自殺預防研究對於實現愛滋感染者的健康公平至關重要
資料來源：www.thelancet.com/hiv Vol 9 November 2022 / 財團法人台灣紅絲帶基金會編譯
自殺是一個主要的公共衛生問題，影響著世界上最脆弱的人群。據估計，2019 年有 759,000 人死於自殺，佔全球死亡人數的 1·3%，即每 40 秒約有 1 人。全球 3,800 萬愛滋病毒感染者的自殺率很高。一項 2021 年的薈萃分析發現，愛滋病毒感染者死於自殺的可能性是普通人群的 100 倍。
生物、心理、社會和結構決定因素增加了愛滋病毒感染者的自殺風險。除了與該疾病相關的慢性和嚴重症狀外，愛滋病毒感染者還經常面臨創傷和壓力經歷，對身心健康造成負面影響。面臨與愛滋病毒相關的污名化之重點人群（即特別容易感染愛滋病毒的人群以及需要採取介入措施以減輕與 HIV 相關疾病的全球負擔的人群）缺乏社會支持，以及很少有精神衛生專業人員願意或能夠提供適當的照護，會增加 HIV 感染者自殺的風險。具體而言，自殺風險在性少數群體（例如，男男性行為者）和其他受 HIV 影響特別大的群體（例如，跨性別女性）中往往會增加。自殺預防應該是一個至關重要的優先事項，並且應該緊急擴大以證據為基礎的做法，以降低愛滋病毒感染者和有感染愛滋病毒風險人群的自殺風險。許多 HIV 感染者患有心理健康合併症，這會增加他們自殺的風險。包括抑鬱症在內的精神障礙會進一步降低治療順從性、惡化總體預後並加劇健康不平等。由於它們的雙向關係及其複雜的社會和臨床關聯，應優先考慮針對具體情況並結合心理健康和 HIV 介入措施的綜合服務。
WHO 和 UNAIDS 建議將心理健康和 HIV 綜合服務分為三個層次：在臨床和社區環境中，在專業和組織團隊中，以及在更廣泛的衛生系統中。整合策略可能因資源水平而異，需要利益相關方的共同承諾和充分參與，以及既定的監測和評估。除了減少污名化的社區介入外，愛滋病毒感染者的心理健康服務可以設在愛滋病診所，以加快分流、支持和轉診。精神衛生和 HIV 服務的整合為更公平和更有針對性的衛生服務提供了機會，以增強 HIV 感染者的心理健康和預防自殺。
AHS 報告了 ViiV Healthcare 和 Gilead Sciences 向她的機構提供的資助。所有其他作者聲明沒有競爭利益。
Yuming Liu、Wipaporn Natalie Songtaweesin、Joesph D Tucker、Annette H Sohn、Carl A Latkin、
*Brian J Hall brianhall@nyu.edu
中國上海，上海紐約大學全球健康股權中心（YL、JDT、CAL、BJH）；美國馬里蘭州巴爾的摩，約翰霍普金斯大學彭博公共衛生學院國際衛生、衛生系統 (YL) 和衛生、行為與社會 (CAL、BJH) 系；泰國曼谷，朱拉隆功大學醫學院兒科 (WNS)；泰國曼谷，朱拉隆功大學兒科傳染病和疫苗卓越中心 (WNS)；美國北卡羅來納州教堂山，北卡羅來納大學全球健康與傳染病研究所 (JDT)；英國倫敦，倫敦衛生與熱帶醫學學院傳染病與熱帶病學院臨床研究系 (JDT)； 泰國曼谷，TREAT Asia，amfAR，愛滋病研究基金會 (AHS)；美國紐約州紐約市，紐約大學全球公共衛生學院 (BJH)
Suicide prevention research is crucial to achieving health equity for people with HIV
Suicide is a major public health problem that affects the world’s most vulnerable populations. An estimated 759 000 people died by suicide in 2019, representing 1·3% of deaths globally, or about one person every 40 s. Suicide rates are high among the 38 million people living with HIV worldwide. A 2021 meta-analysis found that people with HIV were 100 times more likely to die by suicide than the general population.
Biological, psychological, social, and structural determinants increase suicide risk among people with HIV. In addition to chronic and serious symptoms related to the disease, people with HIV often face traumatic and stressful experiences, with negative physical and mental health consequences. HIV-related stigma against key populations (ie, groups of individuals who are especially vulnerable to acquiring HIV, and for whom interventions are needed to reduce the global burden of disease associated with HIV), poor social support, and few mental health professionals willing or able to deliver appropriate care increase the risk of suicide in people with HIV. Specifically, suicide risk is often increased among sexual minorities (eg, men who have sex with men) and other groups disproportionately affected by HIV (eg, transgender women). Suicide prevention should be a crucial priority and evidence-based practices should urgently be expanded to reduce suicide risk among people with HIV and populations at risk of HIV. Many people with HIV have mental health comorbidities that increase their risk of suicide. Mental disorders, including depression, can further decrease treatment adherence, worsen overall prognosis, and exacerbate health inequalities. 3 Because of their bidirectional relationship and their complex social and clinical linkages, integrated services that are context specific and bring together mental health and HIV interventions should be prioritised.
WHO and UNAIDS suggest three levels of integrated mental health and HIV services: in clinical and community settings, in professional and organisational teams, and in the broader health system. 4 Integration strategies might differ by resource level and require shared commitment and full participation of stakeholders, as well as established monitoring and evaluation. 4 In addition to communitylevel interventions to reduce stigma, mental health services for people with HIV can be colocated in HIV clinics to accelerate triage, support, and referral. 5 Integration of mental health and HIV services provides an opportunity for more equitable and targeted health services to enhance mental wellbeing and prevent suicide among people with HIV.
AHS reports grants to her institution from ViiV Healthcare and Gilead Sciences. All other authors declare no competing interests. Yuming Liu, Wipaporn Natalie Songtaweesin, Joesph D Tucker, Annette H Sohn, Carl A Latkin,
*Brian J Hall brianhall@nyu.edu Center for Global Healthy Equity, New York University Shanghai, Shanghai 200122, China (YL, JDT, CAL, BJH); Department of International Health, Health Systems (YL) and Health, Behavior and Society (CAL, BJH), Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA; Department of Pediatrics, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand (WNS); Center of Excellence for Pediatric Infectious Diseases and Vaccines, Chulalongkorn University, Bangkok, Thailand (WNS); Institute for Global Health and Infectious Diseases, University of North Carolina, Chapel Hill, NC, USA (JDT); Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, UK (JDT); TREAT Asia, amfAR, The Foundation for AIDS Research, Bangkok, Thailand (AHS); New York University School of Global Public Health, New York, NY, USA (BJH)