資料來源:www.thelancet.com/hiv Vol 9 March 2022,財團法人台灣紅絲帶基金會編譯
2020 年朝向終結愛滋病毒流行的全球目標並未實現,而跨性別女性和男男性行為者 (MSM) 等關鍵人群往往被遠拋在後。南部非洲關鍵人群特別面臨根植其身上堅固的愛滋病毒不公平之數據。然而,這些研究中很少有將跨性別女性的數據與 MSM 的數據分開,也沒有一個明確地包括性別酷兒個體。儘管聯合國愛滋病規劃署強調接觸關鍵人群(包括 MSM 和跨性別女性)以實現 90-90-90 目標的重要性(即,90% 的愛滋病毒感染者知道自己的感染狀況,90% 的愛滋病毒感染者在抗反轉錄病毒治療 [ART] 中,以及 90% 接受 ART 的人病毒載量受到抑制),關於 MSM 或跨性別女性和性別酷兒個體朝向實現這些目標的數據非常稀缺。在《刺胳針愛滋病毒》醫學期刊中,Tiffany Harris 及其同事的研究透過描述辛巴威 MSM 、跨性別女性和性別酷兒個體的 HIV 照護連續性之特徵,朝著解決這些差距邁出了重要的一步。
與該地區先前的研究一致,跨性別女性和性別酷兒個體的愛滋病毒盛行率高於男男性接觸者,男男性接觸者和跨性別女性和性別酷兒個體的愛滋病毒盛行率均高於該國的一般男性人群。愛滋病毒盛行率的這些差異主要是由污名化和社會排斥所驅動的,它們會增加愛滋病毒風險行為並減少獲得預防介入的機會。因此,實施有效的減少污名化策略對於減少新的愛滋病毒感染至關重要。
哈里斯及其同事發現,對於 MSM 和跨性別女性以及性別酷兒個體,ART 的取得和病毒抑制接近或超過了聯合國愛滋病規劃署的目標。然而,在愛滋病毒檢測呈陽性的人中,MSM 的自我報告對愛滋病毒狀況的認知僅為 48%,而跨性別女性和性別酷兒個體則僅為 37%。儘管狀態意識遠低於聯合國愛滋病規劃署的目標,但總體治療層級上的數字顯示,MSM、跨性別女性和性別酷兒個體一旦意識到自己的狀態並有效參與照護,就可以成功地接受抗反轉錄病毒治療並抑制病毒。然而,跨性別女性和 MSM 經常因基於設施上的污名而避免去尋求 HIV 服務。與 HIV 相關的污名和與主要人群相關的污名,在HIV 檢測和照護參與上是有據可尋的障礙。因此,確保獲得去污名且確認之愛滋病毒檢測以及醫療照護上的連結,對於實現聯合國愛滋病規劃署的目標至關重要。
當自我報告為 HIV 陰性或不知道自己的感宋狀態,但其病毒載量已受到抑制的 HIV 陽性受訪者則被歸類為是了解自己的狀態,在接受 ART 和病毒抑制上,其90-90-90 之HIV照護層級目標在 MSM 中提高到 73-97-87,在跨性別女性和性別酷兒個體中則提高到 58-94-92。儘管令人鼓舞的是,愛滋病毒照護連續性的結果在現實中可能比自我報告中的要好,但這種對愛滋病毒狀況的低報可能反映了否認、愛滋病毒污名或對愛滋病毒結果意義上的了解不足。在普遍的流行中愛滋病毒教育通常是為順性別之異性戀成年人所設計,知識貧乏更可能與跨性別女性、性別酷兒個體和 MSM 等尤其相關。需要為 MSM、跨性別女性和性別酷兒個體提供包容性的 HIV 教育和適當的安全性行為諮詢,以彌合知識上之差距。
Harris 及其同事發現,愛滋病毒知識和同儕工作者的參與與 MSM 中更高的愛滋病毒狀況意識之勝算比相關,強調了同儕網絡對於確保關鍵人群參與愛滋病毒照護層級上的重要性。令人遺憾的是,最近的性傳染病感染 (STI) 和B型肝炎檢測呈陽性與 MSM 中病毒抑制的勝算比之降低有關,這顯示醫療保健提供者錯失了就 STI 預防和對 HIV陽性 MSM 之 ART 順從性上進行有效對話的機會。減少設施層面的污名化可能有助於提高重點人群對 HIV 照護的參與度,並提高醫療保健提供者在為性少數群體和性別少數群體顧客提供適當性健康教育方面上的舒適度和能力。幸運的是,撒哈拉以南非洲以設施為基礎的減少污名化策略已取得成功。
由於哈里斯及其同事並未專門招募跨性別女性和性別酷兒個體,而且樣本量相對較小,因此該研究不足以檢測與這一關鍵人群的意識狀態和病毒抑制相關的因素。我們迫切需要針對撒哈拉以南非洲的這一群體進行研究,以確保公平獲得愛滋病毒照護和治療的好處。在沒刻意招募的情況下跨性別女性和性別酷兒個體參與本研究的意願顯示,為這一人群量身定制的研究是可行的。
總體而言,Harris 及其同事的研究確定了在什麼時候需要對 HIV照護之連續性進行介入,並為我們指明了變革的機會。現有研究支持我們的斷言,即解決跨性別女性、性別酷兒個體和 MSM 所面臨的普遍污名是必要的,這不僅可以降低感染 HIV 的易感性,而且可以提高對 HIV照護連續性的參與並實現聯合國愛滋病規劃署(UNAIDS) 的90-90-90 目標。
*Tonia C Poteat, L Leigh Ann van der Merwe ;tonia_poteat@med.unc.edu
(TCP) 北卡羅來納大學教堂山分校社會醫學系,美國北卡羅來納州教堂山 27599;
(LLAvanderM) 社會健康賦權,非洲跨性別女性女權合作組織,南非東倫敦。
Stigma reduction is key to improving the HIV care continuum
Global targets toward ending the HIV epidemic were missed in 2020, and key populations such as transgender women and men who have sex with men (MSM), were often the ones left behind. Data are mounting on the substantial HIV inequities faced specifically by key populations in southern Africa. However, few of these studies have disaggregated the data for transgender women from that of MSM, and none have explicitly included genderqueer individuals. Although UNAIDS emphasises the importance of reaching key populations, including MSM and transgender women, to achieve the 90–90–90 goals (ie, 90% of people with HIV being aware of their status, 90% of status-aware people with HIV on antiretroviral treatment [ART], and 90% of people on ART with a suppressed viral load), the data on progress towards these goal among MSM or transgender women and genderqueer individuals are quite scarce. In The Lancet HIV, Tiffany Harris and colleagues’ study takes important steps toward addressing these gaps by characterising the HIV care continuum among MSM and transgender women and genderqueer individuals in Zimbabwe.
Consistent with previous research in the region, HIV prevalence among transgender women and genderqueer individuals was higher than among MSM, and both MSM and transgender women and genderqueer individuals had an HIV prevalence higher than the general population of men in the country. These disparities in HIV prevalence are largely driven by stigma and social exclusion that increase HIV risk behaviour and reduce access to prevention interventions.Thus, implementing effective stigma reduction strategies will be essential to reducing new HIV infections.
Harris and colleagues found that ART uptake and viral suppression approached or exceeded UNAIDS goals for both MSM and transgender women and genderqueer individuals. However, self-reported awareness of HIV status among those who tested HIV-positive was only 48% for MSM and a mere 37% for transgender women and genderqueer individuals. Although status awareness falls well below UNAIDS targets, overall cascade numbers suggest that MSM and transgender women and genderqueer individuals can successfully take ART and have viral suppression once they are aware of their status and effectively engaged in care. However, transgender women and MSM often avoid seeking HIV services because of facility-based stigma. HIV-related stigma and key population-related stigma are well documented barriers to HIV testing and care engagement. Therefore, ensuring access to stigma-free and affirming HIV testing and linkage to care are crucial for meeting UNAIDS goals.
When HIV-positive respondents who self-reported being HIV-negative or not knowing their status, yet had a suppressed viral load, were categorised as being aware of their status, on ART, and virally suppressed, the 90-90-90 HIV care cascade target improved to 73–97–87 among MSM and 58–94–92 among transgender women and genderqueer individuals. Although it is encouraging that the HIV care continuum outcomes might be better in reality than in self-report, this under-reporting of HIV status might reflect denial, HIV stigma, or poor knowledge about the meaning of HIV results. Poor knowledge might be especially relevant for transgender women, genderqueer individuals, and MSM in generalised epidemics during which HIV education is typically designed for cisgender heterosexual adults. Inclusive HIV education and appropriate safer sex counselling for MSM, transgender women, and genderqueer individuals are needed to bridge gaps in knowledge.
Harris and colleagues found that HIV knowledge and peer worker engagement were associated with higher odds of HIV status awareness among MSM, highlighting the importance of peer networks for ensuring key populations are engaged in the HIV care cascade. The unfortunate finding that recent sexually transmitted infections (STIs) and testing positive for hepatitis B were associated with lower odds of viral suppression in MSM suggests missed opportunities for healthcare providers to engage in effective conversations about both STI prevention and ART adherence with MSM living with HIV. Reducing facility-level stigma might serve the dual purpose of increasing engagement of key populations in HIV care and improving healthcare providers comfort and competence in providing appropriate sexual health education for sexual and gender minority clients. Fortunately, strategies for facility-based stigma reduction in sub-Saharan Africa have shown success.
Because transgender women and genderqueer individuals were not specifically recruited by Harris and colleagues, and the sample size was relatively small, the study was underpowered to detect factors associated with status awareness and viral suppression for this key population. We urgently need studies focused on this group in sub-Saharan Africa to ensure equitable access to the benefits of HIV care and treatment. The willingness of transgender women and genderqueer individuals to participate in this study without intentional recruitment indicate that research tailored for this population is feasible.
Overall, Harris and colleagues’ study identifies at what point intervention in the HIV care continuum is needed and points us towards opportunities for change. Extant research supports our assertion that addressing the pervasive stigma faced by transgender women, genderqueer individuals, and MSM will be necessary, not only to reduce vulnerability to HIV acquisition, but also to improve engagement in the HIV care continuum and achieve the UNAIDS 90–90–90 goals.
*Tonia C Poteat, L Leigh Ann van der Merwe tonia_poteat@med.unc.edu Department of Social Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA (TCP); Social Health Empowerment, Feminist Collective of Transgender Women of Africa, East London, South Africa (LLAvanderM)
www.thelancet.com/hiv Vol 9 March 2022