烏克蘭的愛滋感染者命運岌岌可危
資料來源:http://www.thelancet.com/hiv Vol 9 April 2022;財團法人台灣紅絲帶基金會編譯
隨著烏克蘭戰爭升級,人道主義危機繼續加劇。自俄羅斯於 2 月 24 日入侵該國以來,對人口的破壞性影響變得越來越嚴重。對平民和民用基礎設施的不分青紅皂白的襲擊正在增加,人道主義走廊很少或根本沒有得到承認,生命損失也在增加。迄今為止,估計有 200 個醫療保健設施位於衝突地區,數家醫院已被軍事行動摧毀。對需要進入該國衛生系統的人們的影響是災難性的。
在烏克蘭繼續為愛滋感染者和受愛滋病毒影響的人,去提供和安全地獲得愛滋病毒治療和預防服務的風險很大。在戰爭初期,人們對衝突期間愛滋病毒服務的可用性表示擔憂,聯合國愛滋病規劃署表示,該國超過 15 萬接受愛滋病毒治療的人的抗反轉錄病毒藥物供應僅限於幾週。據世衛組織稱,雖然最初的援助交付集中在基本藥物和應急物資上,但抗反轉錄病毒藥物的供應將透過國際援助機構、烏克蘭衛生部和當地非政府組織的資助和合作來滿足。
在被入侵之前,烏克蘭對愛滋病毒的反應參差不齊,受到社會經濟條件惡劣、外部資金減少以及東部分離主義省份動蕩的阻礙。然而,近年來,該國在應對疫情主要集中在注射藥癮人群中的流行方面取得了實質性進展。估計注射藥癮人群超過 35 萬,其愛滋病毒感染率為 21%。特別是,減害服務的規模大幅擴大,包括針頭交換計畫和在東歐和中亞最大規模的阿片受體激動劑治療計畫(註:如美沙酮之替代治療)。自 2010 年以來,該國的新感染病例減少了 21%。被圍困的第聶伯羅、基輔和奧德薩等城市最近簽署了快速通道城市倡議,但這場衝突之威脅有可能使多年的進步付之東流。
該國有抗反轉錄病毒藥物,但在受衝突影響最嚴重的地區,供應已經受到限制,正如《剌胳針愛滋病毒》本期專題中所強調的那樣。隨著衝突的加劇,該國內在供應上的儲存、交付和分配可能會受到干擾。緩解抗反轉錄病毒藥物供應中斷和受限上的措施,預計將包括嘗試去預測缺貨、開給數月份的處方,以及確認那些預計將有國內流離失所之愛滋感染者湧入的地區。用於阿片受體激動劑治療的美沙酮之供應和分配也存有潛在的困難。令人震驚的是,到目前為止,俄羅斯軍方對人道主義走廊很少尊重——這些走廊的存在不僅對平民的安全逃生至關重要,而且對確保醫療用品到達最需要的人手中亦是不可或缺的。一些組織已經不得不縮減或停止提供他們的愛滋病毒計畫。
正如 2018 年《剌胳針愛滋病毒》所報導的那樣,在分離的東部分離主義省份盧甘斯克和頓涅茨克受到俄羅斯軍隊持續的衝突和占領,已摧毀了該地區的愛滋病毒服務,意味著如果俄羅斯支持的政權在烏克蘭取得成功,將成為對愛滋感染者健康和福利的警告。被吞併的克里米亞的分離主義當局和俄羅斯政府停止了阿片受體激動劑治療,這反映了俄羅斯聯邦的情況,亦即這種治療是非法的。
衝突也可能對鄰近國家的愛滋病毒應對工作產生嚴重影響。根據聯合國移民機構的數據,截至 3 月 11 日,已有 250 萬難民越過烏克蘭西部邊境前往鄰近的友好國家,據估計,這一數字將很快達到 400 萬。為那些確實到達鄰國的難民提供愛滋病毒服務其連續性亦是一個問題。必須支持這些國家的衛生系統,尤其是歐洲最貧窮的國家之一摩爾多瓦。制裁也可能對俄羅斯聯邦已經有限的愛滋病毒服務資金造成影響,俄羅斯聯邦是東歐和中亞地區愛滋病毒流行最嚴重的國家。
儘管政府、援助機構和民間社會做出了巨大的人道主義努力,但如果衝突繼續下去,就不可能提供一個有效的衛生系統來確保人們(包括愛滋感染者)的健康、安全和福祉。除非入侵現在結束,否則烏克蘭的愛滋病毒反應和該地區的愛滋病毒反應將處於危險之中。 《剌胳針愛滋病毒》
Fate of people with HIV in jeopardy in Ukraine
As the war in Ukraine escalates, the humanitarian crisis continues to grow. Since Russia invaded the country on Feb 24, the devastating effects on the population have become ever more acute. Indiscriminate attacks on civilians and civilian infrastructure are increasing, with little or no recognition of humanitarian corridors, and mounting loss of life. To date, an estimated 200 healthcare facilities are situated in the conflict zones, and several hospitals have been destroyed by military operations. The implications for people needing access to the country’s health systems are catastrophic.
Continued provision of, and safe access to, HIV treatment and prevention services in Ukraine for those living with and affected by HIV are at great risk. Early in the war, concerns had been expressed about the availability of HIV services during the conflict, with UNAIDS stating that supplies of antiretrovirals for the country’s over 150000 people on HIV treatment were limited to a few weeks. Although initial aid deliveries have concentrated on essential medicines and emergency materials, according to WHO, supplies of antiretrovirals will be met through funding and cooperation with international aid agencies, Ukraine Ministry of Health, and local non-governmental organisations.
Before the invasion, Ukraine’s response to HIV had been mixed, hampered by poor socioeconomic conditions, reduced external funding, and unrest in the eastern separatist provinces. However, in recent years the country had made substantial progress in tackling the epidemic, which is mainly concentrated among people who inject drugs. The estimated population of people who inject drugs is over 350000 with an HIV prevalence of 21%. In particular, there was a big scale-up in harm reduction services, including needle exchange programmes and the largest opioid agonist therapy programme in eastern Europe and central Asia. The country has seen a 21% reduction in new infections since 2010. The besieged cities of Dnipro, Kyiv, and Odessa had recently signed up to the Fast Track Cities initiative. The conflict threatens to undo years of progress.
There are antiretrovirals in the country, but access to supplies are already limited in the areas worst affected by the conflict, as highlighted in a Feature in this issue. In-country storage, delivery, and distribution of supplies may be disrupted as the intensity of the conflict spreads. Mitigations for interrupted and limited supplies of antiretrovirals are expected to include trying to anticipate stockouts, multimonth prescribing, and identifying areas expected to have an influx of internally displaced people with HIV. Potential difficulties also exist for the supply and distribution of methadone for opioid agonist therapy. It is shocking that, so far, respect for humanitarian corridors from Russian military has been scant—the existence of these corridors is not only essential for the safe escape of civilians but also to ensure medical supplies reach those most in need. Some organisations have already had to scale back or stop their HIV programmes.
As covered by The Lancet HIV in 2018, the ongoing conflict and occupation by Russian forces in the breakaway eastern separatist provinces of Luhansk and Donetsk decimated HIV services in the area, and serves as a warning for the health and welfare of people with HIV should a Russian-supported regime succeed in Ukraine. The separatist authorities and the Russian administration in annexed Crimea stopped opioid agonist therapy, reflecting the situation in the Russian Federation where the therapy is illegal.
The conflict could have serious implications for the HIV response in adjacent countries too. As of March 11, according to the UN migration agency, 2·5 million refugees had crossed the western Ukraine border to neighbouring friendly countries and estimates suggest that this will soon reach 4 million. Continuity of HIV services for those refugees who do make it to adjacent countries is a concern. It is imperative that health systems in these countries are supported, particularly Moldova, one of the poorest countries in Europe. The sanctions too are likely to take a toll on the already limited funding to HIV services in the Russian Federation, which has the largest HIV epidemic in eastern Europe and central Asia.
Provision of a functioning health system that ensures the health, safety, and wellbeing of people, including those affected by HIV, is impossible if the conflict continues, despite the immense humanitarian efforts of governments, aid agencies, and civil society. Ukraine’s HIV response, and the HIV response in the region are in peril unless the invasion ends now. ■ The Lancet HIV