猴痘疫苗接種——預防愛滋病毒的機會
http://www.thelancet.com/hiv 2022 年 11 月 9 日
隨著世界應對持續的 COVID-19 大流行，世衛組織於 2022 年 7 月 23 日宣布猴痘病毒的爆發為全球公共衛生緊急事件。這種與引起天花的病毒有關的人畜共通正痘 DNA 病毒自 1970 以來在過去的 50 年中就已在人類中被描述，非洲的零星暴發病例通常被描述，源自與野生動物儲藏宿主（尤其是囓齒動物）的接觸。然而，在 2022 年，幾乎同時發生的全球暴發正在影響性活躍的男同性戀、雙性戀和其他幾乎完全是男男性行為者。與 COVID-19 大流行相反，一種可用於治療猴痘的疫苗已經上市，但關鍵挑戰是根據全球需求量來部署疫苗大大超過供應量。鑑於稀缺性，良好的公共衛生要求將疫苗提供給風險最高的人群——即在當前疫情中，性活躍的同性戀、雙性戀和其他有多個性伴侶、以及參與集體性行為或在性場域進行性行為的男男性行為者。很明顯，猴痘與其他性傳播疾病（尤其是愛滋病毒）具有相同的危險行為。事實上，在全球大型病例系列中，41% 的猴痘感染發生在 HIV 感染者中，而幾乎 60% 的未感染 HIV 的人正接受了暴露前預防 (PrEP)。
抗反轉錄病毒療法在發生率、死亡率和傳播率方面從根本上改變了 HIV 感染的自然史。儘管如此，所有治療級聯 (treatment cascades) 都顯示，晚期診斷仍然是一個主要障礙。事實上，延遲診斷的 HIV 感染者（即 CD4 計數低於 350 個細胞/μL，甚至低於 200 個細胞/μL）在過去的 20多年間佔歐洲每年新增確診病例數40% 以上均未見改善。晚期診斷，死亡率約為 5%，不僅對個人而言是臨床挑戰，也是消除 HIV 的主要障礙。導致延遲的重要原因包括對個人風險以及社會、人際和內在污名的理解不足。媒體對猴痘緊急情況的強烈關注，代表了一個千載難逢的機會，藉由提供大型疫苗接種活動的機會，為可能有感染 HIV 風險或可能不知道自己的 HIV 感染狀況的人進行檢測。每一次疫苗接種活動都提供了一個獨特的機會，除可增加愛滋病毒和其他性傳播疾病的檢測，抑或預防新的感染。實際上，公共衛生機構對疫苗接種工作的方法不應僅僅複製 SARS-CoV-2 的疫苗接種事件，而係應提供整合型之性健康診所。
這種以人為本、整體性針對性健康方法，可能需要對 HIV 感染者進行 HIV 檢測和促進快速抗反轉錄病毒治療，或在 HIV 檢測呈陰性的情況下評估 PrEP的提供。這也可能是一個機會，可以在如意大利等尚未給付 PrEP 的國家引發圍繞著 PrEP 的進一步行動。
不幸的是，這種以人為本的性健康方法並未被採納為照護標準。 Thornhill 及其同事描述，在 310 例既往 HIV 檢測中未知或陰性的病例中，只有 122 例（39%）患者在猴痘診斷後接受了 HIV 檢測，其中 2 例（2%）結果呈陽性。世衛組織宣布猴痘突發公共衛生事件反映了感染人數的增加，幸運的是，這與嚴重後果或死亡無關。在媒體對 COVID-19 和現在的猴痘的關注中，不應忘記愛滋病毒大流行正持續進行中，全球有超過 5,000 萬愛滋病毒感染者和數千人死亡，不僅在低收入和中等收入國家，而且在高收入國家，特別是在感染者晚期呈現者中。為了減少延遲呈現，已經嘗試了許多方法；例如，歐洲 HIV 倡議提供了一份指標疾病清單，以確定應該接受 HIV 檢測的人群，包括性傳播疾病、淋巴瘤和血小板減少症。其他方法包括在急診室對就診人員進行檢測。我們認為，不僅猴痘本身應該被包括在這個愛滋病毒檢測的指標疾病列表中，而且，每個接受猴痘疫苗接種的人都應該接受愛滋病毒檢測，如果他們是陰性的，就應該接受有關 PrEP 的諮詢。
CM 報告來自 Gilead 的贈款和差旅支持，來自 ViiV Healthcare 的個人費用，以及來自 CORIMUNO、ViiV Healthcare、ROCHE、Janssen、Gilead Sciences 和 Merck Sharp & Dohme 的顧問委員會的參與。 GG 報告來自 Gilead Sciences、ViiV Healthcare 和 Merck Sharp & Dohme 的贈款、個人費用、差旅支持和參與諮詢委員會，以及 Janssen 的個人費用。
CO 報告來自 ViiV Healthcare 的贈款、個人費用和旅行贊助，以及來自 GlaxoSmithKline、Gilead Sciences、Merck Sharp & Dohme、Janssen 和 AstraZeneca 的贈款和個人費用。
*Cristina Mussini, Giovanni Guaraldi, Chloe Orkin cristina.mussini@unimore.it
意大利摩德納，摩德納和雷焦艾米利亞大學傳染病診所 (CM, GG)；英國倫敦，倫敦瑪麗女王大學，Barts Health NHS Trust (CO)
Monkeypox vaccination—an opportunity for HIV prevention
http://www.thelancet.com/hiv Vol 9 November 2022
As the world copes with the ongoing COVID-19 pandemic, WHO declared the outbreak of monkeypox virus a global public health emergency on July 23, 2022. This zoonotic orthopox DNA virus, related to the virus that causes smallpox, has been described in humans since 1970. In the past 50 years, cases were described in sporadic outbreaks in Africa, typically originating from contact with wildlife reservoirs (particularly rodents). However, in 2022, the near-simultaneous global outbreaks are affecting sexually active gay, bisexual, and other men who have sex with men almost exclusively. Contrary to the COVID-19 pandemic, a vaccine that could be used for monkeypox was already available, but the key challenge has been deploying the vaccine according to global demand that substantially exceeds supply. Given the scarcity, good public health dictates that the vaccines are offered to those at the highest risk—ie, in the current outbreak, sexually active gay, bisexual, and other men who have sex with men who have multiple partners, and who participate in group sex or attend sex on premises venues. It is clear that monkeypox shares the same risk behaviours with other sexually transmitted diseases, most notably HIV. In fact, 41% of monkeypox infections in a large global case series were in people with HIV, and almost 60% of those without HIV were on pre-exposure prophylaxis (PrEP).
Antiretroviral therapy has fundamentally changed the natural history of HIV infection in terms of morbidity, mortality, and rate of transmission. Nevertheless, all treatment cascades show that late diagnosis remains a major obstacle. Indeed, people with HIV who present late (ie, with a CD4 count below 350 cells per μL, or even less than 200 cells per μL) represent more than 40% of the new diagnoses in Europe annually with no improvement in the past 2 decades. Late diagnosis, with a mortality rate of around 5%, not only represents a clinical challenge for the individual but is also the main obstacle for HIV elimination. Important reasons driving late presentation include poor understanding of personal risk, and social, interpersonal, and internalised stigma. The intense media attention surrounding the monkeypox emergency, and the access to large vaccination events for people who might be at risk of acquiring HIV infection or might be unaware of their HIV status, represents a golden opportunity. Each vaccination event offers a unique opportunity, either to increase HIV and other sexually transmitted disease testing, or to prevent new infections. Indeed, the approach of public health agencies to the vaccination effort should not merely replicate the vaccination events for SARS-CoV-2 but should offer an integrated sexual health clinic.
This person-centred, holistic approach to sexual health could entail HIV testing and promotion of rapid antiretroviral therapy for people with HIV or evaluation for PrEP in case of a negative HIV test. This could also be an opportunity to spark further activism around PrEP in countries such as Italy where PrEP is still not reimbursed.
Unfortunately, this person-centred approach to sexual health has not been adopted as standard of care. Thornhill and colleagues described that among the 310 cases of unknown or negative previous HIV tests, only 122 (39%) patients underwent a HIV test after monkeypox diagnosis, and two (2%) of those had positive results. The WHO declaration of public health emergency for monkeypox reflects the growing number of infections, which fortunately have not been associated with severe outcomes or death. Amid the media attention around COVID-19 and now monkeypox, it should not be forgotten that the HIV pandemic is ongoing, with more than 50 million people living with HIV globally and thousands of deaths, not only in low-income and middle-income countries, but also in high-income countries, especially among late presenters. In the attempt to decrease late presentation, many approaches have been tried; for example, the HIV in Europe initiative has provided a list of indicator diseases to identify people who should be tested for HIV, including sexually transmitted diseases, lymphomas, and thrombocytopenia. Other approaches have included testing people in emergency departments. In our opinion, not only should monkeypox itself be included in this list of indicator diseases for HIV testing, but also, everyone undergoing vaccination should be tested for HIV and, if they are negative, counselled about PrEP.
CM reports grants and travel support from Gilead, personal fees from ViiV Healthcare, and participation on advisory boards from CORIMUNO, ViiV Healthcare, ROCHE, Janssen, Gilead Sciences, and Merck Sharp & Dohme. GG reports grants, personal fees, travel support, and participation on advisory boards from Gilead Sciences, ViiV Healthcare, and Merck Sharp & Dohme, and personal fees from Janssen.
CO reports grants, personal fees, and travel sponsorship from ViiV Healthcare, and grants and personal fees from GlaxoSmithKline, Gilead Sciences, Merck Sharp & Dohme, Janssen, and AstraZeneca.
*Cristina Mussini, Giovanni Guaraldi, Chloe Orkin cristina.mussini@unimore.it Clinic of Infectious Diseases, University of Modena and Reggio Emilia, 41121 Modena, Italy (CM, GG); Queen Mary University of London, Barts Health NHS Trust, London, UK (CO)