親密伴侶暴力 (IPV) 預防必須納入 HIV 關懷
www.thelancet.com/hiv /2022 年 12 月 1 日線上發布 https://doi.org/10.1016/S2352-3018(22)00329-0
南非對親密伴侶暴力 (intimate partner violence, IPV) 和 HIV 的縱向研究顯示，暴露於 IPV 與女性感染 HIV 的可能性增加有關。在該國，估計四分之一的女性感染是由於 IPV 和伴侶控制行為。 南非的研究還顯示，童年時期的虐待和忽視會增加感染愛滋病毒的風險。此外，在南非被強暴的婦女在強暴後的幾個月內感染愛滋病毒的風險增加，除了處於透過因強暴行為感染愛滋病毒的風險。撒哈拉以南非洲，尤其是南非，是全球愛滋病毒流行的中心，婦女承擔著大部分疾病負擔。因此，了解該地區 IPV 和 HIV 之間的關聯尤為重要。 Salome Kuchukhidze 及其同事採用了一種新方法，透過匯集來自六項具有 HIV 近期生物標誌物數據的人口調查的數據，來檢查身體或性的 IPV 經歷與撒哈拉以南非洲婦女感染 HIV 事件之間的關聯。這種方法使作者能夠提高對時間序列的理解，顯示接觸 IPV 的女性感染 HIV 的風險增加。此外，作者評估了女性在接觸身體或性的 IPV 後參與 HIV 照護級聯的情況，檢查與 HIV 檢測的關聯（57 項調查），以及在感染 HIV 的女性中，抗反轉錄病毒療法 (ART) 的獲取和病毒載量的抑制（7 項調查）。 現有文獻很少有縱向研究的貢獻，因此這項研究是一個重要的進展。
在國際上，薈萃分析提供了一些證據顯示，與未經歷過 IPV 的女性相比，經歷過 IPV 的 HIV 陽性女性可能較少使用 ART，並且 ART 順從性和病毒載量抑制較差，儘管該研究主要在北美或特定人群中進行，包括孕婦或產後婦女、性工作者和年輕人， Kuchukhidze 及其同事在論文中進行了總結。非洲婦女的性或身體 IPV 的經歷與愛滋病毒治療和照護的級聯 (care cascade) 之間的關係。作者將來自該地區的基於人口的數據與全球愛滋病毒流行率最高的地區相結合。他們顯示，在參與調查的女性中，與未接觸 IPV 相比，在過去一年中接觸過身體或性的 IPV 增加了她們感染 HIV 的風險，並降低了病毒抑制的可能性。另與未接觸相比，過去一年接觸IPV 與過去一年自我報告的 HIV 檢測或 ART 的接受無關。
該論文的一個新穎方面是對身體或性的 IPV 對撒哈拉以南非洲病毒抑制的影響的薈萃分析。 據報導，與未接觸 IPV 的女性相比，接受 ART 的 IPV 暴露女性病毒抑制的可能性降低 9%，作為七個數據集中的平均值，這一點雖然不大但很重要。然而，分析中包含的全國人口調查並未提供有關小型關鍵人群的信息，而這些人群可能比一般女性人群更容易接觸 IPV 和其他形式的暴力，對 HIV 結果的影響更大。來自 2019 年南非女性性工作者的全國調查的證據顯示，這一人群明顯暴露於基於性別的高發的暴力，並且病毒載量抑制較差（74% 接受 ART 的女性被病毒抑制）。Kuchukhidze 及其同事顯示，有 IPV 經歷的女性病毒抑制頻率低可能是由於順從性差，但也可能部分是由於 ART的耐藥性，這可能源於耐藥毒株的再感染。這種可能性尤其值得關注，因為暴力男性會有高風險的性行為。
作者正確地強調，研究結果的含義是必須消除 IPV 作為預防 HIV 和優化女性治療的主要策略。 使用基於證據的 IPV 預防計畫可以幫助降低女性感染 HIV 的風險，以及在遭受暴力侵害的女性中，提供心理健康照護和支持以減少情緒失調以及其對感染 HIV 風險較高的性行為的影響上也很重要。以心理健康為目標是降低接受抗反轉錄病毒治療者順從性差風險之潛在重要途徑。該策略要求將改進的心理健康支持納入 HIV 治療和照護服務。鑑於精神衛生保健領域的大量人力資源限制，需要進行大量創新和研究，以有效利用非專業精神衛生從業者提供的介入措施。透過了解創傷的心理健康照護有效解決 IPV 暴露對女性的影響，對於優化 HIV 預防、照護和支持至關重要。
我聲明沒有競爭上的利益。
Rachel Jewkes rjewkes@mrc.ac.za 南非普利托利亞，南非醫學研究委員會性別與健康研究組和執行科學家辦公室
IPV prevention must be integrated into HIV care
www.thelancet.com/hiv Published online December 1, 2022 https://doi.org/10.1016/S2352-3018(22)00329-0
Longitudinal research on intimate partner violence (IPV) and HIV in South Africa has shown that exposure to IPV is associated with an increased likelihood of women having HIV. In the country, an estimated one in four infections in women are due to IPV and partner controlling behaviour . South African research has also shown that abuse and neglect in childhood elevate the risk of HIV acquisition. Furthermore, women who have been raped in South Africa are at increased risk of HIV acquisition in the months after the rape, in addition to being at risk of HIV acquisition through the act of rape. Sub-Saharan Africa, particularly South Africa, is the epicentre of the global HIV epidemic, and women bear much of the disease burden. Thus, understanding the connections between IPV and HIV in this region is particularly important. Salome Kuchukhidze and colleagues have taken a novel approach of examining associations between experience of physical or sexual IPV and incident HIV infection among women in subSaharan Africa, by pooling data from six populationbased surveys that had HIV recency biomarker data. This approach enabled the authors to improve understanding of the temporal sequence, showing that the risk of HIV acquisition is increased among IPV-exposed women. Furthermore, the authors assessed women’s engagement in the HIV care cascade following exposure to physical or sexual IPV, examining associations with HIV testing (57 surveys), and, among women living with HIV, antiretroviral therapy (ART) uptake and viral load suppression (seven surveys). The available literature has few contributions from longitudinal research, and so this study is an important advance.
Internationally, meta-analyses have provided some evidence that HIV-positive women who experience IPV might have lower use of ART and poorer ART adherence and viral load suppression than those who do not experience IPV, although the research has largely been conducted in North America or in specific populations including pregnant or post-partum women, sex workers, and young people, summarised in the paper by Kuchukhidze and colleagues. The analysis presented by Kuchukhidze and colleagues represents a key step forward, as it is the first major attempt to examine the relationships between women’s experience of sexual or physical IPV and the HIV treatment and care cascade in Africa. The authors have combined population-based data from the region with the highest population prevalence of HIV globally. They have shown that among women included in the surveys, exposure to physical or sexual IPV in the past year, versus no exposure, increased their risk of HIV infection and reduced their likelihood of viral suppression. Exposure to past-year IPV was not associated with self-reported HIV testing in the past year or ART uptake compared with no exposure.
A novel aspect of the paper is the meta-analysis of the effect of physical or sexual IPV on viral suppression in sub-Saharan Africa. The reported 9% lower likelihood of viral suppression among IPV-exposed women taking ART, versus those not exposed to IPV, as an average across the seven datasets, is modest but important. However, the national population surveys included in the analyses do not provide information on small key populations that might have a much higher exposure to IPV and other forms of violence than the general population of women, with greater effect on HIV outcomes. Evidence from a national survey of female sex workers in South Africa in 2019 showed that this population is exposed to markedly high rates of genderbased violence and has poor viral load suppression (74% of those on ART were virally suppressed). Kuchukhidze and colleagues suggest that the low frequency of viral suppression among women with experience of IPV could be due to poor adherence, but it might also be partly due to ART resistance, which could stem from reinfection with drug-resistant strains. This possibility is a particular concern as violent men are known to have high-risk sexual behaviours.
The authors rightly highlight that the implications of the findings are that IPV must be eliminated as a main strategy to prevent HIV and optimise treatment among women. Use of evidence-based IPV prevention programming can help to reduce women’s risk of HIV, and among women who are exposed to violence, providing mental health care and support to reduce emotional dysregulation and its impact on sexual practices at higher risk of HIV acquisition is also important. Targeting mental health is a potentially important pathway for reducing the risk of poor ART adherence among those who are on treatment. This strategy calls for an integration of improved mental health support within HIV treatment and care services. Given the substantial human resource constraints within mental health care, considerable innovation and research will be required to establish the effective use of interventions delivered by lay mental health practitioners. Effectively addressing the effect of IPVexposure on women through trauma-informed mental health care, is crucial for optimising HIV prevention, care, and support.
I declare no competing interests.
Rachel Jewkes rjewkes@mrc.ac.za Gender and Health Research Unit and Office of the Executive Scientist, South African Medical Research Council, Pretoria 0001, South Africa