解決不平等問題仍然是終結愛滋病毒/愛滋病的關鍵

資料來源：http://www.thelancet.com/hiv / 2023 年 1 月 10 日/財團法人台灣紅絲帶基金會編譯

不平等繼續嚴重破壞對愛滋病毒/愛滋病的反應。 UNAIDS Dangerous Inequalities 發布的世界愛滋病日報告描述了解決性別不平等以及兒童和重點人群面臨的不平等問題如何成為實現 2030 年目標和消除 HIV/AIDS 對公共健康的威脅的關鍵。 如果消息聽起來很熟悉，那應該是這樣。 長期以來，不平等一直被認為是愛滋病流行的驅動力。

性別不平等繼續在減緩愛滋病毒/愛滋病應對方面發揮重要作用，特別是在撒哈拉以南非洲。 2021 年，儘管全球女性佔新感染愛滋病毒的 49%，但在撒哈拉以南非洲，這一數字為 63%。 尤其是該地區的少女和年輕女性（15-24 歲）受愛滋病毒的影響尤為嚴重，感染愛滋病毒的風險是同年齡段男孩和男性的三倍。 此外，與青春期男孩和年輕男性相比，青春期女孩和年輕女性新感染病例的下降速度要慢。

造成這些差異的原因很多，包括接受愛滋病服務的政策和法律障礙； 歧視性法律和慣例； 社會恥辱； 難以獲得服務； 缺乏專門用於滿足婦女愛滋病毒相關需求的預算； 以及婦女缺乏教育和經濟機會。在許多國家，國家政策和法律規定青少年必須得到父母或監護人的同意才能獲得愛滋病毒服務。這些法律還可以限制在青春期女孩可以合法發生性行為之後很久才獲得節育和性健康信息。 已婚或同居的少女和年輕女性也報告說，她們在決定自己的性健康方面的自主權較小。預防方案也沒有惠及少女和年輕女性。

親密伴侶對女性的身體暴力或性暴力也是導致女性易感染愛滋病毒的重要因素。 據估計，在撒哈拉以南非洲中部和東部，終生親密伴侶暴力的發生率可能高達 40%。 在《刺胳針愛滋病毒》雜誌上，Salome Kuchukhidze 及其同事最近的一份報告對來自撒哈拉以南非洲 30 個國家的 57 項調查進行了匯總分析，結果顯示表明，在過去一年中遭受過親密伴侶身體或性暴力的女性可能最近感染了愛滋病毒是一般女性的 3·22 倍，而感染愛滋病毒的婦女也不太可能實現病毒抑制。

性別差異可以透過為婦女主導的舉措提供更多資源來解決，以改變不平等的性別規範和愛滋病毒應對措施，並廢除歧視性法律。在衛生部門之外，需要共同努力解決婦女遭受的多重歧視，這些歧視影響她們的健康和福祉，並使她們特別容易感染愛滋病毒。 支持女童完成中學教育、提供資源使婦女實現經濟獨立以及基於性別的暴力的預防和應對都是至關重要。 同樣，需要改變男性和男孩中有害的性別規範，以改善愛滋病防治結果。

兒童也仍然得不到愛滋病毒/愛滋病應對措施的服務。 2021 年，兒童佔愛滋病毒感染者的 4%，但佔愛滋病相關死亡人數的 15%； 76% 的成年人正在接受 ART，但只有 52% 的兒童正在接受治療。 根據該報告，過去 5 年兒童新感染病例的減少速度有所放緩，對青春期女孩和年輕女性需求的關注不足阻礙了垂直傳播的消除。 晚期診斷也繼續造成差異； 例如，在西非和中非，只有 25% 的 HIV 暴露嬰兒在 2 個月大時接受了檢測。 正如報告所描述的，解決這些問題的關鍵是在受孕前、懷孕期間和分娩後擴大對婦女的愛滋病毒檢測和照護，並加強支持以確認兒童在出生時和母乳喂養結束時的愛滋病毒感染狀況。 兒童治療方案的改進導致病毒抑制率提高，但成人和兒童之間的差異仍然存在。

由於恥辱、歧視和刑事定罪，重點人群繼續首當其衝地無法平等地獲得治療和預防。 Lancet HIV 定期就這些挑戰發表社論，最近的重點是 LGBT 社區。

關於不平等如何繼續侵蝕愛滋病毒/愛滋病應對措施並更廣泛地侵犯人權的證據是顯而易見的。 然而，隨著政府和政策制定者繼續視而不見，缺乏解決社會和結構性不平等問題的政治意願同樣具有破壞性——我們現在的挑戰是幫助他們看到造成的損害並採取行動。 ■ 剌胳針愛滋病毒 

Addressing inequalities still key to ending HIV/AIDS

http://www.thelancet.com/hiv / Vol 10 January 2023

Inequalities continue to seriously undermine the response to HIV/AIDS. A World AIDS Day report from UNAIDS Dangerous Inequalities, describes how tackling gender inequalities and the inequalities faced by children and key populations is key to achieving 2030 targets and ending HIV/AIDS as a threat to public health. If the message sounds familiar, it should. Inequalities have long been recognised as a driving force for the HIV epidemic. 

Gender inequalities continue to play an important part in slowing the HIV/AIDS response, particularly in subSaharan Africa. In 2021, although women worldwide accounted for 49% of new HIV infections, in subSaharan Africa this figure was 63%. Adolescent girls and young women (aged 15–24 years) in the region, in particular, are disproportionately affected by HIV, with a three times higher risk of acquiring HIV than the risk for boys and men in the same age range. Also, the decline in new infections has been slower in adolescent girls and young women than in adolescent boys and young men. 

The reasons for these disparities are numerous and include policy and legal barriers to receiving HIV services; discriminatory laws and practice; social stigma; poor access to services; lack of dedicated budgets for women’s HIV-related needs; and lack of education and economic opportunities for women. In many countries, national policies and laws mean that adolescents must have parental or guardian consent to access HIV services. These laws can also limit access to birth control and information on sexual health at ages well after adolescent girls can legally have sex. Adolescent girls and young women who are married or cohabiting also report less autonomy for decisions on their own sexual health. Prevention programmes too are not reaching adolescent girls and young women. 

Physical or sexual intimate partner violence perpetrated on women is also a significant factor making women susceptible to acquiring HIV. In central and eastern sub-Saharan Africa, it is estimated that prevalence of lifetime intimate partner violence could be as high as 40%. In The Lancet HIV, a recent report by Salome Kuchukhidze and colleagues of a pooled analysis of 57 surveys from 30 countries in sub-Saharan Africa showed that women who had experienced physical or sexual intimate partner violence in the past year were 3·22 times more likely to acquire a recent HIV infection, and women with HIV were also less likely to achieve viral suppression. 

Gender disparities can be addressed with more resources for women-led initiatives to transform unequal gender norms and the response to HIV, and the repeal of discriminatory laws. Outside the health sector, a concerted effort is needed to address the multiple discriminations that women endure that affect their health and wellbeing and make them particularly susceptible to HIV. Supporting girls so they can complete their secondary education, providing resources to enable women’s economic independence, and preventing and responding to gender-based violence are all crucial. Equally, transforming harmful gender norms among men and boys is needed to improve HIV outcomes. 

Children too remain underserved by the HIV/AIDS response. In 2021, children accounted for 4% of people with HIV but 15% of AIDS-related deaths; 76% of adults were receiving ART, but only 52% of children were receiving treatment. According to the report, reductions in new infections among children have slowed in the previous 5 years, with a lack of focus on the needs of adolescent girls and young women hampering the elimination of vertical transmission. Late diagnosis also continues to drive disparities; for example, only 25% of HIV-exposed infants in western and central Africa are tested by 2 months of age. As the report describes, essential to addressing these issues is the scale-up of HIV testing and care for women before conception, during pregnancy, and after birth and improved support to confirm children’s HIV status at birth and at the end of breastfeeding. Improvements in treatment options for children have resulted in increases in rates of viral suppression, but disparities between adults and children also still exist. 

Key populations continue to bear the brunt of unequal access to treatment and prevention, held back by stigma, discrimination, and criminalisation. The Lancet HIV has regularly editorialised on these challenges, most recently focusing on the LGBT community. 

The evidence on how inequalities continue to erode the HIV/AIDS response, and impinge on human rights more widely, is clear. However, as governments and policy makers continue to turn a blind eye, the lack of political will to address societal and structural inequalities is just as damaging—our challenge now is to help them see the damage done and act. ■ The Lancet HIV