www.thelancet.com/hiv Vol 11 August 2024 / 線上發布 2024年7月23日 https://doi.org/10.1016/ S2352-3018(24)00180-2
高效抗逆轉錄病毒療法 (ART) 的成功促成了 2011 年消除嬰兒愛滋病毒新感的全球目標的確立。到了2016年，多個國家實現這一目標，2021年，波札那成為第一個實現這一目標的高負擔國家。 這些成果在一定程度上是由B+ 選項策略推動的，即立即讓所有孕婦接受 ART，無論其健康狀況如何。儘管透過B+ 選項方案在懷孕期間提供抗病毒治療在公共衛生方面取得了令人印象深刻的進步，但周產期治療的覆蓋率和垂直傳播率已趨於穩定。
衛生系統是確保儘早持續獲得周產期治療的核心要素之一。然而，需要更多關注在周產期接受抗病毒治療的社會和背景驅動的因素，以防止垂直傳播並確保孕婦的健康和福祉。在本期《剌胳針愛滋病毒》中，莎樂美·庫楚克希澤 (Salome Kuchukhidze) 及其同事出色地估計了懷孕期間的暴力與新嬰兒愛滋病毒感染之間的關係。對現實世界流行病學數據進行建模的細緻工作是引人注目的。 Kuchukhidze 及其同事使用深入的建模方法來評估親密伴侶暴力 (IPV) 對愛滋病毒垂直傳播的影響。他們將 IPV 定義為來自關係夥伴的任何身體暴力或性暴力行為，並收集了聯合國愛滋病規劃署和世界衛生組織對 46 個非洲國家婦女的估計數據。
研究發現，八分之一的兒科感染可歸因於母親 IPV 暴露。預計到 2022 年，將有 22,000 例兒童感染由 IPV 引起，人群中 IPV 感染比例從尼日的 4% 到烏干達的 28% 不等。在非洲南部和東部等地區，由 IPV 引起的新生兒愛滋病毒感染比例上升至垂直感染的五分之一。這些估計是由愛滋病毒高發病率和抗反轉錄病毒治療高採用率所驅動的。換句話說，由於衛生系統能夠有效地向愛滋病毒感染者提供藥物，因此確實發生的新生兒感染很可能是由額外的臨床原因（例如 IPV）引起的。重要的是，本文也為減輕暴力對垂直傳播的顯著影響奠定了基礎。
在懷孕期間發生血清轉換的婦女中，由 IPV 引起的新生兒感染發生率較高。從愛滋病毒照護的角度來看，這項發現要求在懷孕期間進行重複檢測，以告知患者整個周產期的新診斷，並在常規周產期照護期間提供暴露前預防。針對愛滋病毒狀態中立式的照護刻不容緩；這需要進行研究和介入措施，共同為愛滋病毒感染者和有新感染風險的人提供服務。
應將一套新的暴力預防介入措施納入常規愛滋病毒照護中。這些方法的初步數據顯示周產期 IPV 有所減少：南非由護理師主導的安全規劃會議、奈及利亞的全民周產期家訪以及衣索比亞的問題解決療法（處於試點階段）。然而，終止IPV 的這項證據基礎遠遠落後於周產期憂鬱症和愛滋病毒相關恥辱等相關主題，這顯示需要有針對性的資金來將功效轉化為對最需要的婦女達成更廣泛的有效性。
青春期懷孕女孩迫切需要熟練的周產期照護，包括預防 IPV。懷孕的青少年在研究中表示，早期生活中的困難事件（例如被迫的第一次性行為、亂倫或強姦）常常使年輕的關係成為有害家庭生活的策略替代方案。一旦懷孕，許多青少年會被診所工作人員拒絕其接受終止懷孕服務或避孕照護，因為工作人員認為他們太年輕，不適合發生性關係。Kuchukhidze 及其同事提醒我們，為了有效終止新的嬰兒感染，青少年的愛滋病毒治療必須為其篩檢並巧妙地解決暴力問題。
除了適當強調擴展計畫（例如，歐盟資助的 Spotlight Initiative 和英國資助的 What Works 計畫）之外，還沒有為關鍵的、成型的試驗和縱向性研究而提供相應的資金，以開發在HIV背景下懷孕期間的 IPV 解決方案。周產期人群的預防可以透過愛滋病毒、孕產婦保健或嬰兒保健機制來資助。新的努力可針對那些終止伴侶暴力可能對免除愛滋病毒之嬰兒生存產生最大連鎖反應的人群上。庫楚希澤的分析認為，這些族群可能包括第一次懷孕的青少年、懷孕期間新發生血清轉換的婦女和女孩以及產後婦女。
政策和治理的領導力對於消除愛滋病毒垂直傳播和保護孕婦和女孩免受 IPV 感染至關重要。政策制定者和慈善資助者在設想愛滋病毒應對措施時應優先考慮解決IPV 問題，這可以透過整合策略或健康框架的社會決定因素來實現。而國家法律和全球的承諾同樣至關重要。
預防新的嬰兒感染不再只屬於生物醫學領域。我們現在面臨著建設基礎設施、衛生服務提供者支持和強有力的監測的艱鉅任務，以確保婦女的安全並確保她們在懷孕期間能夠獲得愛滋病毒預防和治療。預防 IPV 的策略可能為愛滋病領域提供急需的動力，以消除新的嬰兒感染並確保孕產婦健康。
AMH 得到美國國家衛生研究院的支持（撥款編號 K01MH121185）。本評論中表達的觀點和觀點僅代表作者個人觀點，不一定反映全球對抗愛滋病、結核病和瘧疾基金的觀點或信念。
*AM Hatcher，L Kimbo abbeymae@email.unc.edu
北卡羅來納大學教堂山分校吉林斯全球公共衛生學院健康行為系，Chapel Hill, NC 27599, USA (AMH)；南非豪登省約翰尼斯堡威特沃特斯蘭德大學健康科學學院公共衛生學院 (AMH)；全球抗愛滋病、結核病和瘧疾基金技術諮詢和夥伴關係部，瑞士日內瓦 (LK)
Addressing partner violence to end infant HIV infection
www.thelancet.com/hiv Vol 11 August 2024 / Published Online July 23, 2024 https://doi.org/10.1016/ S2352-3018(24)00180-2
The success of highly active antiretroviral therapy (ART) led to the establishment of the 2011 global goal to eliminate new infant HIV infections. By 2016, multiple countries achieved this goal, and, in 2021, Botswana was the first high-burden country to do so. These gains were driven, in part, by the Option B+ strategy to immediately initiate all pregnant women on ART, regardless of their health status. Although ART provision around the time of pregnancy through Option B+ has been an impressive public health advance, coverage of perinatal treatment and rates of vertical transmission have plateaued.
Health systems are one core element of ensuring early and consistent access to perinatal treatment. However, increased attention to the social and contextual drivers of perinatal ART access will be required to prevent vertical transmission and ensure the health and wellbeing of pregnant women. In this issue of The Lancet HIV, Salome Kuchukhidze and colleagues do a remarkable job of estimating how violence around the time of pregnancy relates to new infant HIV infections. The careful work of modelling real-world epidemiological data is compelling. Kuchukhidze and colleagues use an in-depth modelling approach to assess the contribution of intimate partner violence (IPV) to vertical HIV transmission. They define IPV as any physical or sexual act of violence from a relationship partner, and they gathered data from UNAIDS and WHO estimates among women in 46 African countries.
The study found that one in eight paediatric infections are attributable to maternal IPV exposure. An estimated 22 000 paediatric infections could be attributed to IPV in 2022, with the population attributable fraction ranging from 4% in Niger to 28% in Uganda. In settings such as southern and eastern Africa, the proportion of new infant HIV infections attributed to IPV rises to one-fifth of vertical infections. These estimates are driven by high HIV incidence and high ART uptake. In other words, as the health system is effective in delivering medication to patients living with HIV, new infant infections that do occur are disproportionately more likely to be due to extra clinical causes, such as IPV. Importantly, this paper also creates a foundation for mitigating the pronounced effect of violence on vertical transmission.
New infant infections attributable to IPV occur at higher rates among women who seroconvert during pregnancy. From an HIV care standpoint, this finding calls for repeat testing during pregnancy to inform patients about new diagnoses throughout the perinatal phase and to offer pre-exposure prophylaxis during routine perinatal care. HIV status-neutral care is of urgent importance; this would require research and interventions that jointly serve individuals with HIV and those at risk of new infection.
A newer set of interventions for violence prevention should be incorporated into routine HIV care. These approaches have preliminary data showing reductions in perinatal IPV: one session of nurse-led safety planning in South Africa, universal perinatal home visits in Nigeria, and problem-solving therapy in Ethiopia (which is at the pilot phase). However, this evidence base for ending IPV is well behind related topics such as perinatal depression and HIV-related stigma, suggesting targeted funding will be required to translate efficacy into wider effectiveness for the women who need it most.
Adolescent pregnant girls urgently require skillful perinatal care that includes safety from IPV. Pregnant adolescents have expressed in research studies how difficult early life events (such as forced first sex, incest, or rape) often make young relationships a strategic alternative to harmful home lives. Once they do become pregnant, many adolescents are refused access to termination services or contraceptive care by clinic staff who view them as too young for sexual relationships. Early pregnancy could be viewed as a diagnostic marker for other types of risk, deserving the highest quality of HIV-related care. Kuchukhidze and colleagues remind us that, to be effective at ending new infant infections, HIV treatment among adolescents must screen for and skillfully address violence.
Alongside a rightful emphasis on scaling programmes (eg, the European Union-funded Spotlight Initiative and the UK-funded What Works programme), there has yet to be concomitant funding for the crucial, formative trial and longitudinal research necessary to develop solutions for IPV in pregnancy within the context of HIV. Violence prevention among perinatal populations could be funded through HIV, maternal health, or infant health mechanisms. New efforts could target populations for whom ending IPV might have the greatest knock-on effects for HIV-free infant survival. Kuchukhidze’s analysis suggest that these populations might include those who are adolescent at f irst pregnancy, women and girls newly seroconverted during pregnancy, and women in the postpartum period.
Leadership in policy and governance is crucial for eliminating vertical HIV transmission and protecting pregnant women and girls against IPV. Policymakers and philanthropic funders should prioritise addressing IPV when envisioning their HIV response—and this can take place using integration strategies or social determinants of health framing. Community-based supports and intersectoral referrals are similarly essential for national laws and global commitments to end IPV.
Preventing new infant infections no longer lies solely within the realm of biomedicine. We now face the formidable task of building the infrastructure, health provider supports, and robust monitoring for keeping women safe and ensuring they can access HIV prevention and treatment around the time of pregnancy. Strategies to prevent IPV might offer the momentum the HIV field badly needs to eliminate new infant infections and ensure maternal health.
AMH is supported through National Institutes of Health (grant number K01MH121185). The opinions and sentiments expressed in this commentary are solely those of the author and do not necessarily reflect the views or beliefs of The Global Fund to Fight AIDS, Tuberculosis and Malaria.
*A M Hatcher, L Kimbo abbeymae@email.unc.edu
Department of Health Behavior, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA (AMH); School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, Gauteng Province, South Africa (AMH); Technical Advice and Partnerships Department, The Global Fund to Fight AIDS, Tuberculosis and Malaria, Geneva, Switzerland (LK)