效益和差距：解決不同性工作者群體中的愛滋病毒問題

在過去四十年的愛滋病毒大流行中，不同群體的性工作者在不同環境中受到了不成比例的影響。社會和結構性因素，包括性工作刑事定罪、經濟不安全以及交叉污名、歧視和暴力，被認為是關鍵因素。儘管社區驅動的綜合預防介入措施在減少性工作者新發愛滋病毒感染和改善性工作者愛滋病毒照護和治療結果方面顯示出希望，但擴大這些努力規模的投資卻滯後遠遠落後於歷史和現實上的需要。

有效倡導增加愛滋病毒相關服務的資源分配以及促進性工作者的整體健康和人權受到數據差距的嚴重影響。公共衛生領域能否適當應對性工作者中愛滋病毒感染和治療結果的不平等問題，部分取決於對流行病學趨勢的及時監測。然而，有關不同性工作者群體的新愛滋病毒感染頻率和愛滋病毒照護連續數據的數據很少，特別是在資源有限的環境中。《刺胳針愛滋病毒》上發表的兩篇論文重點關注辛巴威性工作者中的愛滋病毒，有助於縮小這些數據差距。

Harriet Jones 及其同事報告了性工作者中愛滋病毒血清轉化的時間趨勢和危險因素。他們根據來自辛巴威 6,665 名主要是順性別女性性工作者的常規愛滋病毒服務使用數據，對一種創新且具有成本效益的愛滋病毒發生率趨勢估計方法進行了重要分析。 數據來自於性工作者，她們透過「姐妹之聲」國家社區愛滋病毒預防計畫在 10 年來反復進行了愛滋病毒檢測。 瓊斯及其同事的分析顯示，隨著時間的推移，參與國家計畫的性工作者的愛滋病毒發生率呈下降趨勢。然而，他們也認識到將性工作者與全面的愛滋病毒預防服務聯繫起來、維持性工作者從第一次接觸開始就參與服務以及確保愛滋病毒計畫惠及年輕性工作者（<25 歲）和有性傳播感染史的人的重要性——這些血清轉化風險顯著增加的群體。

瓊斯及其同事為使用服務提供數據來估計資源有限環境中的愛滋病毒發生率上提供了強有力的理由，但他們也指出了這種方法的一些局限性。例如，調查結果和趨勢不能推廣到國家計畫中失去後續追蹤的女性性工作者，瓊斯及其同事無法根據現有數據準確地估計愛滋病毒血清轉化的時間。

儘管越來越多由社區驅動的愛滋病毒綜合預防介入措施已被證明可以顯著減少順性別女性性工作者（包括撒哈拉以南非洲地區）的新愛滋病毒感染數量，但針對跨性別性工作者和順性別男性性工作者的有效愛滋病毒預防介入措施的數據非常稀缺。 儘管越來越多的流行病學數據顯示該地區這些性工作者亞群體存在嚴重的愛滋病毒不平等現象，但在撒哈拉以南非洲地區，幾乎沒有為這些關鍵人群建立經過驗證的愛滋病毒預防模型。

Mariëlle Kloek 及其同事報告了辛巴威 1,003 名賣淫的順性別男性、跨性別女性和跨性別男性的愛滋病毒盛行率、危險行為以及治療和預防級聯結果。這些數據雖然受到與研究橫斷面設計相關的時間偏差的限制，但提供了關於社會和結構因素對愛滋病毒高感染率的顯著性的重要信息（範圍從順性別男性性工作者的26·2 % 到跨性別女性性工作者中的39·4%）、服務提供方面的差距（多達三分之一的參與者不知道自己的愛滋病毒感染狀況）以及愛滋病毒照護和治療的使用率極低（研究人群中11·9–15·7% 罹患有愛滋病毒的參與者正在接受抗反轉錄病毒治療）。 Kloek 及其同事的分析強調了將順性別女性性工作者的愛滋病毒預防和照護效益成果擴增到跨性別性工作者和順性別男性性工作者的重要性，他們都在獲得服務方面面臨著獨特的挑戰，並強調了這些群體充分融入國家愛滋病毒規畫的社會重要性。。

瓊斯及其同事以及克洛克及其同事的工作顯示，迫切需要增加對社區驅動的綜合性愛滋病毒服務之提供和常規數據系統的投資，以及與不同群體的性工作者合作進行嚴格的前瞻性和假設檢驗研究，確保性工作者在全球消滅愛滋病毒/愛滋病的努力中不被拋在後面。

作者聲明沒有競爭利益。 迪安娜·克里根 dkerrigan@gwu.edu

喬治華盛頓大學米爾肯公共衛生研究所，華盛頓特區 20052，美國

Gains and gaps: addressing HIV in diverse sex worker groups

www.thelancet.com/hiv Vol 10 July 2023

Over the past four decades of the HIV pandemic, diverse groups of sex workers have been disproportionately affected across settings.1 Social and structural factors including the criminalisation of sex work, financial insecurity, and intersectional stigma, discrimination, and violence have been identified as key drivers of sex workers’ disproportionate HIV risk and poor treatment outcomes.2 Although community-driven combination prevention interventions have shown promise in reducing new HIV infections and improving HIV care and treatment outcomes among sex workers,3 investments to bring these efforts to scale have lagged far behind historical and current needs.

Effective advocacy for increased resource allocation for HIV-related services and to promote overall health and human rights among sex workers is substantially affected by data gaps. The ability of the public health field to appropriately respond to inequities in HIV acquisition and treatment outcomes among sex workers partly depends on time-sensitive monitoring of epidemiological trends. Yet few data for the frequency of new HIV infections and HIV care continuum data have been available for diverse groups of sex workers, particularly in resource-constrained settings. Two papers published in The Lancet HIV focusing on HIV in sex workers in Zimbabwe help to close these data gaps.

Harriet Jones and colleagues report on temporal trends and risk factors for HIV seroconversion among sex workers. They provide an important analysis of an innovative and cost-effective approach to estimation of trends in HIV incidence based on routinely available HIV service-use data from 6665 mainly cisgender female sex workers in Zimbabwe. Data were drawn from sex workers who tested for HIV repeatedly through the Sisters with a Voice national community-based HIV prevention programme over 10 years. Jones and colleagues’ analysis showed downwards trends in HIV incidence among sex workers engaged in the national programme over time. However, they also identified the importance of linking sex workers to comprehensive HIV prevention services, sustaining sex workers’ engagement with services from first contact onwards, and ensuring that HIV programmes reach young sex workers ( <25 years) and those with a history of sexually transmitted infections—groups who were at significantly increased risk of seroconversion.

Jones and colleagues provide a strong rationale for the use of service-delivery data to estimate HIV incidence in resource-constrained settings, but they also identify some limitations of this approach. For example, findings and trends could not be generalised to female sex workers who were lost to follow-up in the national programme, and Jones and colleagues could not precisely estimate the timing of HIV seroconversion on the basis of the available data.

Although a growing number of community-driven combination HIV prevention interventions have been shown to significantly reduce the number of new HIV infections among cisgender female sex workers, including in sub-Saharan Africa, data for effective HIV prevention interventions for transgender sex workers and cisgender male sex workers are very scarce. Almost no proven HIV prevention models have been established for these key populations in sub-Saharan Africa, despite growing epidemiological data pointing to substantial HIV inequities in these subgroups of sex workers in the region.

Mariëlle Kloek and colleagues report HIV prevalence, risk behaviour, and treatment and prevention cascade outcomes among 1003 cisgender men, transgender women, and transgender men who sell sex in Zimbabwe. These data, although limited by the temporal biases associated with the cross-sectional design of the study, provide crucial information about the salience of social and structural factors to the high HIV prevalence (ranging from 26·2% among cisgender male sex workers to 39·4% among transgender female sex workers), gaps in service provision (up to a third of participants were unaware of their HIV status), and extremely low use of HIV care and treatment (11·9–15·7% of participants living with HIV were on antiretroviral therapy) in the study population. Kloek and colleagues’ analysis highlights the importance of extending HIV prevention and care gains among cisgender female sex workers to transgender sex workers and cisgender male sex workers, all of whom face unique challenges accessing services, and underscores the importance of these groups’ full inclusion in national HIV programmes.

Both Jones and colleagues’ and Kloek and colleagues’ work shows the acute need for increased investments in community-driven comprehensive HIV service delivery and routine data systems, as well as rigorous prospective and hypothesis-testing research in partnership with diverse groups of sex workers, to ensure that sex workers are not left behind in global efforts to end HIV/AIDS.

I declare no competing interests. Deanna Kerrigan dkerrigan@gwu.edu

The George Washington University Milken Institute of Public Health, Washington, DC 20052, USA