資助愛滋病毒應對的未來
資料來源：www.thelancet.com/hiv / 2022 年 9 月 9 日 / 團法人台灣紅絲帶基金會編譯
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在過去十年中，在抗擊愛滋病毒方面取得了實質性進展。 HIV 預防、檢測和治療的進步與 HIV 發生率和 HIV 相關死亡人數的下降相匹配。儘管資源有限，波札那成功實現了 95-95-95 目標，這預示著一個充滿希望的未來。然而，最近出版的《危險中：聯合國愛滋病規劃署全球愛滋病更新 2022》，聯合國愛滋病規劃署的年度報告，描繪了這些成果的脆弱性，令人警醒。愛滋病毒應對資金停滯不前、全球不平等現象持續存在，以及 COVID-19 大流行的影響危及進展。目前的預測顯示，聯合國愛滋病規劃署的 2025 年 95-95-95 目標和到 2030 年結束愛滋病流行的目標都將無法實現。
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用於應對愛滋病毒的資金短缺。聯合國愛滋病規劃署計算，到 2025 年，低收入和中等收入國家將需要 293 億美元才能實現目標。根據目前的籌資模式，聯合國愛滋病規劃署預測短缺 80 億美元。政府和其他捐助者未能承諾提供這一水平的資金是短視的。愛滋病毒發生率增加和與愛滋病毒相關的死亡的長期成本——包括人力和財力——將會更大。中亞、東歐、拉丁美洲、中東和北非的感染率已經上升。聯合國愛滋病規劃署報告稱，2021 年有 65 萬人死於與愛滋病相關的原因，而且這個數字不能再上升了。今年晚些時候，全球抗擊愛滋病、結核病和瘧疾基金開始第七次增資（涵蓋 2023-2026 年期間），捐助者將有機會在財務上重申他們對愛滋病毒防治的承諾。我們希望看到獲得 180 億美元資金的目標得以實現。
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除了資金短缺外，COVID-19 大流行還影響了愛滋病毒應對措施。在響應中看到了巨大的彈性，在服務上迅速適應社會接觸的減少和擴大提供的選擇，例如多月處方。但是，服務受到了影響。儘管根據聯合國愛滋病規劃署的報告，2021 年全球還有新增 147 萬人開始接受抗反轉錄病毒治療 (ART)，但這一數字遠低於前幾年的 200 萬增長。東部和南部非洲在 2021 年和 2020 年進行的愛滋病毒檢測比 2019 年少。我們不能讓這些數字進一步下降。擴大和擴大愛滋病毒檢測的範圍必須是一個優先事項。必須關注特別脆弱的群體，例如嬰兒和重點人群，他們對愛滋病毒狀況的了解遠遠低於普通人群。聯合國愛滋病規劃署的目標是到 2025 年 30% 的檢測和治療項目將由社區主導的組織運行，這對於擴大覆蓋範圍至關重要。
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儘管增加檢測和治療機會必須是優先事項，但不能忘記那些獲得治療的人的需求。隨著越來越多的人接受抗反轉錄病毒治療，必須增加病毒載量和耐藥性監測，以確保接受治療的人從中受益。愛滋病毒感染者和老年人的醫療保健需求超出了愛滋病毒照護範圍。在資金不確定的情況下，必須擴大過去幾年在 HIV 照護中看到的創新和差異化服務提供，以涵蓋對其他疾病的綜合和整體照護，包括心理健康支持。
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儘管發生了 COVID-19 大流行，聯合國愛滋病規劃署報告稱，接受暴露前預防 (PrEP) 的人數大幅增加，從 2020 年的 82萬 人增加到 2021 年的 160 萬人。東部和南部非洲在他們的 PrEP 方面取得了特別令人印象深刻的擴大進展。然而，許多其他地區遠遠不夠，特別是亞太地區，該地區有大量的人將從 PrEP 中受益，而包括馬來西亞和菲律賓在內的一些國家的感染率也在上升。為了實現到 2025 年讓 1000 萬愛滋病毒高風險人群接受 PrEP 的全球目標，必須迅速加快 PrEP 計畫。增加 PrEP 選擇，包括長效注射劑，有可能幫助實現這一目標。然而，正如我們之前所論證的，獲得新藥必須是公平的，並且所有受益者都可以使用。
儘管愛滋病毒反應可能處於危險之中，但現在不是失去希望的時候。全球基金的全面補充推動增加和公平地獲得預防、檢測、治療以及綜合和高效的照護，有能力使愛滋病毒應對工作重回正軌。政府和其他捐助者必須滿足資金需求，而不是袖手旁觀，看著愛滋病毒感染率上升、讓可避免的死亡發生以及讓可實現的目標遙遙無期。 ■ 刺胳針愛滋病毒
Funding the future of the HIV response
www.thelancet.com/hiv / Vol 9 September 2022
Substantial progress in the fight against HIV has been made over the past decade. Advances in HIV prevention, testing, and treatment have been matched by declines in HIV incidence and HIV-related deaths. The success of Botswana reaching the 95-95-95 targets, despite resource limitations, points to a hopeful future. However, the recent publication of In Danger: UNAIDS Global AIDS Update 2022, the UNAIDS annual report, paints a sobering picture of the fragility of these gains. Stagnating financing for the HIV response, alongside continued global inequities, and the impact of the COVID-19 pandemic, jeopardises progress. Current projections indicate that neither the UNAIDS 2025 95-95-95 targets nor the goal of ending the AIDS epidemic by 2030 will be met.
Funding for the HIV response is falling short. UNAIDS calculates that low-income and middle-income countries will need US$29·3 billion by 2025, to achieve targets. Based on current funding patterns UNAIDS predicts a shortfall of $8 billion. A failure by governments and other donors to commit to this level of funding is short-sighted. The long-term costs—both human and financial—of increasing HIV incidence and HIV-related deaths will be greater. Rising infections are already seen in central Asia, eastern Europe, Latin America, the Middle East and north Africa. UNAIDS reports 650000 deaths due to AIDS-related causes in 2021, and this number cannot be allowed to rise. Donors will have a chance to financially reaffirm their commitment to the HIV fight later this year when The Global Fund to Fight AIDS, Tuberculosis and Malaria begin their Seventh Replenishment (to cover the period 2023–2026). We hope to see the target of securing US$18 billion in funding met.
Alongside funding shortfalls, the COVID-19 pandemic has impacted the HIV response. Huge resilience has been seen in the response, with services quickly adapting to reduced social contact and expanding provision of options, such as multimonth prescribing. However, services have been impacted. Although an additional 1·47 million people started taking antiretroviral therapy (ART) globally in 2021, as reported by UNAIDS, this figure was far lower than the 2 million increases seen in previous years. Eastern and southern Africa saw fewer HIV tests done in 2021 and 2020 than 2019. We cannot afford to allow these numbers to fall further. Scaling up and extending the reach of HIV testing must be a priority. Focus must be given to particularly vulnerable groups, such as infants and key populations, for whom knowledge of HIV status falls far short of that of the general population. The UNAIDS target that 30% of testing and treatment programmes will be run by community-led organisations by 2025 will be crucial in increasing the reach.
Although increasing testing and treatment access must be priorities, the needs of those accessing treatment cannot be forgotten. As increasing numbers of people are accessing ART, viral load and resistance monitoring must be increased to ensure those accessing treatment are benefiting. The health-care needs of people living and ageing with HIV go beyond HIV care. At a time of funding uncertainty, the innovations and differentiated service delivery seen in HIV care over the past few years must be expanded to encompass integrated and holistic care for other conditions, including mental health support.
Despite the COVID-19 pandemic, UNAIDS reports a large increase in the number of people taking pre-exposure prophylaxis (PrEP), from 820000 in 2020 to 1·6 million in 2021. Eastern and southern Africa have made particularly impressive progress in their PrEP scale-up. However, many other regions are falling far short—particularly the Asia-Pacific region, which has large numbers of people who would benefit from PrEP and some countries, including Malaysia and the Philippines, with rising infections. To reach the global target of 10 million people at substantial HIV risk taking PrEP by 2025, acceleration of PrEP programmes must be swift. Increasing PrEP options, including long-acting injectables, has the potential to help reach this target. However, as we have argued previously, access to novel agents must be equitable and available to all who would benefit.
Although the HIV response could be in danger, it is not time to lose hope. Full replenishment of the Global Fund driving increased—and equitable—access to prevention, testing, treatment, and integrated and efficient care has the power to put the HIV response back on track. Governments and other donors must meet the funding needs, not stand by and watch as HIV infections rise, avoidable deaths occur, and achievable goals slide out of reach. ■ The Lancet HIV