服務提供者應與所有HIV感染者討論U=U
資料來源：刺胳針愛滋病毒期刊；www.thelancet.com/hiv Vol 6 April 2019；財團法人台灣紅絲帶基金會編譯
隨著圍繞在HIV病毒抑制和傳播風險之間關聯上之科學知識的發展，對患者的訊息必須相應地更新。 Alison Rodger在第22屆國際愛滋病大會上展示了多點觀察性的PARTNER2研究之結果，報告指出，在病毒受抑制的男性和他們的HIV陰性男性伴侶間超過76,000次無套性行為後，沒有發生系統發生上相關的感染。這一發現加強了世界衛生組織和全世界750多個其他的組織現已達成共識，即愛滋病毒載量穩定受到抑制的人不能透過性去傳播病毒。在壓倒性之證據支持「無法檢測到=無法傳播」（U = U）（參見附表），服務提供者應該定期向所有愛滋病毒感染者傳達訊息。
告知愛滋感染者關於U = U的好處很多。感染者對U = U的認識可以透過強化患者啟動和堅持於抗反轉錄病毒治療方案中的動機，來實現並維持病毒被抑制，從而與治療的目標保持一致。關於U = U的教育可為那些病毒已被穩定抑制者提供社會心理上的許多利益，可減輕其自我恥辱感，緩解潛在傳播的罪惡感，並在不恐懼的情況下實現性行為。除了直接的益處，教育感染者關於U = U訊息，可以透過鼓勵對愛滋病毒藥物的順從性和隨後而來的病毒抑制，來間接減少社區中整體病毒載量，去支持公共衛生的目標，達到減少人口水平上的發生率。
此外，感染者的教育可促進知識的散佈向其伴侶和社交網絡傳播。目前包括在男男間性行為者等重點人群中，圍繞在U = U週邊錯誤的信息和普適的未能認知，使得知識之傳播尤為重要。提高社會意識可以在更廣泛的社區減少愛滋污名，促使不確定自我血清狀況的人們進行愛滋病毒檢測，減少血清反應陰性者對感染愛滋病毒的焦慮。這些社會上的結果可能終極地加速有利於愛滋感染者之結構性改革，例如廢除全球普遍存在針對愛滋病毒罪刑化的懲罰性法規。
在基於強有力的科學證據支持U = U以及認知到其對患者和公共衛生上的積極意涵下，與我們所預期的卻相反，初步研究顯示，衛生保健提供者並未始終如一地教育感染者關於U = U。最近對1000多位醫療服務提供者進行的一項國際調查顯示，只有77％的傳染病專家和42％的初級保健醫生在告知患者其病毒載量已達到無法檢測水平時同步向患者傳達了訊息。所報告隱瞞此類信息的原因包括懷疑（即，儘管有其他證據，但仍然認為愛滋病毒風險沒有得到充分緩解）、認為U = U否定個人責任，以及對患者的行為和可能會誤解上的擔憂。
最近所推出的愛滋病毒暴露前預防投藥（PrEP）提供了類似的情況，涉及醫療提供者在教育消費者此項生物醫學上的突破時沉默以對，有時係基於並無醫學證據支持之類似於道德上和家長式的原因。與PrEP一樣，在已建立的規範和協議的彈性下，允許對患者U = U的教育是可選擇性的並依賴於服務提供者的自由裁量，可能導致訊息傳遞的不一致。無論是否於意識中或無意，醫療提供者對於不同類型的消費者在其個人責任、行為和理解能力存疑上的偏見，可能表現在他們關於U = U教育的決定中。這更在臨床實務上為加劇現有愛滋上的不公提供了機會。
不幸的是，U = U不可避免地加劇了現有的差異。無論醫療服務提供者是否向患者傳達了關於U = U的訊息，當愛滋感染者如果沒有能負擔得起的愛滋治療，就如同他們般應更有權利的其他對應者亦仍然無法獲得U = U上相同的酬賞。同樣地，那些面臨罪刑化和醫療保健上遭歧視的人群，在安全地接受治療並在自己的生活中擁抱U = U時，亦經歷了獨特的挑戰。而特別是在可以獲得治療的環境中，對於任何愛滋感染者當其在U = U訊息上被拒絕時都是不可原諒的，。
愛滋感染者的照顧提供者，應該將告知患者有關U = U之訊息普遍地視為愛滋常規照護的一部分。在病患作決策時傳達任一治療周邊的利益和風險是最基本的原則，而此項愛滋治療上的利益當然也不例外。對於最大限度地提升愛滋感染者及其社區之福祉，以及盡其可能地減少服務提供者之偏見所導致愛滋上的不公，感染者U = U的教育其影響至關緊要。
Providers should discuss U=U with all patients living with HIV
As scientific knowledge surrounding the link between HIV viral suppression and transmission risk evolves, messaging to patients must be updated accordingly. Presenting the results of the multisite, observational PARTNER2 study at the 22nd International AIDS Conference, Alison Rodger reported that no phylogenetically linked infections occurred following more than 76 000 condomless sex acts between virally suppressed men and their HIV-negative male partners. This finding reinforces existing consensus by WHO and more than 750 other organisations worldwide that people whose HIV viral load is stably suppressed cannot sexually transmit the virus. With evidence supporting undetectable=untransmittable (U=U) now overwhelming (table), providers should be routinely communicating the message to all of their patients living with HIV.
The benefits of informing patients with HIV about U=U are numerous. Patients’ awareness about U=U incentivises attainment and maintenance of viral suppression, thus aligning with treatment goals by strengthening patients’ motivation to initiate and adhere to antiretroviral regimens. Education about U=U offers psychosocial benefits for individuals who are stably suppressed, alleviating self-stigma, relieving guilt surrounding potential transmission, and enabling sex without fear. Beyond direct benefits, educating patients about U=U could indirectly reduce community viral load by encouraging HIV medication adherence and consequent viral suppression, supporting public-health goals to reduce population level incidence. Additionally, education of patients facilitates knowledge dissemination to partners and social networks. Widespread unawareness and misinformation surrounding U=U at present, including within key populations such as men who have sex with men, make knowledge dissemination especially vital. Resultant increases in social awareness might reduce HIV stigma in the broader community, motivate HIV testing among people uncertain of their serostatus, and lessen anxiety about HIV acquisition among seronegative individuals. These social consequences could ultimately accelerate structural reforms that benefit people living with HIV, such as dismantling punitive HIV criminalisation laws, which are prevalent globally.
Contrary to what might be expected on the basis of robust scientific evidence supporting U=U and the positive implications of awareness for patient and public health, preliminary research suggests that health-care providers are not consistently educating patients with HIV about U=U. A recent international survey of more than 1000 providers found that only 77% of infectious disease specialists and 42% of primary care physicians communicated the message to patients when informing them of their undetectable viral load level. Reported reasons for withholding such information included disbelief (ie, belief that HIV risk is not fully mitigated, despite evidence otherwise), perception that U=U negates personal responsibility, and concerns about patients’ behaviour and misunderstanding.
The recent roll-out of HIV pre-exposure prophylaxis (PrEP) offers an analogous circumstance involving provider reticence to educate patients about a biomedical breakthrough, sometimes on similarly moralistic and paternalistic bases unsupported by medical evidence. As with PrEP, the flexibility of established norms and protocols, which allows education of patients about U=U to be optional and reliant on provider discretion, might lead to inconsistent delivery. Whether consciously or not, providers’ biases about the type of patient whose personal responsibility, behaviour, and capacity for understanding is in question might manifest in their decisions about whom to educate about U=U. This presents the opportunity for clinical practices to exacerbate existing HIV disparities.
Unfortunately, and inevitably, U=U potentiates existing disparities. Irrespective of providers’ messaging to patients about U=U, people living with HIV who do not have affordable access to HIV treatment lack the opportunity to reap the same rewards of U=U as their more privileged counterparts. Likewise, populations facing criminalisation and health-care discrimination experience unique challenges to accessing treatment safely and embracing U=U within their own lives. However, for the U=U message to be withheld from any person living with HIV is inexcusable, particularly in settings where treatment is accessible.
Providers caring for patients with HIV should universally inform their patients about U=U as part of routine HIV care. Conveying benefits and risks surrounding any treatment is fundamental to patients’ decision-making, and this HIV treatment benefit should be no exception. Education of patients about U=U is crucial to maximising the wellbeing of people living with HIV and their communities and to minimising the contribution of provider biases to HIV disparities.
*Sarah K Calabrese, Kenneth H Mayer
George Washington University, Washington, DC, USA (SC);
and Harvard Medical School and The Fenway Institute, Boston,
MA, USA (KHM)
skcalabrese@gwu.edu
