愛滋病毒感染者的老化
資料來源：http://www.thelancet.com/healthy-longevity / 2022 年 3 月 3 日；財團法人台灣紅絲帶基金會編譯
抗反轉錄病毒療法 (ART) 的功效和全球治療計畫的成功意味著，只要個人能夠獲得照護，HIV 感染就不再是致命的感染。 然而，伴隨這一成功而來的是意想不到的後果：越來越多的老年人感染愛滋病毒（通常定義為 50 歲或以上）。 這一人口正在增加，因為感染愛滋病毒的年輕人正在存活和老齡化，而且越來越多的老年人正在感染愛滋病毒。 因此，50 歲及以上人群的盛行率和新發感染率的增長速度高於整體人口； 例如，在美國，2015 年至 2019 年期間，HIV 感染者的總體盛行率增加了 8%，發生率下降了 4%，而在 50 歲及以上的人群中，盛行率增加了 40%，發生率增加了 15% 。 UNAIDS 估計，全球 50 歲或以上感染 HIV 的人數從 2015 年的 540 百萬增加到 2020 年的 810 萬。本期我們與 The Lancet HIV 聯合發布了關於老齡化與愛滋病毒挑戰的系列文章。 我們討論了四個重要主題：老年愛滋病毒感染者高多重疾病負擔背後的老年科學； 恥辱感與健康相關生活品質的交叉性； 延遲的 HIV 表現； 以及衛生系統如何適應感染愛滋病毒和合併症的人口老齡化。 我們希望與刺胳針愛滋病毒與健康地長壽峰會（2022 年 3 月 17 日至 18 日，線上）一起討論的這個系列將激發老年病學家、老年科學家、傳染病專家以及愛滋病毒感染者和衰老者之間的辯論。
老年愛滋病毒感染者面臨著獨特的挑戰。 包括醫療保健專業人員在內的社會普遍認為老年人感染新的愛滋病毒的風險較小。 由於社會假定老年人不是性活躍者或吸毒者，因此在獲取保護性健康信息和早期 HIV 檢測方面存在障礙。 因此，將近一半感染 HIV 的老年人在病程晚期才被診斷出來（定義為 CD4 細胞計數 < 350 個細胞/µL，或愛滋病定義事件之出現）。 在他們的系列論文中，Amy Justice 及其同事使用國際流行病學數據庫評估愛滋病 (the International epidemiology Databases to Evaluate AIDS , IeDEA) 全球聯盟的數據來確定與老年人 HIV 晚期表現相關的因素。
老年人比年輕人更有可能患有多種合併症（multimorbidity）。 然而，與沒有感染愛滋病毒的同齡人相比，感染愛滋病毒的老年人也有更高水平的共病。 在了解 HIV 如何影響衰老過程方面存在相當大的研究差距。 在他們的論文中，Monty Montano 及其同事從老年科學的角度研究了 HIV 的生物衰老，以檢查衰老的主要標誌是否可能與 HIV 感染協同作用，成為 HIV 感染者的老化驅動因素 (gerodrivers)。 除了更高水準的多種疾病外，感染 HIV 的老年人還面臨污名化。 在他們的論文中，Evelyn Hsieh 及其同事討論了老年 HIV 感染者如何面臨年齡相關和 HIV 相關恥辱的交集，這對他們與健康相關的生活品質產生了創傷性影響。 作者回顧了這些恥辱在中國、歐洲和拉丁美洲的交叉性，它們在老齡化和 HIV 發生率方面具有明顯的流行病學和文化趨勢，並發現證據不足和框架使用不一致，特別是在拉丁美洲，這可能會阻礙提供照顧和適當的政策和研究。
最後，全球的醫療保健系統無法滿足不斷增長的感染愛滋病毒的老年人口的需求。 醫療保健系統為感染愛滋病毒的老年人提供零散的照護，由於缺乏綜合老齡化和愛滋病毒相關服務和支持系統，情況更加惡化。在他們的論文中，Jepchirchir Kiplagat 及其同事提出了如何透過因應的全民健康覆蓋方法來改善醫療保健。
即使是一個實現聯合國愛滋病規劃署 95-95-95 目標的理想世界，也將繼續有越來越多的老年人需要適當的照護。 因此，可以說需要一個新的研究領域來了解在抗反轉錄病毒治療 (ART) 抑制下的 HIV 慢性感染如何與衰老過程相互作用——以及這種理解是否可以讓我們了解基本的衰老機制。 這項研究的必要性是 ART 成功的結果：我們必須繼續在這一成功的基礎上再接再厲，以確保感染 HIV 的老齡化值得慶祝，而不是哀悼。 ■ 刺胳針健康地長壽
Ageing with HIV
http://www.thelancet.com/healthy-longevity / Vol 3 March 2022
The efficacy of antiretroviral therapy (ART) and the success of global treatment programmes has meant that, provided individuals have access to care, HIV infection is no longer a life-limiting infection. However, with this success comes unexpected consequences: a growing population of older people with HIV (normally defined as those aged 50 years or older). This population is increasing because young people with HIV are surviving and ageing, and an increasing number of older people are acquiring HIV. Consequently, prevalence and incident infections in people aged 50 years and older are increasing at a faster rate than in the population as a whole; for example, in the USA, between 2015 and 2019, the overall prevalence of people with HIV infection increased by 8% and incident infections decreased by 4%, whereas in people aged 50 years and older, prevalence increased by 40% and incidence by 15%. UNAIDS estimates that the number of people aged 50 years or older with HIV infection globally increased from 5·4 million in 2015 to 8·1 million in 2020. In this issue, we publish a joint Series with The Lancet HIV on the challenges of ageing well with HIV. We address four important topics: the geroscience underlying the high multimorbidity burden in older people with HIV; intersectionality of stigma and health-related quality of life; delayed HIV presentation; and how health systems can adapt to a population ageing with HIV and comorbidities. We hope this Series, discussed alongside The Lancet Summit on HIV and Healthy Longevity (March 17–18, 2022, virtual), will stimulate debate between geriatricians, geroscientists, infectious disease specialists, and those living and ageing with HIV.
Older people with HIV face unique challenges. Older people are widely perceived by society, including by health-care professionals, to be less at risk of contracting new HIV infections. Because society assumes that older people are not sexually active or drug users, there are barriers to access to protective health information and early HIV testing. Consequently, nearly half of older adults with HIV are diagnosed late in the course of their disease (defined as having CD4 cell counts < 350 cells per µL, or an AIDS-defining event). In their Series paper, Amy Justice and colleagues use data from the International epidemiology Databases to Evaluate AIDS (IeDEA) global consortium to identify the factors associated with late HIV presentation in older adults.
Older people are more likely than younger people to have multiple comorbid conditions (multimorbidity). However, older people with HIV also have higher levels of multimorbidity compared with people of similar age without HIV. There is a considerable research gap in understanding how HIV affects the ageing process. In their paper, Monty Montano and colleagues examine biological ageing with HIV from a geroscience perspective to examine whether the major hallmarks of ageing might act synergistically with an HIV infection to become gerodrivers in people with HIV. In addition to higher levels of multimorbidity, older adults with HIV also face stigmatisation. In their paper, Evelyn Hsieh and colleagues discuss how people ageing with HIV face an intersection of age-related and HIV-related stigma, which has a traumatic impact on their health-related quality of life. The authors reviewed intersectionality of these stigmas in China, Europe, and Latin America, which have distinct epidemiological and cultural trends in ageing and HIV incidence, and found a paucity of evidence and inconsistent use of frameworks, especially in Latin America, which might impede provision of care and appropriate policy and research.
Finally, health-care systems globally are not equipped to meet the needs of the growing population of older people with HIV. Health-care systems provide fragmented care to older people with HIV, worsened by the lack of integrated ageing and HIV-related service and support systems. In their paper, Jepchirchir Kiplagat and colleagues propose how health care could be improved through a responsive universal health coverage approach.
Even an ideal world that achieves the UNAIDS 95-95-95 goal will continue to have a growing population of older people who will need appropriate care. As such, there is arguably a need for a new research area to understand how chronic but ART-suppressed HIV infection interacts with the ageing process—and if this understanding can inform our knowledge of basic ageing mechanisms. The need for this research is the result of the success of ART: we must continue to build on that success to ensure that ageing with HIV is something to be celebrated, not mourned. ■ The Lancet Healthy Longevity