達到90-90-90目標：愛滋病毒自我檢測的學習經驗

資料來源：剌胳針愛滋病毒醫學期刊；www.thelancet.com/hiv，2018年12月17日，財團法人台灣紅絲帶基金會編譯

透過拯救生命的抗反轉錄病毒療法（ART），以達到聯合國愛滋病規劃署所定至少有73％之愛滋病毒感染者其病毒被有效抑制的目標，其關鍵取決於在已感染愛滋病毒者當中如何去確認90％的人這一項目標。以社區為基礎的愛滋病毒檢測，成功地增加了愛滋病毒感染者被確認和進入照護體系人數的比例，但卻仍然存在著差距，需要採取創新的檢驗策略來解決這些問題。具體而言，撒哈拉沙漠以南非洲的男性不太像女性般地接受愛滋病毒檢測並聯結到醫療照護，導致男女之間長達10年的預期壽命之差距，以及男性對女性持續的傳播愛滋病毒。

以社區為基礎的愛滋病毒檢測以及與醫療照護和預防間的聯結之成效正接受HPTN 071 / PopART研究之評估，該項目是在桑比亞和南非的21個社區所進行的一項集團隨機試驗，以評估家戶愛滋病毒預防綜合套組計劃對人群中愛滋病毒感染率的影響。在刺胳針愛滋病毒醫學雜誌中，Chama Mulubwa 和他的同事們報告了於PopART研究所進行的巢套集團隨機試驗中，在桑比亞四個參與的社區中針對16歲及其以上年齡參與的個人，評估其採愛滋自我測試方式與標準的指尖扎血檢驗方式成果的比較。在3個月的時間裡，社區愛滋照護提供者列舉了參與愛滋病毒自我測試小組的13,267名成員（在伴隨著以家戶為基礎所提供的指尖扎血快速愛滋檢測服務的同時，亦挨家挨戶地提供口腔愛滋自我檢測之額外選擇）和非愛滋病毒自我檢測組中的13,706成員（提供以家戶為基礎由非專業之諮商員單獨進行的指尖扎血愛滋快速檢測）。在介入組中，這些非專業的諮商員是在監督或無監督的情況下，或通過二次分發的方式，提供其服務對象愛滋病毒自我檢測之選擇。主要結果是個案是否了解愛滋病毒感染狀況（其定義為向社區愛滋病治療提供者自我報告其為愛滋病毒陽性，或是接受愛滋病毒檢測服務的提供）。

介入措施導致愛滋病毒自我檢測組其對愛滋病毒感染的知識提高了1·30倍，愛滋病毒自我測試組有68％的人知道其愛滋病毒感染狀況，相較於非愛滋病毒自我測試組則有65％，愛滋病毒自我檢測的影響僅發生在男性身上，在愛滋病毒感染狀況的知識上增加了5％。對於年齡在30歲或以上男性，接受無監督的愛滋病毒自我檢測的可能性是16歲至30歲以下男性的兩倍。在沒有參加PopART研究之前兩輪家戶愛滋篩檢的人們中，愛滋病毒自我檢測的受試者人數從21％增加到30％。

對年輕人（16至29歲）而言，自我測試的介入措施其對愛滋病毒感染狀況的知識影響雖小但仍有顯著意義；然而，有28％的青少年並沒有被觸及，主要是因為男性和年齡較小的群體在家訪期間更常缺席。

因此，愛滋病毒自我檢測觸及了最難接觸的個體，包括男性、年輕人和以前居住在社區中但未參與PopART前兩輪檢測的個人。透過指尖札血愛滋測試、愛滋自我測試和無監督的愛滋自我測試等方式，其愛滋病毒的陽性率均相似，證據顯示在本研究中所採用之測試策略並沒有選擇性偏差，這使得在介入組中允許選擇是在監督下或在無監督的狀況下進行愛滋自我測試。更重要的是，在愛滋病毒自我檢測組中很少見到有社會危害之情形。

從個人和公共衛生的角度來看，最有意義的結果是，愛滋病毒陽性之個體能與抗反轉錄病毒治療和達到病毒被抑制等結果之間的聯繫（即愛滋病規劃署90-90-90目標框架中的第二個和第三個目標）。雖然這項研究設置的目的並不是評估與照護以及病毒被抑制間的聯繫，但所採取之介入措施仍需要促進和監測愛滋病毒自我檢測與愛滋照護之間的聯繫，以期發揮其對於接受抗反轉錄病毒治療和達到病毒被抑制最大的影響（完整的90-90-90階層）。

我們讚揚本項研究之研究者發現了在愛滋病毒檢測方面上的落差，並嚴格地評估愛滋病毒自我檢測方式。展望未來，愛滋自我檢測方式和以社區為基礎的策略，在達到第一個90之目標和持續連結到治療和預防方面的作用是什麼呢？

隨著愛滋病毒自我檢測其經驗和取得的增加，生活在中、高度愛滋病發生率環境中的人們，將可以獨立地進行愛滋病毒自我檢測，這將進一步使檢測正常化並降低成本。為實現這一目標，一些證據上的缺口需要解決。首先，可以透過在社交場域或工作場所進行測試來找到不常在家的男性。其次，雖然觀察到女性在愛滋病毒自我檢測上對其感染狀態的知識沒有提升，而且女性更經常選擇在監督下接受檢測，但女性仍可由增加愛滋病毒自我檢測的機會中受益，且相較於指尖扎血愛滋檢測其更加方便。第三，世衛組織呼籲要提供適當的監督，這對於年輕人來說，這可能意味著可採同儕指導或應用軟體指導的愛滋自我測試策略。能夠滿足男性、女性和年輕人的優先順序和開啓其動機，將可以進一步地提升愛滋病毒之測試。最後，需要創新作為來將人們與預防或治療等服務設施聯繫起來，以便觸及具雄心意志之愛滋病毒檢測、治療和預防，並達到實現疫情控制的目標。

作者： Connie Celum及Ruanne Barnabas；美國西雅圖華盛頓大學全球衛生、醫學和流行病學系

Reaching the 90-90-90 target: lessons from HIV self-testing

Reaching the UNAIDS goal of viral suppression among at least 73% of people who are living with HIV through

lifesaving antiretroviral therapy (ART) hinges on reaching the key goal of identifying 90% of people living with HIV. Community-based HIV testing is successful in increasing the proportion of people living with HIV identified and linked to care, but gaps persist and innovative testing strategies are needed to address them.1–4 Specifically, men in sub-Saharan Africa are less likely than women to undergo HIV testing and link to care, leading to a gap in life expectancy of up to 10 years between men and women and ongoing HIV transmission from men to women.

Community-based testing and linkages to HIV care and prevention are being assessed in HPTN 071/PopART, a cluster-randomised trial in 21 communities in Zambia and South Africa to estimate the effect of a household combination HIV prevention package on populationlevel HIV incidence. In The Lancet HIV, Chama Mulubwa

and colleagues8 report assessment of HIV self-testing compared with standard finger-prick testing in a nested

cluster-randomised trial in individuals aged 16 years and older in four Zambian communities participating

in PopART. In a 3-month period, community HIV care providers enumerated 13 267 individuals in the HIV

self-testing group (a door-to-door offer of the option of oral HIV self-testing alongside the offer of home-based

finger-prick rapid HIV testing) and 13 706 in the non-HIV self-testing group (the offer of home-based finger-prick

rapid HIV testing alone done by lay counselors at the household). In the intervention arm these lay counselors

offered a choice of HIV self-testing, with or without supervision or through secondary distribution. The primary outcome was knowledge of HIV status (defined as self-reporting HIV positive to the community HIV care providers or accepting an offer of HIV testing services).

The intervention led to a 1·30 increased odds in knowledge of HIV status in the HIV self-test group, 68% in the HIV self-test group had knowledge of HIV status compared with 65% in the non-HIV self-test group. The effect of HIV self-testing only occurred in men, among whom there was a 5% increase in knowledge of HIV status. Unsupervised HIV self-testing was twice as likely to be used by men aged 30 years or older as among men aged 16 to less than 30 years. The number of people tested increased from 21% to 30% with HIV self-testing among those who didn’t participate in the first two rounds of household HIV testing in PopART.

The self-testing intervention also had a small but significant effect on knowledge of HIV status among younger individuals (aged 16 to 29 years); however, 28% of adolescents were not reached, primarily because males and younger age groups were more often absent during household visits.

Thus, HIV self-testing accessed the hardest to reach individuals, including men, younger people, and individuals previously resident in the community but who did not participate in two rounds of PopART. HIV positivity was similar among those tested by HIV fingerprick, HIV self-tests, and unsupervised HIV self-tests, suggesting that there was no evidence of selection bias by testing strategy in this study, which allowed choice of supervised or unsupervised HIV self-testing in the intervention arm. Importantly, social harms were rare in the HIV self-testing group.

The most meaningful outcome from the perspective of both individual and public health was the linkage of HIV-positive individuals to ART care and viral suppression (ie, the second and third 90s in the UNAIDS 90-90-90 target framework). Although this study was not designed to assess linkage to care and viral suppression, interventions might be needed to facilitate and monitor linkage of HIV self-testing to HIV care to maximise the effect on initiation of ART and viral suppression (the full cascade of 90-90-90).

We commend the investigators for seeing the gap in HIV testing and rigorously assessing HIV self-testing. Looking ahead, what is the role for HIV self-testing and community-based strategies to reach the first 90 target and sustained linkage to treatment and prevention?

With increased experience and access to HIV selftesting, people living in medium and high HIV-incidence settings could independently do HIV self-tests, which will further normalise testing and also bring down the costs. To get there, several gaps in evidence need to be addressed. First, men who were absent from their homes might be reached by testing at social venues or in their work place. Second, although no increase among women in knowledge of HIV status with HIV self-testing was observed, and women more often chose supervised testing, women could also benefit from increased access to HIV self-testing, which is more convenient than HIV finger-prick tests. Third, WHO calls for appropriate supervision to be available, and for young people this might mean peer-guided or App-guided HIV  self-testing strategies. Unpacking and meeting the priorities and motivation of men, women, and young people could further increase HIV testing. Lastly, innovation is needed to link persons to prevention or treatment services to reach the ambitious HIV testing, treatment, and prevention targets needed to achieve epidemic control.

*Connie Celum, Ruanne Barnabas; Departments of Global Health, Medicine and Epidemiology, University of Washington, Seattle, WA 98195, USA

www.thelancet.com/hiv Published online December 17, 2018 http://dx.doi.org/10.1016/S2352-3018(18)30289-3