[外文專譯] 愛滋防治上的十項迷思
(資料來源：國際HIV/AIDS聯盟)
本文由財團法人台灣紅絲帶基金會編譯，若有引用，請註明出處，商用行為請於本會聯絡。
彼得•皮奧特，前聯合國愛滋病規劃署主任，現任倫敦熱帶醫學與衛生學院的主任及教授，是國際HIV/AIDS聯盟成立20週年紀念大會第二天的主講人。
在向該聯盟相關的團體、捐助者和其他合作夥伴等聽眾演講時，皮奧特也在祝賀聯盟週年之際，強調聯盟過去著力的三個主要方法，在愛滋疫情上已經造成了明顯區別，分別為：於全球宣導倡議上的影響，在某些關鍵工作上的努力所造成極大的影響(如愛滋傳播)，以及於民間社會強化地方能力上的工作等。
他警告-「提起風險聽起來好像有點陳詞濫調」-愛滋防治工作正處於一個關鍵路口上。他承認在新科技發展下的樂觀情緒，但也敦促謹慎行事。圍繞在「愛滋病的終結」之論調，可以被翻轉成之「愛滋防治運動的終結」。他說， “如果我們現在誤事，我們可能會得到無法中斷此一流行病的結果。 ”
他在上週的演講話中概述了，他所認為今日圍繞著愛滋病對應上的危險“迷思” 。
10項走向集體否定狀態的迷思
1、終點就在眼前，隨著情勢變化愛滋病即將結束。
“我希望它是真實的，它應該是我們的目標。我不是說情勢並無進展，但人們的行為和社會並非數學模型且無法預測；讓我們不要說愛滋病已經結束，有一天，我們將會抵達那裡，但目前卻還沒有！ “
2、我們所需要的是達成抗病毒藥劑的更佳涵蓋率，這將消滅疫情。
“如果我們學會了一件事情，那就是並沒有神奇子彈或靈丹妙藥。目前確實已經有研究（如HPTN052研究顯示抗病毒藥劑已可以防止愛滋病毒的傳播），但從這些結果到落實在社會面的實現上，卻仍究需要巨大的飛躍以跨越鴻溝，目前也仍未有證據支持此種結果。＂
3、行為介入措施起不了作用，我們只能依靠生物醫學上的預防。
“我們必須記住的是，即使治療也是種行為介入，尤其更高度重視治療順從性。我們應該記住，例如暴露前預防性投藥( PrEP ) ，也只有當你把藥服下時才有效！＂
4、我們不再需要有不同及區別性的愛滋防治方案，整合就是答案！
“有人說，我們需要的是由意識形態所驅動或健康理論所支持下之衛生系統的強化。雖然有些領域整合是有益且符合成本效益的，如母子垂直感染阻斷計畫( PMTCT ) 以防治愛滋之傳播 ；但我們仍必須知道那些是可以整合的？而那些卻是不行。特別當標籤和歧視同時仍是此流行病的一個標誌時。＂
5、疫情已呈現下降的軌跡 –讓我們持續進行我們現所做的，它會消滅愛滋病毒。
“確實呈現向下趨勢，但並不是隨處可見。在許多不同地方愛滋的流行有它自己的動力學，而這些疫情需要單獨地和適當地被處理。＂
6、標籤和歧視已經消失了，現在我們有了抗病毒藥劑，可以透過其他別種方法來處理，將人權促進作為愛滋防治工作的一部份是不必要的奢侈。
“雖然很多人都希望，引入有效的治療就意味著「愛滋病的正常化」，但絕對沒有證據顯示已達此種情況。無論你走到哪裡，你仍然到處可以看到標籤和歧視對愛滋防治結果的破壞性影響。＂
7、不再需要有民間社會參與，醫生將為您解決這個問題。
“雖然在目前情況上有部份成理，但其實也是一種醫療的傲慢。”
8、國內的資金現在將能涵蓋得了工作應對上的所有必要費用。
“一些國家，絕對可以負擔得起這樣做 – 印度，南非 – 但大多數國家並不能。甚至大多數國家不會優先考慮健康消費，所以你不能指望在一個已取消優先順序的更大的競爭範圍內，愛滋能被優先考慮。現實的情況是，許多國家多年來他們對愛滋的防治工作，仍將取決於國際資金對其的援助。＂
9、以目前的資金我們不能做的更好，而管理和計畫上的效率是不必要的商業經營理念。
“我們可以用現有的資金做的更好。特別是，錢用在刀口上，我們需要集中我們的資源於疾病流行之所在- 然後採用通常可節約成本的辦法。＂
10、沒有必要繼續去投資疫苗！
“要終結愛滋沒有疫苗將根本是不可能的！”
仍有許多山峰等待我們去攀登
皮奧特引述已故前南非總統納爾遜•曼德拉的話：當我們攀登完一座大山之後，人們常發現仍有許多山峰等待著去克服”。
他承認，雖然在過去30年中我們已經達成許多成就，但他也說道 “我們也不要欺騙自己：前面仍有無數巨大的山峰仍等待著我們去克服”。
仔細考量未來漫漫長路
他強烈要求愛滋行動家們對愛滋的反應仍應採取主動攻勢，要提醒大家的是， “每一天，人們仍然不斷地在死亡。”他呼籲復興早年由激進主義所主導的情勢。他想要知道“「憤怒在哪裡？」，而不僅是在不同顧客彼此間之戰鬥，而是協議共同合作以提供協調一致的領導而邁向前進。
皮奧特呼籲所有行動者在愛滋病防治工作上採取綜合性措施，並專注於高傳播地區和確保重點人群不致於掉隊。他更呼籲在下列三個方面上要有更大的改革創新：
•在執行面上，應包涵對愛滋感染者長期照護的準備，他並警告“在今日已被確診為愛滋病感染者的年輕人，在本世紀結束時仍然會與愛滋病毒長存＂。
•在財務融資上，指向一個事實，在應對目前疫情上它仍需數十億美完，儘管全球基金在其最後一輪增資上確保了120億元美金，但這僅足以提供維持未來三年之所需。
•在全球的物資上，應包涵藥物。
總之，他說，我們的目標不應只是在疫苗發展出來前，把這個疫情降至感染人數最少和死亡降至最低的可能水平，而是要在與其他健康問題整合上，發揮其催化促進之角色。
最後，他說： “我怕在後續許多年的未來，仍將需要本聯盟來持續偉大的工作，永不放棄。＂
10 myths about the AIDS response
International HIV/AIDS Alliance/ Together to end AIDS 17, Feb, 2014 by Peter Piot
Peter Piot, ex-UNAIDS director and now director and professor at the London School of Hygiene and Tropical Medicine, was a keynote speaker on day two of a convention organised by the Alliance to mark its 20th anniversary.
Speaking to an audience of Alliance Linking Organisations, donors and other partners, Piot congratulated the Alliance on its anniversary, calling out three major ways it has made a difference to the AIDS epidemic: the impact of its global advocacy, its efforts to work in the areas where it can make the greatest impact (in terms of HIV transmission) and its work to strengthen the local capacity of civil society.
He warned – at the risk of sounding a bit clichéd – the AIDS response is at a critical junction. He acknowledged the optimism around new scientific developments but urged caution that the rhetoric around ‘the end of AIDS’ could translate into ‘the end of the AIDS movement’. He said, “If we drop the ball now, we may get to a situation where we can’t break the epidemic.”
In his speech at the event last week, he went on to outline what he sees as the dangerous ‘myths’ around the AIDS response today.
10 myths towards a collective state of denial
1. The end is in sight, with a variation that AIDS is over.
“I wish it were true, and it should be our goal. I am not saying there hasn’t been progress but people’s behaviour and societies are not mathematical models and cannot be predicted. Let’s stop saying AIDS is over. One day, we will be there, but not yet!”
2. All we need is better coverage of ART, which will wipe out the epidemic.
“If we have learned one thing, there is no magic bullet. Yes, there have been studies (such as HPTN052 which showed that ART can prevent HIV transmission) but it is a gigantic leap from these results to the reality of the community and is simply not yet supported by evidence.”
3. Behavioural interventions don’t work, we can only rely on biomedical prevention
“What we have to remember is that even treatment is a behavioural intervention with its strong emphasis on compliance. We should remember that for example PrEP only works when you take it!’”
4. There is no longer a need for distinct HIV programmes, integration is the answer!
“Some say all we need is health system strengthening which is ideologically driven, or supported by academic health theories. Whilst there are areas where integration will be beneficial and cost effective, such as PMTCT, we have to know what we can integrate and what not. Particularly whilst stigma and discrimination remain a hallmark of this epidemic.”
5. The epidemic is on a downward trajectory – let’s continue doing what we are doing and it will wipe out HIV
“Downward yes, but not everywhere. There are many different epidemics with their own dynamics, and these need to be dealt with individually and appropriately.”
6. Stigma and discrimination has disappeared now we have ART, and the promotion of human rights as part of the AIDS response is an unnecessary luxury which can be handled by others
“Whilst many hoped that the introduction of effective treatment would mean ‘normalisation of AIDS, there is absolutely no evidence that this is the case. Everywhere you go you can still see the devastating impact of stigma and discrimination as a result of HIV.”
7. There is no longer a need for civil society, physicians will fix this for you
“Whilst this position may have some rational ground, some of it is also medical hubris.”
8. Domestic funding will now cover all necessary costs of the response
“Some countries can definitely afford to do this – India, South Africa – but most can’t. And most won’t even prioritise health spending, so you can’t expect HIV to be prioritised within a bigger context of de-prioritisation. The reality is that many countries for many years will depend on international funding for their AIDS response”.
9. We cannot do better with current funding, and managerial and programmatic efficiency are unnecessary business concepts
“We CAN do better with available funding. In particular, we need to concentrate our resources on where the epidemics are – and then apply the usual cost-saving approaches.”
10. There is no need to continue investing in a vaccine
“Ending HIV without a vaccine will simply not be possible.”
More hills to climb
Piot quoted the late Nelson Mandela:
“After climbing a great hill, one only finds out that there are many more hills to climb”.
He acknowledged that whilst much has been achieved in the last 30 years, but said “let us not fool ourselves: the hills to overcome are huge and numerous.”
Reflecting on the way forward
Piot urged all actors in the AIDS response to go on the offensive, reminding everyone that “every day, people are still dying.” He called for a renaissance in the activism that dominated the early years. He wanted to know ‘where is the anger?’ and not just the in-fighting between different constituencies, but the agreement to work together and provide concerted leadership to move forward.
He called for a combination prevention approach, with a focus on high transmission geographies and ensuring that key populations are not left behind.
He called for greater innovation in three areas:
• In implementation, including preparing for the long term care of people living with HIV, warning “the young person who has been diagnosed with HIV today will still be living with HIV at the end of this century”.
• In financing, pointing to the fact that it is billions that are still needed to tackle the epidemic, and even though the Global Fund secured $12 billion in its last replenishment round, this is only sufficient to last for the next three years.
• In global goods, including medicines.
In summary, he said that our ambition should not only be to bring this epidemic down to the lowest levels possible in terms of reducing the number of people infected and dying until there is a vaccine, but also to play a catalytic role in convergence and other health issues.
In closing, he said “I am afraid the Alliance will remain necessary for many years to come. Keep up the great work and never give up.”