www.thelancet.com/hiv Vol 11 July 2024

人們普遍呼籲將性傳播感染 (STI) 服務納入愛滋病毒預防和治療計畫，以提高照護效率和品質。在目前罹患有性傳播感染的人群中其愛滋病毒的易感性增加，越來越多的人認識到，性傳播感染服務與愛滋病毒檢測和預防服務缺乏整合是一個重大的機會錯失。

聯合國愛滋病規劃署的數據顯示，2022 年，南非發生了16 萬例愛滋病毒感染事件，其中約三分之一是少女和年輕婦女。尤其是青春期女孩和年輕女性，是南非性傳播染感染發生率最高的族群，每 100 人年會感染 10 至 30 例。 這些數據顯示，將愛滋病毒預防服務納入性傳染感染服務可能對青少年和年輕人等易感人群，降低其愛滋病毒發生率上產生潛在影響。

在本期《刺胳針HIV》中，Maryam Shahmanesh 及其同事 報告了他們的開放標籤2 × 2 隨機析因試驗，Isisekelo Sempilo ，的結果，該試驗評估了將性健康和生殖健康服務與同伴支持等相結合對於提高愛滋病毒生物醫學預防方法採用的有效性，以減少南非年輕人中愛滋病毒的傳播。作者假設，提供基於風險差異化之抗反轉錄病毒 (ART) 的預防方法，例如廣泛地檢測、治療和暴露前預防 (PrEP)，以及性健康和生殖健康服務，可以作為識別性活躍青少年和有感染愛滋病毒風險之年輕人的一種手段，進而降低經由性傳染愛滋病毒的盛行率。

這項研究對南非誇祖魯-納塔爾省uMkhanyakude 農村地區的3,000 名青少年和年輕人（16-29 歲）進行了抽樣調查，並將其中的1,743 名抽樣個體分為四個隨機分配的組。每個研究小組透過不同的方法提供愛滋病毒預防服務：透過流動診所提供標準照護；同儕支持；自我收集的性傳播感染檢測以及性健康和生殖健康服務；或自行收集的性傳播感染檢測以及性健康和生殖健康服務和同儕支持。研究人員追蹤了與愛滋病毒預防服務的連結聯繫（註冊後 60 天內）以及經由性行為感染HIV的盛行情況（註冊後 12 個月內）。

作者發現，與接受過性健康和生殖健康服務的個人相比，接受過性健康和生殖健康服務的個人更有可能獲得風險差異化的愛滋病毒預防服務（即避孕套、檢測結果呈陽性時啟動ART 的愛滋病毒檢測服務以及檢測結果呈陰性時的PrEP 服務）。同時接受性健康和生殖健康服務以及同儕支持的個人其照護存留率最高。然而，僅靠同儕支持並不能改善與愛滋病毒預防服務的連結。 Shahmanesh 和同事指出，這項研究的時間安排在 COVID-19 大流行期間，迫使同儕支持以虛擬方式進行，因此可能會最大限度地減少了同儕指導的影響。結果還顯示，不論是性健康和生殖健康服務抑或是同儕支持都無法降低經由性傳播愛滋病毒的盛行率。

在南非，針對沙眼衣原體和淋病奈瑟菌的一站式 STI 檢測照護，其作為產前照護的一項功能，改善了孕婦之PrEP 的啟動。同儕指導是肯亞青少年和年輕女性參與 PrEP 和堅持存留於計畫中的有用工具，也是在尚比亞改善孕婦愛滋病毒預防和照護存留的一種經濟有效的方法。

在愛滋病毒高負擔國家，其他的性傳播感染的預防和診斷經常會被遺忘，而依據症狀的方法來診斷和治療性傳播感染也很常見。在這裡，Shahmanesh 及其同事有力地表明，除了提高性傳播感染診斷的準確性和適當地治療之外，擴大性健康和生殖健康服務，也可以作為有效識別和聯繫個人至愛滋病毒預防策略的一種手段，特別是青少年和年輕人等優先群體。在診斷和適當治療之外，擴大性傳播感染的範圍也很重要 。這種整合的服務更應優先考慮要快速地實施，未來的工作則應著重於優化整合的擴增規模之策略上。

我們聲明不存在競爭利益。

Megan A Hansen, *Brooke E Nichols   brooke.nichols@finddx.org

阿姆斯特丹大學全球健康與發展研究所全球健康系

Integration of sexual health and HIV services

www.thelancet.com/hiv Vol 11 July 2024

There is a general call to integrate sexually transmitted infection (STI) services into HIV prevention and treatment programmes to improve efficiency and quality of care.1 Given the high rate of co-infection of STIs and HIV, and the biologically increased susceptibility of HIV acquisition among people who currently have STIs, the absence of integration of STI services with HIV testing and prevention services is increasingly recognised as a significant missed opportunity.

UNAIDS data indicate that, in 2022, South Africa had 160000 incident HIV infections, of which approximately a third were among adolescent girls and young women. Adolescent girls and young women, in particular, have some of the highest incidence rates of STIs in South Africa, ranging from ten to 30 infections per 100 person-years.  These data suggest the potential effect that integration of HIV prevention services into STI services might have in reducing HIV incidence in susceptible populations such as adolescents and young adults.

In this issue of The Lancet HIV, Maryam Shahmanesh and colleagues report on results of their open-label 2 × 2 randomised factorial trial, Isisekelo Sempilo, evaluating the effectiveness of integrating sexual and reproductive health services with peer support on increasing uptake of biomedical HIV prevention and decreasing transmissible HIV among young people living in South Africa. The authors hypothesised that offering risk-differentiated antiretroviral (ART)-based prevention methods, such as universal test-and-treat and pre-exposure prophylaxis (PrEP), with sexual and reproductive health services could serve as a means to identify sexually active adolescents and young adults who are risk of becoming infected with HIV, and thereby reduce prevalence of sexually transmissible HIV.

This study sampled 3000 adolescents and young adults (aged 16–29 years) in the rural district of uMkhanyakude, KwaZulu-Natal, South Africa, and enrolled 1743 of the sampled individuals into four randomly assigned groups. Each study group offered HIV prevention services through different methods: standard of care with access to mobile clinics; self-collected STI testing with sexual and reproductive health services; peer support; or self-collected STI testing and sexual and reproductive health services and support. The researchers tracked linkage to HIV prevention services (within 60 days of enrolment) and prevalence of sexually transmissible HIV (12 months after enrolment).

The authors found that individuals who were offered sexual and reproductive health services were more likely to access risk-differentiated HIV prevention services (ie, condoms, HIV testing services with ART initiation accompanying a positive test result, and PrEP for negative test results) compared with those who were not. Individuals who received both sexual and reproductive health services and peer support had the highest retention in care. However, peer support alone did not have any effect on improving linkage to HIV prevention services. Shahmanesh and colleagues note that the timing of this study during the COVID-19 pandemic forced peer support to be conducted virtually, and therefore might have potentially minimised the effect of mentorship. The results also showed that neither sexual and reproductive health services nor peer support reduced prevalence of sexually transmissible HIV.

Point-of-care STI testing for Chlamydia trachomatis and Neisseria gonorrhea improved PrEP initiation in pregnant women as a function of antenatal care in in South Africa. Peer mentorship is a useful tool for PrEP enrolment and adherence among adolescents and young women in Kenya, and serves as a cost-effective method to improve HIV prevention and care retention among pregnant women in Zambia. Although evaluated in different settings, these studies each offer support for the authors’ hypothesis that the COVID-19 pandemic might have diminished the potential effectiveness of virtual peer support.

In countries with high burdens of HIV, prevention and diagnosis of other STIs are often forgotten and syndromic approaches to diagnosing and treating STIs are common. Here, Shahmanesh and colleagues robustly show that beyond improving accurate diagnosis and appropriate treatment of STIs, expansion of sexual and reproductive health services can also be used as a means to effectively identify and link individuals, particularly priority groups such as adolescents and young adults, to HIV prevention strategies. This integration of services should be prioritised for rapid implementation, and future work should focus on optimising integrated scale-up strategies.

We declare no competing interests.

Megan A Hansen, *Brooke E Nichols brooke.nichols@finddx.org

Department of Global Health, Amsterdam Institute for Global Health and Development, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands (MAH, BEN); FIND, Geneva 1218, Switzerland (BEN)