資料來源：刺胳針愛滋病毒醫學期刊，www.thelancet.com/hiv Vol 6 November 2019，財團法人台灣紅絲帶基金會編譯

非洲是大多數減輕愛滋病毒全球負擔的工作應專注於該地區進行的區域，因為70％的愛滋病毒感染者和新感染者是位居於該大陸上。

儘管全球朝向聯合國愛滋病規劃署90-90-90或95-95-95目標上的進展令人鼓舞 （於2020年或2030年時，能達到90％或95％的HIV陽性者了解自己感染的狀況，並提供90％或95％的確診者接受抗反轉錄病毒藥物治療，而接受抗反轉錄病毒藥物治療者，其病毒被抑制的比例亦將達到90％或95％），各個地區仍然存在高度的異質性，而非洲的指標最差。

要實現這些雄心勃勃的目標仍然面臨著許多挑戰，其中之一就是愛滋病毒感染負擔上的關鍵人群要以較高的比例覆蓋，包括男男間性行為者（MSM）。於2017年，在非洲新的愛滋病毒感染人口中MSM佔比為6–17％，構成愛滋新感發生率第二高的人群。在結束全球愛滋病毒流行的最後階段，重要的是掌握有關非洲如此重要人口指標演變的關鍵數據。

在《刺胳針愛滋病毒》中， James Stannah及其同事對來自28個非洲國家75項研究的盛行率數據（總計44,993 名MSM）進行系統的回顧和薈萃分析。儘管異質性很大，可能會阻礙作者的發現對整個非洲地區普遍性的適用，但所有MSM中其HIV照護層級的指標並不理想，並且距離90-90-90目標還很遠。  

他們報告說， MSM之愛滋病毒感染者中有24％的人接受了抗轉錄病毒治療（ART），其中有25％的治療者其病毒被抑制，且南部非洲的一些指標似乎較好。作者還發現HIV檢測與MSM狀況之披露間有正向的關聯存在。

此外，在接受測試與對感染狀態的認知上的較低水平亦與更具敵意的立法有關。

這項研究填補了文獻上一個重要的知識空白，並確定終結愛滋病毒流行的總體範圍上的挑戰。Stannah和同事強調了在愛滋病毒檢測、參與在照護體系，以及抗反轉錄病毒療法的起始和順從性方面上的差距，在雄心勃勃的90-90-90目標下可能無法實現。的確，要達到90％的愛滋感染者意識到自己的狀況，受限於對愛滋病毒檢測的接受程度低，並否認存有感染愛滋病毒的風險。特別是MSM族群，對於污名、歧視和缺乏機密隱私等方面之懼怕也是很重要。要達到90％確診的人接受ART治療的目標所面臨的挑戰，包括於經測試HIV呈現陽性後對ART真正拒絕和錯誤接受的起始態度，或開始ART治療時的不適當狀況或藥物庫存的不足，並且缺乏從篩查、診斷到開始治療等，實際執行上相關的具體指導。在據報導有三分之二的非洲國家有如此惡劣的污名、歧視和罪刑化的氣氛下，要在難以觸及的MSM族群中開始ART治療尤其困難。而要實現90％的感染者接受抗病毒藥物治療之目標，在ART患者的順從性差、存留於ART照護狀態不佳以及ART的存量不足等，均會對非洲這一目標的達成產生負面影響。確實，隨著HIV陽性和MSM狀態的雙重負擔，與一般人口中的感染者相比，對ART的順從性可能更低。Stannah和其同事提供了在非洲MSM族群中關於愛滋治療照護層級中重要的及時現狀，並突顯出需要採取緊急行動的地方。非洲各國政府應該為這個難以觸及且飽受污名和歧視的弱勢群體，制定全面性的計劃和整體性地提供照護、支持和預防等的介入措施。透過社區動員、醫護人員的教育以減少污名和歧視以及MSM族群的參與，不僅是在全球範圍內更是在非洲此一疾病的流行中心，在終結愛滋病毒/愛滋病的流行上仍然至關緊要。人權是普遍的，而性取向並不應是被排斥的理由。

儘管非洲某些國家（例如烏干達和奈及利亞）其抗LGBT的立法上增加了嚴重性，希望隨著LGBT權利上的正向變化，MSM族群中的愛滋治療照護層級上的指標，將在未來幾年中有所改善，以邁向終結愛滋病毒的流行。

* Jean Joel Bigna， Jobert Richie Nansseu

（JJB）；流行病學與公共衛生系，喀麥隆巴斯德中心，雅溫得，喀麥隆

法國巴黎薩克萊大學醫學部公共衛生學院，Quentin-en-Yvelines，法國

（JRN）； 流行、大流行與疾病控制處，公共衛生部，雅溫得，喀麥隆

公共衛生系，喀麥隆雅溫得大學醫學與生物醫學學院，雅溫得，喀麥隆

Men who have sex with men: a key population in Africa

Africa is the region where the majority of efforts should be focused to curtail the global burden of HIV infection because 70% of people living with HIV and new HIV infections are located on this continent. Although the progress towards the 90-90-90 or 95-95-95 UNAIDS objectives is encouraging (achieve 90% or 95% of HIVpositive people aware their status, provide antiretroviral therapy for 90% or 95% of those diagnosed, and achieve viral suppression for 90% or 95% of those treated by 2020 or 2030) globally, there remains a high heterogeneity across regions, with Africa having the poorest indicators.

Many challenges remain to achieve these ambitious goals, one of which is to reach key populations with a high burden of HIV infection, including men who have sex with men (MSM). In 2017, MSM accounted for 6–17% of new HIV infections in Africa, constituting the population with the second highest incidence of new HIV infections. In the final stretch to end the global HIV epidemic, it is important to have key data on the evolution of indicators from such a key population in Africa.

In The Lancet HIV, James Stannah and colleagues present a systematic review and meta-analysis of prevalence data of 75 studies (total of 44 993 MSM) from 28 African countries. Although heterogeneity was substantial, which might hinder the generalisability of the authors’ findings for the whole African region, all

indicators of the HIV care cascade among MSM were suboptimal and still very far from the 90-90-90 targets.

They reported that 24% of MSM living with HIV were on antiretroviral therapy (ART) and 25% were virally

suppressed, with southern Africa seeming to have better indicators. The authors also found a positive association between HIV testing and disclosure of MSM status.

Furthermore, lower testing and status awareness were associated with more hostile legislation . This study fills an important knowledge gap in the literature and identifies an overarching range of challenges to end the HIV epidemic. Stannah and colleagues highlight gaps in HIV testing, engagement in care, and initiation and adherence to antiretroviral therapy, which might be unattainable under the ambitious 90-90-90 targets. Indeed, reaching the target of 90% of people with HIV aware of their status is limited by low acceptance of HIV testing and denial of being at risk for HIV infection. For MSM specifically, fear of stigma, discrimination, and lack of confidentiality are also important. To reach the target of 90% of diagnosed people on ART, challenges include understanding the true refusal and false acceptance of ART initiation attitudes after testing HIV positive, inadequate or insufficient stocks of ART to initiate treatment, and the absence of specific guidance on actual real-life implementation of screening, diagnosis, and treatment initiation. Initiating ART in the hard-to-reach MSM population is particularly difficult with the unfavourable climate of stigma, discrimination, and criminalisation reported in twothirds of African countries. To reach the target of 90% of people on ART with viral suppression, poor adherence to ART, poor retention in care, and inadequate stocks of ART can negatively affect this objective in Africa. Indeed, with the double burden of an HIV-positive and MSM status, adherence to ART can be lower compared with the general population living with HIV.

Stannah and colleagues have provided important updates on the current situation regarding the HIV care

cascade among MSM in Africa, and highlight areas where urgent action is needed. Governments in Africa

should develop comprehensive programmes and holistic interventions to provide care, support, and preventive services for this hard-to-reach stigmatized and discriminated vulnerable population. Community mobilisation, health-care worker education to decrease stigma and discrimination, and engagement of MSM remain crucial to end the HIV/AIDS epidemic both globally and at its epicentre in Africa. Human rights are universal, and sexual orientation is no grounds for exclusion.

Although some countries in Africa (eg, Uganda and Nigeria) have increased the severity of their anti-LGBT

legislation, it is hoped that with positive changes in LGBT rights, indicators of the HIV care cascade in MSM will be improved in the upcoming years to end the HIV epidemic.

*Jean Joel Bigna, Jobert Richie Nansseu

Department of Epidemiology and Public Health, Centre Pasteur of Cameroon, Yaoundé 1274, Cameroon (JJB); School of Public Health, Faculty of Medicine, University of Paris Saclay, Saint-Quentin-en-Yvelines, France (JJB); Department for the Control of Disease, Epidemics and Pandemics, Ministry of Public Health,

Yaoundé, Cameroon (JRN); and Department of Public Health, Faculty of Medicine and Biomedical Sciences, University of Yaoundé I, Yaoundé, Cameroon (JRN)

bignarimjj@yahoo.fr

www.thelancet.com/hiv Vol 6 November 2019