and North Africa

More news from North Africa and Middle East

HIV infections increased by 33% in this region from 2020 to 2021. It is one of only three global regions, along with Latin America, and eastern Europe and central Asia, where HIV is still on the rise. In 2021, only 67% of people living with HIV knew their status, 50% were on treatment and 44% were virally suppressed.

“The Middle East and North Africa is the region where the international HIV community has failed,” stated Arda Karapinar, founder of Red Ribbon Istanbul, Turkey’s leading HIV civil society organisation. He emphasised the distinct contextual challenges in the region. HIV-related stigma, combined with conservative religious attitudes towards sex and limited human rights, present formidable challenges in getting the U=U message out.

However, he also spoke of how passionate local activism can result in change and create awareness. “I know from my own experience in Turkey how sometimes, just one activist from a country or a region, dedicated to creating a change in society for the benefit of all, may be highly sufficient. There are great activists in the region who are defending U=U. They continue to work despite countless risks.”

Karapinar argued that Turkey is uniquely positioned between Europe and the Middle East, and can act as a meeting point and a safe harbour for those hoping to improve HIV outcomes and U=U awareness in the Middle East and North Africa region.

United Kingdom

Activist Fungai Murau spoke about the gaps that still exist in U=U awareness, even in the UK. She shared the story of a young woman who had acquired HIV vertically and had never heard about U=U. “Children who acquired HIV vertically in the UK are being transferred from adolescent clinics to adult clinics without being told about U=U,” she said. “Because we are assuming that paediatric doctors should not be talking to young girls about sex. This is not correct. We need to change that. We need to ensure that by the time they transfer to adult clinics, we have closed that gap.”

She advocated for integration across different healthcare services in the UK. “My HIV clinic is my champion, but my GP or my dentist may not know about U=U.”

Criminalisation in the United States

The US is one of the leading countries criminalising people with HIV under laws ranging from non-disclosure to alleged transmission. Convictions under these laws can result in lengthy prison terms and registration as a sex offender.

Krishen Samuel, Florence Anam and Professor Linda-Gail Bekker discuss U=U in our aidsmapLIVE AIDS 2022 special.

While some activists have argued that U=U should be used as a basis for decriminalisation, Catherine Hanssens, founder of the Center for HIV Law and Policy, spoke about the potential pitfalls of being overly reliant on U=U when advocating for HIV decriminalisation, particularly because of the structural barriers to achieving viral suppression in the US.

Hanssens emphasised that advocacy on behalf of an individual is very different from advocacy for equitable policy and law reform. While it may certainly be beneficial to show proof of undetectability (and subsequent lack of ability to transmit HIV) in individual cases, there might be unintended negative consequences if advocates call for undetectable status to be codified into laws – especially for the groups most likely to be targeted by HIV criminalisation.

If viral load is a factor in determining whether a person is guilty, it can lead to using a person’s failure to stay in health care or to achieve viral suppression as evidence of guilt. It can also lead policymakers and prosecutors to believe, and argue, that people living with HIV who are not undetectable pose a significant risk of transmission to sexual partners. “Current science makes it clear that HIV is not easy to transmit,” Hanssens said. “And even when transmitted, it is easily survivable with appropriate treatment.”

She argued that efforts to reform HIV criminal laws should be based on whether intent to harm was present or not, and the fact that HIV is a manageable chronic illness with appropriate treatment, not a death sentence.

References

U=U Global Summit. The Good Fight: Advocacy, policy and the law, Session 5. The 24th International AIDS Conference, Montreal, pre-conference sessions.

U=U Global Summit. A Worldwide View: Challenges and successes, Session 6. The 24th International AIDS Conference, Montreal, pre-conference sessions.

 

 

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