與愛滋病毒共存

資料來源：http://www.thelancet.com/hiv 2019 年 12 月 9 日/財團法人台灣紅絲帶基金會編譯

    據估計，有 3,790萬人感染了 HIV，那些成功接受抗反轉錄病毒療法 (ART) 的人有望過上正常的壽命。 2018 年，全球實現聯合國愛滋病規劃署 90-90-90 目標（讓 90% 的愛滋病毒感染者了解自己的狀況，其中 90% 接受抗反轉錄病毒治療，且其中 90%病毒受到抑制）的進展為 79- 78-86。 儘管要確定未確診的愛滋病毒感染者並向所有人提供治療還有很多工作要做，但衛生服務也必須發展以納入愛滋病病毒感染者複雜、多樣和不斷變化的醫療保健需求。病毒抑制仍然是一個基本目標，但它不是 HIV 照護的唯一終點。認識到關注 HIV 感染者的健康和福祉的重要性，我們很高興推出系列文章「超越病毒抑制的 HIV 結果」，該系列文章發表在《刺胳針愛滋病毒》上，其第一篇論文包含在本期中。

    系列文章作者 Safreed-Harmon 及其同事認為，在ART的現代時代，HIV 感染者與健康相關的生活品質應與UNAIDS 90-90-90目標同等重要：有時稱為第四個 90。但是我們如何定義這第四個 90，我們如何衡量其進展？正如 Kall 及其同事的系列論文所示，存在大量患者報告的結果測量來捕獲這些數據，既有針對 HIV 的，也有更普遍的。然而，由於並沒有就使用哪些方法上達成共識，並且跨研究去比較此類零散收集的數據亦具有挑戰性。在腫瘤學領域，患者報告的結果已被納入試驗十多年，這可為 HIV 研究樹立了榜樣。

    恥辱和歧視很難衡量，但經常被認為是阻礙愛滋病病毒感染者獲得醫療保健的障礙。正如 Andersson 及其同事在系列論文中強調的那樣，旨在減少恥辱感的介入措施的結果往往沒有定論。 聯合國愛滋病規劃署重點人群圖集提供了一些關於恥辱和歧視的數據，但並不完整。然而，我們確實擁有的數據描繪了一幅鮮明的畫面。在阿爾及利亞，53·5% 的愛滋病毒感染者報告說，由於他們的愛滋病毒感染狀況，他們無法獲得醫療保健服務。

    即使在波札納這樣一個對其流行病做出強有力反應的國家，這個數字也是 3%，如果考慮到愛滋病毒感染者的總人口，這相當於 11,100 人。更有可能感染 HIV 或從 HIV 預防措施中受益的重點人群也遭受著巨大的恥辱和歧視，多明尼加共和國 65·1% 的跨性別者和寮國75% 的男男性行為者因此避免了醫療保健。衡量減少恥辱和歧視的進展至關重要，泰國在實施一系列解決這些問題和定期收集數據方面處於領先地位。與其鄰國寮國相比，泰國的男男性行為者報告說由於污名和歧視而避免醫療保健的人數大大地減少(5·6%)。

    愛滋病毒感染者在與健康相關的生活品質方面上面臨許多挑戰。有問題的藥物使用和酒精使用上的障礙比一般人群更為普遍。關於愛滋病毒感染者抑鬱和焦慮的全球發病率缺乏共識，但據報導，中國的一項研究顯示，50·6% 的愛滋病毒感染者患有抑鬱症，而對於一般人群背景比率為 1·6–7·6%，在奈及利亞的一項研究中，21·7% 的愛滋病毒感染者患有焦慮症。據世界衛生組織估計，全球抑鬱症患病率為 4·4%，焦慮症患病率為 3·6%，這顯示愛滋病毒感染者面臨著巨大的負擔。

另一個日益重要的問題是老齡化對 HIV 的影響。聯合國愛滋病規劃署估計，2018 年全球 50 歲或以上感染愛滋病毒的人數為 750 萬，比十年前的 330 萬增加了一倍多。 HIV 流行病不可避免且必然的老齡化正在開始為人們提供照護上帶來一系列全新的挑戰，不僅受到眾所周知時間影響的困擾，而且還受到污名化、長期治療和終身感染等相關問題的困擾。 

    隨著愛滋病毒感染者的醫療保健需求不斷超越專科服務，沒有污名和歧視的優質醫療服務至關重要。愛滋病毒感染狀況不得導致被排除在外或拒絕提供服務。實現這些目標將需要改變衛生和社會保健。需要採用通用且適應性強的方法來衡量實現這一目標的進展情況，以確保每個愛滋病毒感染者都能在病毒抑制之外實現健康和福祉。

   在 2019 年，愛滋病毒感染者還活著是不夠的。 他們也應該過得很好。 ■ 刺胳針愛滋病毒

Living well with HIV 

http://www.thelancet.com/hiv Vol 9 December 2019

  37·9 million people are estimated to be living with HIV, and those on successful antiretroviral therapy (ART) can expect to live a normal lifespan. In 2018 global progress towards the UNAIDS 90-90-90 targets (for 90% of those living with HIV to know their status, 90% of these to be on ART, and 90% of these to be virally supressed) stood at 79-78-86. Although much work remains to identify those living with undiagnosed HIV and to rollout treatment to all, health services must also evolve to incorporate the complex, diverse, and changing healthcare needs of people living with HIV. Viral suppression remains an essential goal, but it is not the sole endpoint of HIV care. In recognising the importance of looking at the health and wellbeing of people with HIV we are delighted to introduce a Series, HIV Outcomes Beyond Viral Suppression, published in The Lancet HIV, the first paper of which is included in this issue. 

  Series authors Safreed-Harmon and colleagues argue that, in the modern ART era, health-related quality of life for people living with HIV should be given equal importance to the UNAIDS 90-90-90 targets: sometimes referred to as a fourth 90. But how do we define this fourth 90, and how do we measure progress? As Kall and colleagues’ Series paper shows, a wealth of patient reported outcome measures exist to capture these data, both specific to HIV and more general. However, with no consensus on which measures to use and patchy collection of such data comparison across studies is challenging. In oncology, patient-reported outcomes have been incorporated into trials for over a decade, which sets an example for HIV research to follow. 

  Stigma and discrimination are difficult to measure but often cited as barriers that prevent access to health care for people living with HIV. As highlighted in the Series paper by Andersson and colleagues, results on interventions aimed at reducing stigma are often inconclusive. The UNAIDS key populations atlas provides some data on stigma and discrimination but is incomplete. The data we do have, however, paint a stark picture. In Algeria 53·5% of people living with HIV reported being denied health-care services because of their HIV status. 

  Even in Botswana, a country that has responded robustly to its epidemic, this figure was 3%, equating to 11100 people if the total population living with HIV is considered. Key populations, who are more likely to be living with HIV or to benefit from HIV prevention measures, also suffer huge amounts of stigma and discrimination, with 65·1% of transgender people in the Dominican Republic and 75% of men who have sex with men in Laos avoiding health care as a result. Measurement of progress on reducing stigma and discrimination is crucial. Thailand is a leader in implementing packages to address these issues and routinely capturing data. Contrasting with its neighbour Laos, substantially fewer men who have sex with men in Thailand report avoiding health care because of stigma and discrimination (5·6%). 

  People living with HIV face many challenges with their health-related quality of life. Problematic drug use and alcohol use disorder are more prevalent than in the general population. Consensus on the global rates of depression and anxiety is missing for people living with HIV, but in a study from China depression was reported in 50·6% of people living with HIV, against a background rate of 1·6–7·6% for the general population, and in a study from Nigeria 21·7% of people living with HIV presented with anxiety disorders. Globally WHO estimates the rate of depression as 4·4% and anxiety disorders as 3·6%, indicating the large burden people living with HIV face. 

  Another issue of growing importance is the effects of ageing with HIV. UNAIDS estimates that in 2018 the number of people aged 50 years or older living with HIV globally was 7·5 million, more than double the 3·3 million from a decade earlier. The inevitable and inexorable ageing of the HIV epidemic is beginning to create a whole new raft of challenges in providing care for people not only beset with the well known effects of time, but allied issues of stigma, long-term treatment, and life-long infection.

  As the health-care needs of people living with HIV continue to move beyond specialist services, good quality care, free from stigma and discrimination, is essential. HIV status must not lead to exclusion from or denial of services. Achieving these aims will require changes across health and social care. Universal and adaptable approaches to measure progress towards this goal are needed to ensure everyone living with HIV can achieve health and wellbeing beyond viral suppression.

  In 2019 it is not enough that people living with HIV are alive. They should also be living well. ■ The Lancet HIV