性別肯定的愛滋病毒照護是結束愛滋病毒流行的工具
資料來源：www.thelancet.com/hiv Vol 10 June 2023
在推進愛滋病毒預防和照護去終結流行上，跨性別女性在全球範圍內的愛滋病毒感染承擔著不成比例負擔及作出了重大貢獻。然而，很少有研究涉及跨性別調查員或有足夠的樣本量和適合跨性別女性的措施，這對於生成特定人群的推論並為跨性別女性制定愛滋病毒策略均極為需要。 Allanise Cloete 及其同事報告了南非首次專門針對跨性別女性的生物行為調查之一的愛滋病毒盛行率和愛滋病毒照護指標。這項研究補充了越來越多的全球證據，顯示專門針對跨性別女性的嚴格研究可以且應該去執行。
Cloete 及其同事採用受訪者驅動抽樣 (respondent-driven sampling, RDS) 來接觸並招募南非三個大都市區的880 多名性活躍的跨性別女性。RDS 方法具有雙重好處，即利用社交網路和社區信任對不存在抽樣框架的人群進行抽樣，並提供近似基於人群的盛行率估計的統計方法。儘管 RDS 的好處已有充分記錄，但它並不總是能成功地應用於接觸跨性別女性。 相反，跨性別女性成功參與這項研究可能歸因於嚴格的研究方法與社區參與的實施策略之結合（即跨性別學者、領導者和跨性別領導的組織在所有研究階段的共同參與）。以這些合作夥伴的科學和社區專業知識為基礎，社區參與的研究增強了社區關注的科學研究問題； 確保研究過程和介入措施在個人、社會和結構層面上都是性別平等的； 支持道德義務以保護和服務研究參與者及其社區； 促進研究成果的有意義傳播，為跨性別者的計畫和政策提供信息。 值得注意的是，它可以開始消除歷史上愛滋病毒不平等現象，這些不平等現象削弱了跨性別群體的權能，並在跨性別群體中產生了研究的不信任。
廣泛地，這項研究以及南非的背景提供了跨性別者人權與其健康結果之間交會的例子，可以利用這些交會來實現愛滋病規劃署在整個愛滋病毒照護過程中的目標，但它們也強調了相應的挑戰。 南非以肯定和歡迎跨性別者和其他性少數群體而聞名：人們有合法權利將文件與自己的性別相一致，立法禁止基於性別的歧視，最近設立了性別肯定診所，該國一直是來自鄰國的 LGBT 族群的避難所，並且已是第一個也是唯一制定國家LGBTI 愛滋病毒策略計畫的國家， 該計畫由社區、學術界和政府合作制定，旨在確保實現人類權利和獲得健康的機會以及應對愛滋病毒的努力。
儘管有這些保護性政策和有利環境，但仍需要做大量工作來確保在整個愛滋病毒照護過程中實現高質量的性別肯定服務，並支持實現聯合國愛滋病規劃署的目標。 例如，儘管南非的九個地區設立了性別肯定診所，但該國大部分地區仍然無法獲得性別肯定服務。此外，跨性別者的暴力受害率仍然以驚人的速度增長。在這項研究中， 15-25% 的跨性別女性報告稱遭受了出於偏見的暴力侵害， 這與其他科學和公開報告一致，即南非乃至全球範圍內針對跨性別女性的暴力行為頻繁，有時甚至是致命的。愛滋病毒盛行率以及對感染、治療和病毒抑制的認識較低，會因種族和地理環境而異，可能反映了種族隔離和殖民主義的歷史遺害，正如類似的差異反映了其他國家奴隸制和種族主義的遺害一樣。 事實證明，解決此類壓迫制度的殘餘影響與愛滋病毒介入措施相結合，可能有助於減少該群體的愛滋病毒不平等現象。
許多支持跨性別女性健康（包括愛滋病毒預防和照護）和福祉之可行的解決方案是存在的。在 愛滋病毒研究和計畫的整個過程中能夠性別確認並採用交會的方法是關鍵。基於證據和反歧視的政策之發展，以及促進健康權和實現權利均同樣地至關重要——有害的法律和最近許多國際環境下的法案都存在著逆轉終結愛滋病毒流行方面上任何潛在進展的真正風險。投資於多層次、綜合的方法上，包括高質量的性別肯定服務、關鍵的衛生服務如初級照護、精神衛生保健，預防或減輕暴力和愛滋病毒並存影響的服務，可能會最有效地影響跨性別女性的愛滋病毒結果。此外，投資培訓跨性別女性作為各級公共衛生和整體研究和計畫的關鍵人員和調查員，可以為未來社區驅動的終結愛滋病毒流行之變革性介入措施開闢道路。
ALW 得到了國家過敏和傳染病研究所、國家心理健康研究所以及美國國家衛生研究院國家兒童健康和人類發展研究所的支持，獎金編號為 UG3/UH3AI133669，並宣布由 ViiV Healthcare 提供資助，在提交的作品之外。 AR 聲明不存在競爭利益。
*Andrea L Wirtz，Arjee Restar awirtz@jhsph.edu
華盛頓大學流行病學、衛生系統和人口健康系，美國華盛頓州西雅圖（阿肯色州）； 耶魯大學公共衛生學院行為與社會科學系，美國康涅狄格州紐黑文（阿肯色州）； 約翰·霍普金斯大學彭博公共衛生學院流行病學系 (ALW) 和國際衛生系 (ALW) 公共衛生和人權中心，巴爾的摩，MD 21205，美國
Gender-affirming HIV care as a tool to end the HIV epidemic
www.thelancet.com/hiv Vol 10 June 2023
Transgender (trans) women have borne a disproportionate burden of HIV infection globally and have contributed substantially to advancing HIV prevention and care to end the epidemic. Yet, few studies involve trans investigators or have sufficient sample sizes and measures appropriate for trans women, which are needed to generate population specific inferences and to inform HIV strategies for trans women. Allanise Cloete and colleagues report HIV prevalence and HIV care indicators from one of the first biobehavioral surveys exclusively for trans women in South Africa. This research adds to a growing body of global evidence that shows that rigorous research exclusively for trans women can and should be done.
Cloete and colleagues employed respondent-driven sampling (RDS) to reach and recruit over 880 sexually active trans women in three metropolitan areas of South Africa. RDS methodology has a dual benefit of leveraging social networks and community trust to sample populations for whom no sampling frame exists and providing statistical methods that approximate population-based prevalence estimates. Although the benefits of RDS are well documented, it has not always been applied successfully in reaching trans women. Rather, the successful engagement of trans women in this research is likely attributed to the coupling of rigorous research methods with a community-engaged implementation strategy (ie, the joint involvement of trans scholars, leaders, and trans-led organisations in all study phases).7 Building on the scientific and community expertise of these partners, community engaged research enhances scientific research questions are salient to communities; ensures that the research processes and the interventions are gender-affirmative across personal, social, and structural levels; supports the ethical obligations to protect and serve research participants and their communities; and facilitates meaningful dissemination of research findings to inform programmes and policies for trans people. Of note, it can begin to dismantle historical HIV inequities that have disempowered and produced research mistrust among trans communities.
This study and, broadly, the context in South Africa provide an example of the intersections between human rights and health outcomes for trans people that can be leveraged to achieve UNAIDS goals across of HIV care continuum, but they also highlight corresponding challenges. South Africa has a reputation for being affirming and welcoming to trans and other sexualminority populations: there is a legal right to align documents with one’s gender, legislation prohibiting gender-based discrimination, gender-affirming clinics have recently been established, and the country has served as a refuge for LGBT people from neighboring nations. South Africa is the first and only country to have developed a National Strategic LGBTI HIV Plan, which was developed by community, academic, and government partnerships to ensure the realisation of human rights and access to health alongside efforts to address HIV.
Despite these protective policies and enabling environments, much work is needed to ensure high quality gender-affirming services across the HIV care continuum are achieved and support the realisation of UNAIDS’ targets. For instance, although gender-affirming clinics have been established in nine districts in South Africa, most of the country still does not have access to gender-affirming services. Further, violent victimisation of trans people continues at alarming rates. In this study, 15–25% of trans women reported bias-motivated violence victimisation, which mirrors other scientific and public reports of frequent and sometimes fatal forms of violence against trans women within South Africa as well as globally. Moreover, the high HIV prevalence and low awareness of infection, treatment, and viral suppression that are different by race and geographic setting probably reflect historical legacies of apartheid and colonisation, just as similar disparities reflect the legacy of slavery and racism in other countries. Addressing the residual impacts of such systems of oppression in tandem with HIV interventions could prove beneficial to reducing HIV inequities for this group.
Several actionable solutions that support health (inclusive of HIV prevention and care) and wellbeing of trans women exist. HIV research and programmes that are gender-affirming across processes and use intersectional approaches are key. Development of policies that are evidence-based and antidiscriminatory and that promote the right to health and realisation of rights is likewise essential—harmful laws and recent bills in many international settings present a real risk of reversing any potential advances in ending the HIV epidemic. Investments in multilevel, combination approaches that include high-quality gender-affirming services, critical health services like primary care, mental health care, and services that prevent or mitigate effects of violence alongside HIV will likely be most effective in impacting HIV outcomes among trans women. Furthermore, investing in the training of trans women as key personnel and investigators throughout all levels of public health research and programmes could open pathways to transformative future community-driven interventions to end the HIV epidemic.
ALW is supported by National Institute of Allergy and Infectious Diseases, the National Institute of Mental Health, and the National Institute of Child Health and Human Development of the National Institutes of Health, under award number UG3/UH3AI133669, and declares grant funding from ViiV Healthcare, outside the submitted work. AR declares no competing interests.
*Andrea L Wirtz, Arjee Restar awirtz@jhsph.edu
Departments of Epidemiology, and Health Systems and Population Health, University of Washington, Seattle, WA, USA (AR); Department of Behavioral and Social Sciences, Yale University School of Public Health, New Haven, CT, USA (AR); Center for Public Health and Human Rights, Department of Epidemiology (ALW) and Department of International Health (ALW), Johns Hopkins Bloomberg School of Public Health, Baltimore, MD 21205, USA