www.thelancet.com/hiv Vol 11 December 2024
在本月的期刊中，我們很自豪地出版了一系列關於流動人口中愛滋病毒的文章。對於降低愛滋病毒相關發病率和死亡率、盡量減少愛滋病毒傳播以及為邊緣化和往往不穩定的人們提供公平和富有同情心的照護而言，這是一個至關重要的主題。該系列中的兩篇論文在方法上相互補充。第一篇由克勞迪婭·科爾特斯(Claudia Cortes) 及其同事撰寫，總結了感染愛滋病毒的難民和尋求庇護者的全球狀況，提出了這些人群面臨的挑戰，並為愛滋病毒照護的人性化方法提供了想法。第二篇論文由 Alena Kamenshchikova 及其同事撰寫，涵蓋了衛生系統全球建議的方法，以確保移民照護的連續性。
有據可查的衝突導致中東和北非地區以及烏克蘭的人員大量流向歐洲；經濟危機和無法獲得基本醫療保健導致大批人從委內瑞拉逃往南美洲其他國家；這些只是世界各地因衝突、邊緣化、受害、自然災害和氣候危機而造成的許多人口劇變的幾個例子。除了引人注目的事件之外，經濟移民的常規模式（例如南部非洲的勞動力移民）也導致大量人員經常跨越國際邊界。這種持續的流動使許多移民面臨不熟悉的醫療保健系統、語言障礙阻礙了照護的獲得以及面對從歡迎到公開敵對的環境。
僅舉一個例子，愛滋病毒照護連續性的挑戰是本系列強調的關鍵面向之一。同樣在本期中，Francesco Vladimiro Segala 及其同事進行的系統性回顧報告了歐洲移民的愛滋病毒感染結果，到 2022 年，歐洲新確診的愛滋病毒患者中近 50% 發生在移民人群中。審查發現，與一般人群中的愛滋病毒感染者相比，歐洲愛滋病毒感染者更有可能患有晚期愛滋病毒、照護中斷或喪失，並面臨病毒學或免疫學治療失敗。
實現照護的連續性需要母國、過渡國和目的地國之間的國際合作。衛生系統應讓面臨愛滋病毒風險或感染愛滋病毒的人，無論官方文件狀況如何，都能輕鬆獲得檢測和治療，以確保迅速、公平和無歧視地提供適當的預防或治療。但在最好的系統之外，這種情況很少發生。許多移民擔心在官方服務中表明自己的身分會受到影響，加劇了塞加拉 (Segala) 及其同事所強調的嚴峻局勢。全球情況多種多樣且充滿挑戰，我們敦促所有讀者研究該系列論文、Segala 及其同事的文章以及與這些文章相關的評論，以便更好地了解照顧感染愛滋病毒的移民和愛滋病毒感染者的眾多阻礙因素。
該系列論文列出了感染愛滋病毒的移民人口所面臨的重大挑戰，其中一些挑戰針對難民、尋求庇護者或移民身份，另一些則與性別、性認同、文化差異等其他因素的交叉相關。臨床醫生、政策制定者和計畫主管所面臨的最大障礙之一是，缺乏關於流動人口中愛滋病毒的高品質數據和有效的介入措施：針對照護需要收集此類數據，以告知服務提供者和流動人口以開放和包容的思想交流，促成彼此之間的合作。沒有簡單的解決辦法，但基於公平的方法承認所有需要愛滋病毒照護者的人性思維，可以幫助解決移民人口面臨的沉重的愛滋病毒負擔。
移民是生活中的事實，並且貫穿世界各地的歷史。人們總是會被機會所吸引，例如，填補勞動力缺口和遵循人們常走的道路。此外，由於各國政府繼續發動衝突，邊緣化和傷害特定群體，並且在危機時期無法為其公民提供保障，被迫移民和突然的人口劇變將繼續存在——這種情況只會因不斷發展的全球氣候危機而加劇。正如該系列文章所強調的，為了實現全球控制愛滋病毒的流行和實現永續發展目標，必須與移民人口合作，以便那些需要的人能夠不受阻礙或恐懼地獲得愛滋病毒預防、診斷和治療。 ■ 剌胳針愛滋病毒
Ending barriers to HIV care for migrant populations
www.thelancet.com/hiv Vol 11 December 2024
In this month’s issue, we are proud to publish a Series on HIV in Migrant Populations. This is a vitally important topic in efforts to reduce morbidity and mortality related to HIV, minimise HIV transmission, and provide equitable and compassionate care for people in marginalised and often precarious circumstances. The two papers in the Series complement each other in their approaches. The f irst, by Claudia Cortes and colleagues, summarises the global situation for refugees and asylum seekers living with HIV, presenting the challenges for these populations and providing ideas for humanising approaches to HIV care. The second paper, by Alena Kamenshchikova and colleagues, covers global recommendations for health systems approaches to ensure continuity of care for migrants.
Well documented conflicts have led to substantial movements of people from the Middle East and north Africa region and from Ukraine into Europe; economic crises and inability to access basic health care have led to a major exodus from Venezuela to other countries in South America; these are just a couple of examples of many demographic upheavals around the world resulting from conflicts, marginalisation, victimisation, natural disasters, and the climate crisis. Beyond headline-grabbing events, regular patterns of economic migration (eg, labour migration in southern Africa) see vast numbers of people routinely crossing international borders. This constant movement exposes many migrants to unfamiliar health-care systems, language barriers that hinder access to care, and environments that range from welcoming to openly hostile.
To pick just one example, the challenge of continuity of HIV care is one of the key aspects highlighted in the Series. Also in this issue, a systematic review by Francesco Vladimiro Segala and colleagues reports HIV outcomes for migrants in Europe, where, in 2022, almost 50% of new HIV diagnoses were among migrant populations. The review finds that, compared with people with HIV in the general population, migrants living with HIV in Europe are more likely to have advanced HIV disease, experience interruption to or loss-from care, and face virological or immunological failure of treatment.
Achieving continuity of care requires international collaboration between home countries, transition countries, and destination countries. Health systems should make it easy for people at risk of or living with HIV, regardless of official documentation status, to access testing and treatment to ensure that appropriate prevention or treatment is provided rapidly, fairly, and without discrimination. But so rarely, outside the very best systems, does this happen. Many migrants fear repercussions of identifying themselves to official services, contributing to the dire situation highlighted by Segala and colleagues. The global situation is diverse and challenging, and we urge all readers to study the Series papers, the article by Segala and colleagues, and the Comments linked to these pieces to better understand the myriad factors contributing barriers to care for migrants living with HIV and the possible solutions.
The Series papers catalogue substantial challenges that migrant populations living with HIV face, some specific to refugee, asylum seeker, or migrant status, others related to the intersection of other factors related to gender, sexual identity, cultural differences, and so on. One of the biggest obstacles clinicians, policy makers, and programme directors face is a lack of high-quality data on HIV in migrant populations and interventions that work: the gathering of such data to inform services requires collaboration between care providers and migrant populations based on open and accommodating exchanges of ideas. There is no simple f ix, but an equity-based approach that recognises the humanity of all people requiring HIV care can help to address the substantial burden of HIV faced by migrant populations.
Migration is a fact of life and has been throughout history the world over. People will always be drawn to opportunities, for example, to fill labour gaps and follow well trodden pathways. Moreover, as governments continue to wage conflict, marginalise and victimise select groups, and fail to provide for their citizens in times of crisis, forced migration and sudden demographic upheavals will continue—a situation that will only be exacerbated by the unfolding global climate crisis. As the Series highlights, to achieve global control of the HIV epidemic and to reach Sustainable Development Goals, it is essential to work with migrant populations so that those who need to can access HIV prevention, diagnostics, and treatment without hindrance or fear. ■ The Lancet HIV