是時候解決延遲診斷了
資料來源：http://www.thelancet.com/hiv/Vol 9,2022 年 3 月；財團法人台灣紅絲帶基金會編譯
在過去十年中，全球HIV新診斷個案下降了近 30%，從 2011 年的 210 萬下降到 2020 年的 150 萬。現代反逆轉錄抗病毒療法 (ART) 獲得極大地改善了 HIV 感染者的預後，他們現在的預期壽命可與普通人群相媲美。然而，延遲診斷繼續危害愛滋感染者的健康。老年人尤其有較晚被診斷的風險。這些人面臨更糟糕的結果，並且增加罹患嚴重疾病和死亡的風險。剌胳針愛滋病毒及剌胳針健康的長壽醫學期刊(The Lancet HIV & The Lancet Healthy Longevity) 正在推出一個關於衰老和 HIV 的系列文章，其中包括 Amy Justice 及其同事的一篇論文，該論文探討了延遲就診的問題。為確保所有愛滋感染者健康長壽意味著應結束延遲診斷。
延遲診斷，通常定義為在接受HIV的治療時其 CD4 細胞計數低於 350 個細胞每μL，或伴有 AIDS 定義病症出現；無論 CD4 細胞計數如何，在全球範圍內其所佔新診斷的比例高得令人無法接受。在 2019 年的英國，與較早診斷的人相比，延遲診斷的人在次年的死亡風險增加了 7 倍。令人擔憂的是，在某些地區，延遲診斷的比例正在增加。聯合國愛滋病規劃署報告稱，2020 年，南非 55% 的診斷患者的 CD4 計數低於每微升 350 個細胞，其中 31% 低於每微升 200 個細胞。一些群體比其他群體更容易被延遲診斷，尤其是老年人。英國衛生福利部報告愛滋病毒檢測、新的愛滋病毒診斷、結果和獲得愛滋病毒服務的人的照護質量：2021 年報告顯示，2020 年英格蘭有42% 的愛滋感染者為延遲診斷（較 2019 年的 40% 有所增加，2016 年為 35%）。然而，對於 50 歲或以上的異性戀男性和女性，63% 的診斷被定義為晚期。在美國，2019 年的診斷中屬率第 3 階段分類者，其定義為 CD4 計數每μL低於 200 個細胞，CD4 佔總淋巴細胞的百分比低於 14，或有愛滋病定義條件的狀況佔 20% 的。然而，對於 55 歲或以上的成年人，這一比例上升到 34%。
在他們的系列論文中，Justice 及其同事使用來自國際流行病學數據庫評估愛滋病 (the International epidemiology Databases to Evaluate AIDS , IeDEA) 的數據，詳細分析了年齡與延遲就診之間的關聯。老年人延遲診斷的原因是多方面的。老年人可能不會認為自己有感染 HIV 的風險。一些衛生保健工作者認為老年人不從事性活動或吸毒，這也可能會減少檢測之機會。生理上的老化會阻礙測試。一些 HIV 指標狀況與年齡較大有獨立的相關，因此可能不會像在年輕人中那樣會詖提示檢測。 Justice 及其同事主張在某些環境中採用普遍性的 HIV 檢測，增加自我檢測的可及性，並使用電子決策支持等工具來避免圍繞在「誰是或誰不是——處於 HIV 感染風險中」的偏見。針對老年人在醫療照護中延遲出現的問題，將於2022 年 3 月 17 日至 18 日的《刺胳針》愛滋病毒和健康的長壽之峰會中進一步討論。
在另一有關老齡化人口中愛滋感染者在衛生系統上的適應之系列論文中，Jepchirchir Kiplagat 及其同事，建議在不同年齡層的區域平均預期壽命中納入愛滋感染者的目標達 90%。除了確保獲得抗反轉錄病毒療法、順從性支持和為愛滋感染者提供整體性照護等因素外，在實現跨越整個生命週期的目標上還是需要減少延遲診斷。正如作者所強調的那樣，這一目標也將具有「間接性的好處，即肯定對愛滋感染者的終身承諾，而不只是對愛滋病毒某些特定方面照護上的承諾」。
將減少延遲診斷的目標與聯合國愛滋病規劃署 2030 年的 95-95-95 目標結合起來的時候到了嗎？在確保取得進展上將需要對有延遲診斷風險的人群進行有針對性的愛滋病毒預防和檢測，其中老年人佔很大比例。每個感染 HIV 的人都將受益於及時的診斷和治療——關於老年人的先入為主的觀念不應成為照護上的障礙。
http://www.thelancet.com/hiv Vol 9, 2022 年 3 月
Time to tackle late diagnosis
Over the past decade, new HIV diagnoses worldwide have dropped by almost 30%, from 2·1 million in 2011 to 1·5 million in 2020. Access to modern antiretroviral therapy (ART) has greatly improved outcomes for people with HIV, who can now expect a lifespan comparable to that of the general population. However, late diagnosis continues to jeopardise the health of people with HIV. Older adults are particularly at risk of being diagnosed late. These individuals face poorer outcomes and are at an increased risk of severe disease and death. The Lancet HIV and The Lancet Healthy Longevity are launching a Series on Ageing and HIV, which includes a paper by Amy Justice and colleagues that explores delayed presentation for care. Ensuring a healthy longevity for all people with HIV means ending late diagnosis.
Late diagnosis, generally defined as presenting for HIV care with a CD4 count below 350 cells per μL, or with an AIDS-defining event, regardless of the CD4 cell count, represents an unacceptably high proportion of new diagnoses globally. In the UK in 2019, people diagnosed late had a seven fold increased risk of death in the following year compared with those diagnosed earlier. Worryingly, in some regions the proportion of late diagnoses is increasing. UNAIDS reports that in 2020, 55% of diagnoses in South Africa were in people with a CD4 count of below 350 cells per μL, with 31% below 200 cells per μL. Some groups are more at risk of a late diagnosis than others, with older adults particularly at risk. The UK Health Security Agency report HIV testing, new HIV diagnoses, outcomes and quality of care for people accessing HIV services: 2021 report shows that 42% of people diagnosed with HIV in 2020 in England were diagnosed late (an increase from 40% in 2019 and 35% in 2016). However, for heterosexual men and women aged 50 years or older, 63% of diagnoses were defined as late. In the USA, stage 3 classification, defined as a CD4 count of below 200 cells per μL, CD4 percentage of total lymphocytes of less than 14, or documentation of an AIDS-defining condition, was made in 20% of diagnoses in 2019. However, for adults 55 years or older this rose to 34%.
In their Series paper, using data from the International epidemiology Databases to Evaluate AIDS (IeDEA), Justice and colleagues present a detailed analysis of the link between age and delayed presentation for care. Reasons for delayed diagnosis in older adults are multifaceted. Older individuals might not consider themselves at risk of HIV acquisition. The perceptions of some health-care workers that older adults do not engage in sexual activity or drug use might also reduce testing opportunities. The biology of ageing can impede testing. Some HIV indicator conditions are independently associated with older age and therefore might not prompt testing as they would do in younger individuals. Justice and colleagues argue for the adoption of universal HIV testing in some settings, increased access to self-testing, and use of tools such as electronic decision support to circumnavigate biases around who is—and who is not—at risk of HIV. Delayed presentation to care for older adults will be further discussed in The Lancet Summit on HIV and Healthy Longevity from March 17 to 18, 2022.
In another Series paper on health-systems adaptations for an ageing population with HIV, Jepchirchir Kiplagat and colleagues propose incorporating a target for people with HIV to reach 90% of the average regional life expectancy across different age strata. Alongside factors such as ensuring access to ART, supporting adherence, and providing holistic care for people with HIV, achieving a target based across a lifespan would also require a reduction in late diagnoses. As the authors highlight, this target would also have the “indirect benefit of affirming a lifelong commitment to people living with HIV rather than a commitment to the HIV specific aspects of their care”.
Is it time to include targets for reducing late diagnoses alongside the UNAIDS 95-95-95 targets for 2030? Ensuring progress will require targeted HIV prevention and testing in those at risk of late diagnosis, among whom older people are a substantial proportion. Everyone who acquires HIV would benefit from prompt diagnosis and treatment initiation—preconceived ideas about older adults should not be a barrier to care.
http://www.thelancet.com/hiv Vol 9 March 2022