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澳大利亞:治療作為預防新 HIV 病例減少了三分之二

澳大利亞:治療作為預防和 PrEP 將男同性戀和雙性戀男性的新 HIV 病例減少了三分之二

Keith Alcorn / 2023 4 21 / aidsmap

 

圖片來源:多米齊亞·薩盧斯特 | www.domiziasalusest.com

 

2010 年至 2019 年間,在澳大利亞接受抗反轉錄病毒治療且病毒載量無法檢測的同性戀和雙性戀男性人數增加了 27%,導致愛滋病毒感染減少了 66%,這顯示作為一種公共衛生措施,治療作為預防是非常有效的, 澳大利亞研究人員在《刺胳針愛滋病毒》雜誌上發表了報告。

引入 PrEP 後,病毒抑制人數增加與 HIV 傳播減少之間的關係變得更加密切,因此到 2019 年,病毒抑制流行率每增加 1% 對應於 HIV 發病率降低 20% .

「我們的結果顯示,雖然治療作為預防的本身有效,但當與 PrEP 分佈和低水平之未確診的 HIV(即高檢測率)相結合時,最有效地降低了 HIV 發病率」,作者評論道。

幾項大型研究顯示,在個人層面上,抗反轉錄病毒治療的病毒抑制消除了將 HIV 傳播給性伴侶的風險。 然而,顯示其對人口水平影響的數據較少,尤其是在高收入國家。

新南威爾士大學柯比研究所的丹頓·卡倫達爾 (Denton Callendar) 博士於 2020 年愛滋病大會上介紹了澳大利亞以治療為預防的影響研究的初步結果。

現在,同一研究小組使用 2010 1 月至 2019 12 月期間收集的數據,評估了增加抗反轉錄病毒治療覆蓋率和提供 PrEP 對新南威爾士州和維多利亞州 HIV 傳播的十年影響。 該研究首次全面分析了男同性戀和雙性戀男性治療作為預防的有效性。

這項縱向研究檢查了在新南威爾士州和維多利亞州於 69 家提供 HIV 檢測的診所中接受醫療服務的 101,772 名男同性戀和雙性戀男性的 HIV 狀況、治療吸收、病毒抑制和 PrEP 使用情況的變化。 參與者可以在追蹤期間的任何時間進入世代。

主要分析著眼於在追蹤期間至少檢測兩次,並且在第一次檢測時呈陰性的男性的 HIV 發病率。 該世代包括 59,234 名男性,其中 1,201 人在追蹤期間檢測出 HIV 陽性,發病率為每 100 人年追蹤 0.4 例。 2010 年至 2019 年間,愛滋病毒發病率下降了 66%,從每 100 人年 0.64 例降至 0.22 例。 30-39 歲男性的下降幅度最大 (88%)

在未感染 HIV 的男性中,使用 PrEP 的人數從 2016 年(引入當年)的 17% 增加到 2019 年的 36%,當時有 12,189 名男性正在服用 PrEP

在研究期間重複檢測 HIV 的人數有所增加,研究人員計算出未確診的 HIV 流行率從 2010 年的略低於 11% 下降到 2019 年的 9%

主要分析還計算了病毒抑制的人口盛行率,並將其用作與 HIV 發病率相關的因素的多變量分析中的變量。 HIV 感染世代包括 12,554 名男性,他們要麼在基線時感染了 HIV,要麼在追蹤期間檢測為 HIV 陽性,並且在診斷後至少進行了一次病毒載量檢測。 病毒感染的男性愛滋病毒感染者其病毒抑制比例從 2010 年的 69% 上升到 2019 年的 88%,增加了 27%

針對社會人口學特徵和 PrEP 使用進行調整的主要多變量分析顯示,低於 200 拷貝/毫升的病毒抑制盛行率每增加 1% HIV 發病率降低 6% 相關(發病率比為 0.94), p<0.001) 與未使用 PrEP 的男性相比,使用 PrEP 的男性的 HIV 發病率低 70%IRR 0.30p<0.001)。

HIV 發病率在 2015 年至 2017 年間下降幅度最大,此後趨於平穩,這顯示擴大 PrEP 的使用加強了未確診 HIV 和未抑制病毒載量下降等對 HIV 發病率的影響。

研究調查人員表示,檢測、治療覆蓋率和病毒抑制的增加反映了診所和社區組織為使服務更容易獲得以及有針對性的教育活動中所做的綜合努力。

在隨附的社論評論中,兩位泰國 HIV 專家強調了圍繞用戶去設計服務的重要性,以最大限度地發揮治療作為預防和 PrEP的影響。 曼谷愛滋病毒研究與創新研究所的 Nittaya 博士和 Praphan Phanuphak 博士強調了社區在共同實施服務以實現信任和公平方面的重要性。 他們指出,州政府和社區迅速採取行動,大規模實施治療作為預防和 PrEP,「使澳大利亞比許多其他國家提前十年接近終結愛滋病」。

 

參考文獻:

Callendar D 等人。 HIV 之治療作為預防及其對澳大利亞順性男同性戀、雙性戀和其他男男性行為者 HIV 發病率的影響:一項為期 10 年的縱向世代研究。 《剌胳針 HIV》,2023 4 14 日線上出版。DOIhttps://doi.org/10.1016/S2352-3018(23)00050-4

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Australia: Treatment as prevention and PrEP reduce new HIV cases in gay and bisexual men by two-thirds

Keith Alcorn / 21 April 2023 / aidsmap

Domizia Salusest | www.domiziasalusest.com

A 27% increase in the number of gay and bisexual men taking antiretroviral treatment in Australia and having undetectable viral load resulted in a 66% reduction in HIV infections between 2010 and 2019, showing that treatment as prevention is highly effective as a public health measure, Australian researchers report in the journal Lancet HIV.

The relationship between the increased number of people who are virally suppressed and reductions in HIV transmission became even stronger after the introduction of PrEP, so that by 2019, every 1% increase in the prevalence of viral suppression corresponded to a 20% reduction in HIV incidence.

“Our results suggest that although effective on its own, treatment-as-prevention most effectively reduces HIV incidence when combined with PrEP distribution and low levels of undiagnosed HIV (ie, high rates of testing),” comment the authors.

Several large studies have shown that at an individual level, viral suppression on antiretroviral treatment eliminates the risk of HIV transmission to sexual partners. However there has been less data showing its effect at the population level, especially in high-income countries.

Preliminary results of a study of the impact of treatment as prevention in Australia were presented at AIDS 2020 by Dr Denton Callendar of the Kirby Institute, University of New South Wales.

Now, using data collected between January 2010 and December 2019, the same research group has assessed the ten-year impact of increasing antiretroviral treatment coverage and providing PrEP on HIV transmission in the states of New South Wales and Victoria. The study is the first comprehensive analysis of the effectiveness of treatment as prevention in gay and bisexual men.

The longitudinal study examined changes in HIV status, treatment uptake, viral suppression and PrEP use in 101,772 gay and bisexual men receiving health services at 69 clinics that provide HIV testing in New South Wales and Victoria. Participants could enter the cohort at any time during the follow-up period.

The primary analysis looked at HIV incidence in men who tested at least twice during the follow-up period and who were HIV-negative at their first test. This cohort comprised 59,234 men, of whom 1201 tested HIV-positive during follow-up, an incidence of 0.4 cases per 100 person-years of follow-up. HIV incidence declined by 66% between 2010 and 2019, from 0.64 to 0.22 cases per 100 person-years. The decline was greatest in men aged 30-39 years (88%).

Among men without HIV, the number of PrEP users increased from 17% in 2016 (the year of introduction) to 36% in 2019, when 12,189 men were taking PrEP.

Repeat HIV testing increased during the study period and the investigators calculated that the prevalence of undiagnosed HIV fell from just under 11% in 2010 to 9% in 2019.

The primary analysis also calculated population prevalence of viral suppression and used this as a variable in the multivariable analysis of factors associated with HIV incidence. The cohort with HIV consisted of 12,554 men who were either living with HIV at baseline or tested HIV-positive during the follow-up period and had at least one viral load test after diagnosis. The proportion of men living with HIV who were virally suppressed grew from 69% in 2010 to 88% in 2019, an increase of 27%.

The primary multivariable analysis, which adjusted for sociodemographic characteristics and PrEP use, showed that each 1% increase in the prevalence of viral suppression below 200 copies/ml was associated with a 6% reduction in the incidence of HIV (incidence rate ratio 0.94), p<0.001). The incidence of HIV was 70% lower in men who used PrEP (IRR 0.30, p<0.001) compared with non-PrEP users.

HIV incidence fell most sharply between 2015 and 2017 and levelled off after this point, suggesting that expanding PrEP use reinforced the impact of declines in undiagnosed HIV and unsuppressed viral load on HIV incidence.

The study investigators say that increases in testing, treatment coverage and viral suppression reflect comprehensive efforts by clinics and community organisations to make services more accessible, as well as targeted education campaigns.

In an accompanying editorial comment, two Thai HIV experts stress the importance of designing services around their users to maximise the impact of treatment as prevention and PrEP. Drs Nittaya and Praphan Phanuphak of the Institute of HIV Research and Innovation in Bangkok emphasise the importance of communities in co-implementing services to achieve trust and equity. They point out that rapid actions by state governments and communities to achieve large-scale implementation of treatment as prevention and PrEP “have brought Australia closer to ending AIDS a decade before many other countries.”

 

References

Callendar D et al. HIV treatment-as-prevention and its effect on incidence of HIV among cisgender gay, bisexual and other men who have sex with men in Australia: a 10-year longitudinal cohort study. Lancet HIV, published online 14 April 2023.

DOI: https://doi.org/10.1016/S2352-3018(23)00050-4

 

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