猴痘和愛滋病毒：相似但並不相同？

資料來源：醫學博士 Paul G. Auwaerter / 2022 年 8 月 9 日 / Medscape / 財團法人台灣紅絲帶基金會編譯

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作為 1980 年代中期在紐約市的一名醫科學生，我親身經歷了愛滋病毒造成的悲劇和破壞。聯邦和地方的反應平淡無奇。作為一名醫科學生，在 1985 年美國疾病控制與預防中心 (CDC) 建議採取普遍預防措施後，我更專注於學習基本的醫術和了解在抽血或拉排水管時是否應該戴手套。

Anthony Fauci 博士是美國政府中為數不多的幾位領導人之一，他們在 HIV 活動家的溫和推動下，開始領導科學工作。 1988 年我來到巴爾的摩進行住院醫師訓練時，約翰·巴特利特博士、弗蘭克·波爾克博士 ( Drs John Bartlett, Frank Polk ) 和其他人努力爭取醫院資源，以建立愛滋病毒診所和住院服務，專門為抗反轉錄病毒時代的伺機性感染者提供照護。

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在許多方面，福奇博士的評論說，全球猴痘的最初幾個月讓人想起早期的愛滋病毒時代。透過親密接觸透過社交網絡傳播的疾病主要困擾著同性戀、性活躍的男性。美國政府的反應一直很慢，包括最近才宣布進入公共衛生緊急狀態。我不禁想到，如果感染影響不同的人群，反應會更強烈、更快。地方上的醫療照護再次地落入公共衛生機構和傳染病臨床醫生的手中，他們目前仍然因持續的 COVID-19 大流行而筋疲力盡，缺乏足夠及時的資源。

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儘管愛滋病毒在 40 年後仍然是一場瘟疫，但出於多種原因，猴痘不太可能變得如此嚴重。如果不加以治療，HIV 會導致一種高死亡率的慢性感染，而透過疫苗接種的實用預防方法卻一直難以捉摸。另一方面，正痘病毒是一種死亡率非常低的急性感染。傳染性似乎與 SARS-CoV-2 相去甚遠，並且與 HIV 不同，因為它的傳染性持續時間相當短。許多感染猴痘的人在多次性接觸後獲得感染。對 2022 年爆發的早期估計將其 R0 數設為 1.29，美國的比率更高，為 1.55。這些數字令人擔憂，因為它們大於 1，但如果它們保持不變，它們仍然與 SARS-CoV-2 或 HIV 相去甚遠。由於這些原因，世界衛生組織在當前環境下建議限制性伴侶的數量。

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目前有一種可能有效的疫苗，即使供應不足。抗病毒藥物，如 tecovirimat，可用於患有嚴重感染（如直腸炎）或免疫抑制的人。然而，我們缺乏明確的證據顯示這些藥物對大多數患者有幫助。

最近宣布的美國突發公共衛生事件是一個非常受歡迎的跡象，顯示在愛滋病毒感染者身上發生的一些失誤和延誤不會以同樣的程度發生。未來幾個月應該會有更多的疫苗供應，美國食品和藥物管理局 (FDA) 正在考慮採用一種減少劑量的皮內注射方法來增加供應。商業實驗室正在提供測試，並且可能很快就會提供即時測試。希望 FDA 將發布緊急使用授權，以改善對 tecovirimat 的取得，並減少 CDC 在擴大取得研究藥物計畫所施加的障礙。

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猴痘的故事還處於起步階段，但全球性傳播使其不太可能被遏制，會成為另一種廣泛的人類感染。 有人可能認為美國已經做好準備，因為天花引發了應對生物恐怖主義事件的相關應對措施。然而這個現實世界的測試也指出了需要緊急解決的問題，包括足夠的接觸者追踪、測試、準備和更多的公共衛生資源。 2007 年，當被問及為什麼在媒體上很少聽到有關愛滋病的消息此種愛滋疲乏現象時，福奇博士在 CNN 的一篇關於愛滋疲乏的報導中發表了評論。 他指出，「世界是一個如此相互聯繫的地方，在世界另一部分發生的事情都會影響我們」。我們現今有各種不同版本的疲乏且不會有舒適狀況會讓我們以不同的方式去處理下一個。

Monkeypox and HIV: Same but Different?

Paul G. Auwaerter, MD / August 09, 2022 / Medscape

As a medical student in the mid-1980s in New York City, I had a firsthand experience of the tragedy and devastation wrought by HIV. Federal and local responses were underwhelming. As a medical student, I was more preoccupied with learning the basics of doctoring and understanding whether we should wear gloves when drawing blood or pulling drains after the 1985 Centers for Disease Control and Prevention (CDC) recommendation of universal precautions.

Dr Anthony Fauci was among the few leaders within the US government who, with more-than-gentle prodding by HIV activists, came to lead the scientific effort. When I came to Baltimore in 1988 for medical residency, Drs John Bartlett, Frank Polk, and others fought to get hospital resources to set up HIV clinics and inpatient services dedicated to caring for people with opportunistic infections in the pre–antiretroviral era.

In many ways, Dr Fauci’s comment that these first months of the global monkeypox are reminiscent of the early HIV days is apt. The spread through social networks by intimate contact is afflicting predominantly gay, sexually active men. US government response has been slow, including only recently declaring a public health emergency. I cannot help but think that reactions would have been stronger and faster if the infection were afflicting a different population. Local health care has fallen again to public health agencies and infectious disease clinicians who remain exhausted from the ongoing COVID-19 pandemic and starved of sufficient and timely resources.

Though HIV continues to be a plague 40 years on, for several reasons monkeypox is unlikely to become as significant. HIV establishes a chronic infection with high mortality if untreated, and a practical preventive approach through vaccination has been elusive. Orthopox, on the other hand, is an acute infection with very low mortality. The transmissibility appears nowhere near SARS-CoV-2 and differs from HIV because it has a fairly short infectivity duration. Many infected with monkeypox acquired infection after participation in multiple sexual encounters. An early estimate of the 2022 outbreak places the R0 number at 1.29, with a higher rate in the United States, at 1.55. These numbers are concerning because they’re greater than 1, but if they hold, they will still be nowhere near those of SARS-CoV-2 or HIV. For these reasons, the World Health Organization suggested limiting the number of sexual partners in the current environment.

A vaccine that probably will be effective is currently available, even if in short supply. Antiviral medications, like tecovirimat, are available for people with severe infections, such as proctitis, or for those who are immunosuppressed. However, we lack clear-cut evidence that these drugs are helpful in most patients.

The recently declared US public health emergency is a most welcome sign that some of the missteps and delays that occurred for those with HIV will not happen to the same degree. More vaccine supply should be available in the forthcoming months, and the US Food and Drug Administration (FDA) is considering a dose-sparing intradermal approach to increase supply. Commercial labs are offering testing, and point-of-care tests may be available soon. Hopefully, the FDA will issue an emergency use authorization to improve access to tecovirimat and reduce the barriers imposed by the CDC’s expanded access investigational drug program.

The story of monkeypox is only in its infancy, but the global spread makes it unlikely that it will be contained, becoming yet another widespread human infection. One might think that the United States was ready since related smallpox prompted countermeasures to face a bioterrorism event. This real-world test points to problems that need urgent addressing, including sufficient contact tracing, testing, preparedness, and more public health resources. In 2007, Dr Fauci commented in a CNN story on AIDS fatigue when asked why you don’t hear about it much in the media. He noted that “the world is a place that is so interconnected that what happens in another part of the world will impact us.” We have a different version of fatigue nowadays and have no comfort we’ll handle the next differently.