評估 HIV/AIDS 預防措施的風險補償
資料來源：www.thelancet.com/infection Vol 22 April 2022，財團法人台灣紅絲帶基金會編譯
Yang Zheng 及其同事評估了過去 30 年中五種性病感染 (STI) 的全球疾病負擔和趨勢。一個有趣的發現是，與穩定的整體發生率趨勢相反，2010 年後青少年梅毒發生率有所上升，尤其是在高收入國家。鄭和他的同事認為，這種增加可能是由於保險套疲乏、對愛滋病毒的自滿，以及在高危人群中愛滋病毒/愛滋病預防和控制措施上取得成功所引起對愛滋病毒治療的樂觀情緒。對抗愛滋病毒的醫療保護措施使用上的增加可能會導致更危險的性行為，並增加其他性病感染的傳播，也稱為風險補償。
2019 年，Chow 及其同事描述了在當前 HIV 控制的背景下，男男性行為者 (MSM) 中性病感染流行上的變化。在美國和歐洲國家，2010 年代引入和推廣暴露前預防 (PrEP) 時，MSM 中通報的梅毒病例在幾種 STI 中增幅最為顯著。巧合的是，於鄭和同事的研究中，在全球範圍內也顯示出類似的趨勢。梅毒流行是愛滋病預防風險補償的一個很好的代表，因為在實際的愛滋病預防和控制實踐中，梅毒和愛滋病毒經常同時進行檢測。
由於愛滋病毒預防措施的多樣性及其在改變性行為和性病感染流行中的複雜作用，最近關於愛滋病毒預防措施風險補償的研究結果不一致。高和其同事的研究顯示，男性包皮環切術不會增加無保險套性行為或多個性伴侶的風險。然而，最近的研究顯示，使用 PrEP 可能會增加危險的性行為和細菌性 STI 的風險，儘管早期的研究並未證實明確的風險補償。因此，我們需要更廣泛的措施來探索風險補償效應，而不是侷限於特定區域和特定人群的特定結果。
鄭和同事的研究或許提供了一個新的視角：愛滋病防治在全球範圍內得到廣泛推廣，那麼為什麼不透過在全球範圍內描述性病流行情況來更直觀地反映愛滋病防治措施的風險補償影響呢？基於鄭和同事的研究，需要更多的生態學研究來探索性病流行與全球愛滋病毒/愛滋病流行以及愛滋病毒/愛滋病預防措施的實施和投資之間的關聯。透過按年齡、地區等對不同愛滋病防治措施的覆蓋面進行分組和調整，可以更有針對性地去執行愛滋病防治風險補償之探索和分類。此外，考慮到 COVID-19 大流行已影響 HIV/AIDS 預防措施的實施和 STI 流行，擴大研究期限至涵蓋大流行期則至關重要。
Xiangyu Yan, Zhongwei Jia, *Bo Zhang zhangbo0136@pku.edu.cn，北京大學公共衛生學院，北京 100191
www.thelancet.com/infection Vol 22 April 2022
Evaluating the risk compensation of HIV/AIDS prevention measures
Yang Zheng and colleagues assessed the global disease burden and trends of five sexually transmitted infections (STIs) over the past three decades. An interesting finding was that, contrary to the overall stable trend of the incidence rate, the incidence of syphilis increased in adolescents after 2010, especially in high-income countries. Zheng and colleagues suggested that this increase might be due to condom fatigue, complacency about HIV, and optimism about HIV treatments caused by the success of HIV/AIDS prevention and control measures among high risk populations. The increasing use of medical protection against HIV might lead to more risky sexual practices and increase the transmission of other STIs, also known as risk compensation.
In 2019, Chow and colleagues2 described the changes in STI epidemics among men who have sex with men (MSM) under the present context of HIV control. In the USA and European countries, notified syphilis cases among MSM showed the most dramatic increase among several STIs during the 2010s when pre-exposure prophylaxis (PrEP) was introduced and promoted.2 Coincidentally, Zheng and colleagues’ study showed a similar trend on a global scale. Syphilis epidemics are a good proxy for the risk compensation of HIV/AIDS prevention because syphilis and HIV are often tested at the same time in actual HIV/AIDS prevention and control practices.
Results of recent studies of the risk compensation of HIV prevention measures are inconsistent because of diversity of HIV prevention measures and their complex role in changing sexual behaviours and epidemics of STIs. Gao and colleagues’ study showed that medical male circumcision did not increase the risk of condomless sex or multiple sexual partners. However, recent studies showed that PrEP use might increase risky sexual behaviours and the risk of bacterial STIs, although earlier studies did not confirm a clear risk compensation. Therefore, we need broader measures to explore the risk compensation effect, not limited to a particular outcome in a specific area and a specific population.
Zheng and colleagues’ study might provide a new perspective: HIV/AIDS prevention and control is widely promoted worldwide, so why not reflect the risk compensation effect of HIV/AIDS prevention measures more intuitively by describing STI epidemics on a global scale? Based on Zheng and colleagues’ study, more ecological research is needed to explore associations between STI epidemics and worldwide HIV/AIDS epidemics and the implementation and investment of HIV/AIDS prevention measures. Through grouping and adjusting for the coverage of different HIV/AIDS prevention measures by age, region, and so on, more targeted exploration and classification of the risk compensation of HIV/AIDS prevention can be implemented. In addition, considering that the COVID-19 pandemic has affected the implementation of HIV/AIDS prevention measures and STI epidemics, expanding the study period to cover the pandemic period is essential.
Xiangyu Yan, Zhongwei Jia, *Bo Zhang zhangbo0136@pku.edu.cn School of Public Health, Peking University, Beijing 100191, China
www.thelancet.com/infection Vol 22 April 2022