資料來源：www.thelancet.com/hiv Vol 10 June 2023 / 財團法人台灣紅絲帶基金會編譯
由於無法獲得金錢、教育、就業、增長機會、社會聯繫和網絡等資源，社會不平等加劇，從而導致貧困。 在一系列社會和經濟劣勢的影響下，受影響人群無法管理自己的健康狀況。儘管在獲得氧氣、及時檢測、疫苗和治療可能可以挽救他們的生命 ，但COVID-19 大流行期間，不平等現象無情地發生。
在愛滋病毒領域，圍繞不平等的討論再次成為焦點，再加上恥辱、歧視和健康問題等社會決定因素，這些因素導致了不良的健康結果。減少重點人群的貧困可以改善他們的生活和條件，但如何才能實現這一目標 ？ 現金轉移計畫等創新提供了解決方案並令人興奮，但必須認真實施，以解決不平等的根本原因，而不僅僅是膚淺的短期解決方案。
有條件現金轉移（Conditional cash transfers ,CCTs）（註）可以提供價值，前提是支付的現金轉移取決於滿足要求。 這包括從尋求檢查或繼續服藥到繼續接受照護。 迄今為止，關於有條件現金轉移的證據尚無定論，但強調了背景和文化因素在其實施中的重要性。 許多 CCT 計畫都涉及強迫顧戶滿足關鍵標準，可能會對顧客的能力、關聯和尊嚴（社會正義的關鍵要素）產生無意的負面影響。CCT 不應導致剝奪個人權力。 儘管有證據顯示有條件現金轉移可能在短期內有效，可以改善愛滋病毒預防和與照護的聯繫，但長期影響可能需要改善教育、就業機會和收入，以直接解決健康的社會決定因素。
在《刺胳針愛滋病毒》中，Nathalia Sernizon Guimaraes 及其同事重新審視了 CCT 的價值。 作者在對隨機對照試驗數據的匯總薈萃分析中顯示，現金轉移計畫對降低愛滋病毒發病率和提高孕婦愛滋病毒照護的存留率具有積極作用。 然而，隨著時間的演變CCT並不影響存留。 臨床試驗是短暫的； 結果和措施並不相同，因此無法明智地匯總。 作者讓我們相信 CCT 對某些人群的重要性，但報告的其他國家的數據不足，呼籲應進行更多研究。 一項針對低收入階層定義的 CCT 的大型多國隨機對照試驗，以及一致的存留措施和長期追蹤的同質報告，可以提供答案。 然而，來自巴西相關助學金計畫的全部證據，使調查人員確信有條件現金轉移可能有助於愛滋病毒控制。
與 CCT 結合的愛滋病毒控制整體方法能否成為另一種解決方案？ 這將包括解決醫療保健機構中的恥辱和歧視問題，這些恥辱和歧視會影響到醫療保健機構的積極性並阻礙其就診，無論這些就診的動機如何。 為此，有條件現金轉移只是解決健康不平等問題的一個因素，必須同時解決其他背景因素，例如對尋求愛滋病毒治療的關鍵群體的高歧視率。 積極主動的個人無論如何都會尋求照護，可能會拒絕 CCT，並希望透過數位化之支持獲得更高質量、定制化和個性化的照護。 在我們的無激勵研究中，提供數位化之支持以及愛滋病毒自我檢測和患者所偏好的富有同情心的照護會影響南非鄉鎮人口的照護聯繫。
或者，一種解決方案可能並不適合所有人； 因此，就針對特定亞人群的最佳方法尋求共識可能是另一個解決方案。 對於一些國家和人群來說，對接受金錢的文化反應可能是一個因素。對於有動機透過 CCT 尋求照護的個人來說，促進客戶參與和賦權的文化定制計畫可以確保 CCT 的長期社會影響。 在適當的情況下，有條件現金轉移可能會幫助那些可能因交通不足而難以前往醫療保健中心或因收入低而希望保持服藥動力的高危人群。
如果我們要結束愛滋病毒大流行並按時實現聯合國愛滋病規劃署的 95-95-95 目標，CCT 可能是一個有希望的解決方案。 如果用更多數據重新審視，CCT 可能會對特定亞群的愛滋病毒計畫有益，這些亞群可能希望控制感染，但因生活環境而感到沮喪而無法做到這一點。 在這種情況下，在正確的時間、以正確的意圖和條件提供一點幫助可能會大有幫助。
我們聲明不存在競爭利益。
*Nitika Pant Pai，Alice Zwerling nitika.pai@mcgill.ca
加拿大魁北克省蒙特利爾麥吉爾大學醫學系和麥吉爾大學健康中心研究所（NPP）； 渥太華大學流行病學與公共衛生學院，加拿大安大略省渥太華 (AZ)
註：有條件現金轉移（CCT）計畫旨在通過使福利計畫以接受者的行動為條件來減少貧困。 政府（或慈善機構）僅將資金轉移給符合特定標準的人， 這些標準可能包括讓兒童入讀公立學校、在醫生辦公室定期檢查、接受疫苗接種等。 有條件現金轉移旨在幫助當代貧困人口，並透過人力資本開發打破下一代的貧困循環；有條件現金轉移並有助於減少貧困女性化（女性或兒童因社經地位的弱勢而落入更貧窮的困境）。
To give or not to give: what is the evidence?
www.thelancet.com/hiv Vol 10 June 2023
Social inequality is precipitated by insufficient access to resources such as money, education, jobs, growth opportunities, social connections, and networks, resulting in poverty. Under the effects of clusters of social and economic disadvantages, affected populations are unable to manage their health conditions. Inequity transpired ruthlessly during the COVID-19 pandemic. Millions of people in poverty lost their lives, although access to oxygen, timely testing, vaccines, and treatment could potentially have saved them.
In the field of HIV, conversations around inequity have become central again, together with stigma, discrimination, and social determinants of health that precipitate poor health outcomes. Reducing poverty in key populations can improve their lives and conditions, but how can this be achieved? Innovations like cash transfer programmes offer a solution and generate excitement but must be carefully implemented to address the root causes of inequity and not simply constitute a superficial short-term solution.
Conditional cash transfers (CCTs) can offer value, provided the cash transfer disbursed depends on meeting a requirement. This varies from seeking a test or staying on a medication to remaining engaged in care. Evidence to date on CCTs has been inconclusive, but has highlighted the strong importance of contextual and cultural factors in their implementation. Many CCT programmes involve compelling clients to meet key criteria and might have inadvertent negative effects on clients’ agency, association, and dignity, key elements of social justice. CCTs should not contribute to disempowering the individual. Although evidence shows CCTs might be effective in the short term by improving HIV prevention and linkage to care, longterm effects are likely to require improvements to education, job opportunities, and income to directly address the social determinants of health.6
In The Lancet HIV, Nathalia Sernizon Guimaraes and colleagues7 re-examined the value of CCTs. The authors showed in their pooled meta-analyses of randomised controlled trial data that cash transfer programmes have a positive effect on reducing HIV incidence and on increasing retention in HIV care for pregnant women. However, CCTs did not affect retention over time. Clinical trials were short-lived; outcomes and measures were not homogeneous and, therefore, could not be pooled intelligently. The authors have convinced us of the importance of CCTs for some populations, yet reported insufficient data from countries for others, calling for more research. A large multicountry randomised controlled trial on CCTs in strata defined by low income levels, with homogeneous reporting of consistent retention measures and long-term followup, could provide an answer. However, the totality of evidence from related bursary programmes in Brazil has convinced the investigators to conclude that CCTs might work for HIV control.
Could a holistic approach to HIV control together with CCTs be another solution? This would include addressing stigma and discrimination in health-care settings that affect motivation and impede visits to health-care facilities however incentivised those visits might be. To this end, CCTs are just one factor in addressing health inequities, and other contextual factors, such as high rates of discrimination against key groups seeking care for HIV, must be addressed concurrently. Highly motivated individuals, who will seek care regardless, might refuse CCTs and desire the better-quality, customised, and personalised care that is possible today with digital support. In our unincentivised studies, offering digital support together with HIV self-testing with patient-preferred compassionate care affected linkages to care in township populations in South Africa.
Alternatively, one solution might not be suitable for all; therefore, seeking consensus on the best approach for specific subpopulations could be another solution. The cultural response to receiving money might be a factor for some countries and populations.9 For individuals motivated to seek care by CCTs, culturally tailored programmes fostering client engagement and empowerment could ensure a long-term social effect of CCTs. CCTs, where appropriate, might help people at risk who might be struggling to visit healthcare centres because of insufficient transportation, or to stay motivated to take their medication due to low income.
If we are to end the HIV pandemic and achieve the UNAIDS 95-95-95 targets on time,10 CCTs could be a promising solution. If revisited with more data, CCTs could become beneficial for HIV programmes for specific subpopulations, who might want to control their infection but are too disheartened by life circumstance to do so. In this case, a little help given at the right time, with the right intention and conditions, might go a long way.
We declare no competing interests.
*Nitika Pant Pai, Alice Zwerling nitika.pai@mcgill.ca
Department of Medicine and Research Institute of the McGill University Health Centre, McGill University, Montreal, QC, Canada (NPP); School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada (AZ) 1 M