社區動員以實現愛滋病毒檢測和照護目標
資料來源；www.thelancet.com/hiv Vol 9 September 2022 / 財團法人台灣紅絲帶基金會編譯
對撒哈拉以南非洲 HIV 介入結果的評估，揭示了 HIV 服務提供者和診所只能針對所服務的社區此種尚未發掘的障礙。 為了顧客與提供者成功的互動，社區參與可以倡導和促進 HIV 檢測、與照護的聯繫、抗反轉錄病毒治療 (ART) 的順從性，並存留在長期照護中。回饋可能會導致以臨床為基礎上的改進， 但社區動員的主要目標則是去解決基本社會障礙以達成有益的結果。
在《剌胳針愛滋病毒》中，Sheri A Lippman 及其同事報告了他們 2015-18 年集團隨機對照試驗的結果，以評估社區動員之介入對 HIV 檢測、照護的聯結和存留於照護中等項目的影響。研究人員將南非東北部姆普馬蘭加省農村阿金庫爾區的 15 個社區隨機分配到實施整套社區動員介入（介入組）或採用標準的測試、聯結或照護（對照組）。以理論為基礎的介入讓社區居民透過尋求提高治療素養、減輕對愛滋病毒的恐懼和恥辱感、對服務的參與改善其社會支持，以及影響阻礙就醫的男性性別規範等來解決愛滋病毒檢測和治療的社會障礙。社區動員介入領域是：對所需變革的共同關注；社區宣傳；組織間的聯繫；領導；集體行動；以及社區凝聚力。作者假設所有這些領域都必須得到解決，社會變革才能影響行為改變、改善社會規範並實現更好的健康結果。
該介入由來自南非非政府組織的社區動員者提供，該組織專注於愛滋病毒計畫、行動主義和性別平等。社區行動團隊在基於社區的活動和為期兩天的密集研討會中使用了七個主題和 50 個模組。這些行動小組包括 170 名社區志願者，他們在自己的村莊中與社區動員者、當地領導人、利益相關者和 3,8392 名參與者一起工作。社區動員以「治療作為預防」的試驗在當地被稱為 Tsima ra rihanyu（意為共同努力為健康而深耕）。
在研究中，男性和女性的愛滋病毒檢測在兩組中都有所改善，社區動員組的相對變化略高。僅在社區動員小組中的女性中注意到與照護聯結上的改善。在研究期間，兩組的存留率都有所下降，但在社區動員組的女性中，這種情況並沒有那麼嚴重。結果顯示，到 2030 年實現聯合國愛滋病規劃署 90-90-90（現為 95-95-95）指標有一定的好處，女性在所有方面都受益，但男性僅在測試中受益。
該研究是撒哈拉以南非洲地區「以治療作為預防」的系列試驗家族其中之一，這些試驗在當地環境中應用快速愛滋病毒檢測和基於抗轉錄病毒治療 (ART) 的照護。所有這些試驗都包括不同程度的社區動員。 ANRS 12249 TaSP、SEARCH、Botswana Ya Tsie 和 HPTN 071 (PopART) 試驗都具有HIV 傳播在社區層面上的結果，而其他試驗，如「治療作為預防」的社區動員、Shikamana 計畫 和 MaxART等試驗則試圖改善涵蓋率和病毒抑制。所有這些研究都有成功和失望之處，而人們可能會問，我們要從這裡再朝向哪裡去呢？
首先，研究資助的一個根本缺陷是介入措施的持續時間往往只有 2-3 年，評估結果的追蹤可能只有 1-2 年。人們可能會假設，短暫的社區參與和動員介入不會扭轉深層嵌入的社會負擔，例如污名、性別權力不平衡或健康素養和計算能力差。事實上，當劑量過低（即，需要更多強度或多年的參與）和追蹤過於膚淺（即，結果可能只會在更長的時間段內才會改善）時，一個有希望的介入措施可能被認為是無效的。科學方法的實施需要有此類長期負擔得起的研究且要能實用。
其次，Lippman 及其同事在試驗中可能已經看到治療的疲乏，因為社區動員和對照組社區的存留率在 3 年研究期間均有所下降。更容易獲得 ART 和使用的維持可能需要創新的計畫、使用長效可注射抗反轉錄病毒藥物以及改善供應鏈以避免藥物缺貨。
第三，採用綜合性的方法至關重要，因為沒有單一的創新會帶來變革。這包括針對女性、男性、青少年、性少數群體和性別少數群體、性工作者、社區領袖、衛生保健工作者和傳統治療師及其他人等的特定群體目標，以及更廣泛的社區動員努力。非洲 95-95-95 指標成功的關鍵，是使用奠基於社區夥伴關係的綜合性預防和照護介入措施，而這些夥伴關係影響著潛在的社會挑戰和不平等。
作者聲明沒有競爭利益。 SHV 部分得到美國國立衛生研究院的支持（授權號 P30MH062294）。資助機構在本評論中沒有任何作用。
sten.vermund@yale.edu
Sten H Vermund，美國康乃狄克州紐黑文市耶魯大學公共衛生學院微生物疾病流行病學系
Community mobilisation to achieve HIV testing and care goals
www.thelancet.com/hiv Vol 9 September 2022
Assessment of outcomes for HIV interventions in sub-Saharan Africa unearth obstacles that HIV service providers and clinics can only address with the communities served. For successful client– provider interactions, community engagement can advocate for and facilitate HIV testing, linkage to care, adherence to antiretroviral therapy (ART), and retention in long-term care. Feedback could lead to clinic-based improvements, but the principal objective of community mobilisation is to address fundamental social obstacles to salutary outcomes.
In The Lancet HIV, Sheri A Lippman and colleagues report on the results of their 2015–18 cluster randomised controlled trial to assess the effect of a community mobilisation intervention on HIV testing, linkage to care, and retention in care. The investigators randomly assigned 15 communities in the Agincourt sub-district of the rural Mpumalanga province in north eastern South Africa to the community mobilisation intervention package (intervention group) or to standard testing, linkage, or care (control group). The theory-based intervention engaged community residents to address social barriers to HIV testing and treatment by seeking to improve treatment literacy, mitigate HIV fear and stigma, improve social support to engage services, and influence male gender norms that inhibit care-seeking. Community mobilisation interventional domains were: a shared concern for needed change; community sensitisation; organisational linkages; leadership; collective actions; and community cohesion. The authors postulated that all these domains must be addressed for social change to influence behaviour change, improve social norms, and achieve better health outcomes.
The intervention was delivered by community mobilisers from a South African non-governmental organisation focused on HIV programmes, activism, and gender equity. Seven themes and 50 modules were used by community action teams within community-based activities and intensive 2-day workshops. These action teams included 170 community volunteers working in their own villages with the community mobilisers, local leaders, stakeholders, and 38,392 participants. The Community Mobilisation for Treatment as Prevention trial was known locally as Tsima ra rihanyu (meaning working together to plough the fields for health).
HIV testing improved in both groups for both men and women in the study, with modestly higher relative changes in the community mobilisation group. Linkageto-care improvements were noted only among women in the community mobilisation group. Retention declined over the study period in both groups, but this was not as severe among women in the community mobilisation group. The results suggested a modest benefit towards achieving the UNAIDS 90-90-90 (now 95-95-95) indicators by 2030, with women benefiting in all elements but men only benefiting in testing.
The study is among a family of sub-Saharan African treatment-as-prevention trials that applied fast track HIV testing and ART-based care in local settings. All included community mobilisations to varying extents. The ANRS 12249 TaSP, SEARCH, Botswana Ya Tsie, and HPTN 071 (PopART) trials had community-level HIV transmission outcomes, whereas other trials such as Community Mobilisation for Treatment as Prevention, Project Shikamana, and MaxART sought to improve coverage and viral suppression. All these studies had successes and disappointments and one might well ask, where do we go from here?
First, a fundamental flaw in the funding of studies is that the interventions tend to be only 2–3 years in duration and follow-up to assess outcomes might be for just 1–2 years. One might posit that transient community engagement and mobilisation interventions will not reverse embedded social burdens such as stigma, gender–power imbalance, or poor health literacy and numeracy. A promising intervention might be deemed ineffective when, in fact, the dosage was too low (ie, more intensity or years of engagement needed), and follow-up too superficial (ie, outcomes might only improve over longer time periods). Implementation science approaches will be needed to make such long-term studies affordable and practical.
Second, treatment fatigue might have been seen in the trial by Lippman and colleagues, as both community mobilisation and control group communities saw a decline in retention rates over the 3-year study period.3 Making it easier to obtain ART and maintain usage might require programmatic innovation, use of longacting injectable antiretroviral drugs, and supply chain improvements to avoid drug stockouts.
Third, combination approaches are essential, as no single innovation will be transformative. This includes specific group-targeted efforts among women, men, adolescents, sexual and gender minorities, sex workers, community leaders, health-care workers, and traditional healers, among others, alongside broader community mobilisation efforts. Essential to the 95-95-95 indicator successes in Africa is the use of a combination of prevention and care interventions grounded in community partnerships that influence underlying social challenges and inequities.
I declare no competing interests. SHV is supported, in part, by National Institutes of Health (grant number P30MH062294). The funding agency had no role in this Comment. Sten H Vermund sten.vermund@yale.edu Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, CT 06510, USA