《刺胳針愛滋病毒》：非洲國家嚴格的反LGBT立法與愛滋病毒的檢測和認知之降低有關

一項涉及非洲44,993名男男性性行為者的薈萃分析發現，反女同性戀、男同性戀、雙性戀和跨性別者的法律與愛滋病毒的檢測和認知之降低有關

《剌胳針》/ 財團法人台灣紅絲帶基金會編譯

    一項涉及非洲44,993名男男性性行為者的薈萃分析發現，反女同性戀、男同性戀、雙性戀和跨性別者的法律與愛滋病毒的檢測和認知之降低有關

這項針對非洲男男性行為者進行HIV檢測、治療和病毒抑制的系統性綜述是首次發現，在最近的研究（2011年之後進行）中，在過去的12個月中，只有一半的男性接受了HIV檢測。此外，只有四分之一的愛滋病毒感染者正在接受抗反轉錄病毒療法或病毒已被抑制。

這項發表在《刺胳針愛滋病毒》雜誌上的分析發現，在具有更多保護性和進步性法規且較少或沒有LGBT相關逮捕的情況下，對HIV的檢測較高。

儘管檢測率大大高於2011年之前，但仍不足以實現聯合國設定的目標（到2020年，讓90％的愛滋病毒感染者，了解自己的狀況的人有90％也接受抗反轉錄病毒治療，以及接受抗反轉錄病毒治療的人有90％實現病毒抑制）。這些發現支持了以前的國家級研究，這些研究表明反LGBT立法與獲得檢測和治療之間存在關聯。

在全球範圍內，男男性行為者感染愛滋病毒的可能性是普通人群中男性的28倍，這在撒哈拉以南非洲尤其明顯，在那裡的這些男性的人權經常受到侵犯。反女同性戀、男同性戀、雙性戀和跨性別者的歧視為實施有效的愛滋病毒研究、政策和衛生計劃以及破壞社區和非政府組織所提供的服務上造成了障礙。

英國倫敦帝國理工學院的Marie-Claude Boily教授說：「每年仍有近一百萬的愛滋病毒感染者死亡，因為他們無法或沒有得到測試和參與治療。我們的結果表明，儘管近年來非洲的情況有所改善，在男男性行為者中進行愛滋病毒檢測和治療的比例仍然很低，迫切需要做出更多的努力，據估計，2011年之後接受調查的非洲的男男性行為者有67％曾接受過愛滋病毒檢測。距實現聯合國愛滋病規劃署90-90-90目標還有很長的路要走。」

該審查使用了2004年至2017年之間來自28個非洲國家的75項獨立研究，以評估男性在愛滋病毒檢測，認知狀況，參與在照護中，抗反轉錄病毒療法的使用以及病毒抑制的情況。

在2011年以後進行的所有研究中，曾經接受過HIV檢測的參與者的估計比例為67％，是2011年之前的1.3倍，在南部非洲最高（80％），在北部非洲最低（34％）。相較之下，在2011年之後的研究中，於過去12個月中曾接受測試的男性比例為50％，是2011年之前的1.6倍，在南部非洲最高，但在東部非洲最低（67％比40％）。

男男性行為者且愛滋病毒呈陽性並認知到自己狀況者的比例更低得多，僅為19％，甚至在2011年之後在東部非洲更是最低（9％）。總體而言，目前只有不到24％的愛滋病毒感染者接受抗反轉錄病毒療法，而目前估計有25％的愛滋病毒感染者受到了病毒抑制。由於這些結果的研究資料不足，因此並無法觀察隨著時間的變化。

與立法最不嚴格的國家相比，反LGBT立法最嚴格的國家在過去12個月的愛滋病毒檢測水平和對愛滋病毒狀況的了解水平較低。在具有更多保護性和進步性法規，且從2014-17年度開始沒有發生與LGBT相關的逮捕之國家中，男性更有可能接受過愛滋病毒檢測。

作者指出了研究的一些限制，包括沒有在26個非洲國家/地區進行研究，其中包括13個同性關係是非法的國家/地區，因此新發現可能不適用於整個非洲大陸，而對於反LGBT立法嚴重程度較高的國家，結果可能會更糟。儘管有關愛滋病毒的檢測、治療和病毒抑制的研究數量大量增加，但除愛滋病毒檢測外，所有結果的數據仍然很少，特別是來自中部和北部非洲的數據。這意味著該研究可能會低估或高估參與度，尤其是對於抗反轉錄病毒療法的使用和病毒抑制。作者指出，這反映了在面臨嚴重污名化的關鍵人群中進行研究的挑戰。

該研究中使用的反LGBT立法指數僅包括有關立法的訊息，而不包括立法的實施方式，因此可能無法了解全貌。由於所包括的大多數研究都是自我報告的，並且使用了非機密訪談方法，因此可能存在低報和報告偏誤的情況。

位於喀麥隆雅溫得的喀麥隆巴斯德中心的Jean Joel Bigna博士在評論文章中說：「Stannah和同事們提供了有關非洲男男性行為者其愛滋病毒/愛滋病治療層級的最新及時性的信息，並指出需緊急行動的區塊，非洲各國政府應制定綜合性計劃和整體的介入措施，為這一難以到達、受到污名和歧視的易受傷害人群提供照護、支持和預防服務。社區動員，醫療照護工作者的教育以減少污名和歧視以及其參與，仍然是結束愛滋病毒/愛滋病在全球各地和在非洲之流行中心流行的關鍵。人權是普遍性的，性取向更沒有排斥的理由。」

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編者註

該研究由英國醫學研究委員會、英國國際發展部和美國國家衛生研究院逶過「HIV預防試驗網絡」資助。由來自英國醫學研究委員會全球傳染病流行病學和HIV預防試驗網絡建模中心、倫敦帝國學院、倫敦衛生與熱帶醫學學院和約翰霍浦京斯大學的研究人員所進行。

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The Lancet HIV: Severe anti-LGBT legislations associated with lower testing and awareness of HIV in African countries

A meta-analysis involving 44,993 men who have sex with men in Africa finds that anti-LGBT legislation is associated with lower HIV testing and awareness

THE LANCET

    A meta-analysis involving 44,993 men who have sex with men in Africa finds that anti-LGBT legislation is associated with lower HIV testing and awareness.

This first systematic review to investigate HIV testing, treatment and viral suppression in men who have sex with men in Africa finds that among the most recent studies (conducted after 2011) only half of men have been tested for HIV in the past 12 months. In addition, only a quarter of men living with HIV were on antiretroviral therapy or virally suppressed.

The analysis, published in The Lancet HIV journal, found that testing for HIV was higher where there was more protective and progressive legislation and fewer or no LGBT-related arrests.

Although rates of testing are substantially higher than before 2011, they are not sufficient to achieve the targets set by the UN (to have 90% of people living with HIV aware of their status, 90% of those aware also on antiretroviral therapy, and 90% of these achieving viral suppression by 2020). The findings support previous country-level studies suggesting an association between anti-LGBT legislation and access to testing and treatment.

Globally, men who have sex with men are about 28 times more likely to be living with HIV than are men in the general population, and this is particularly apparent in sub-Saharan Africa where human rights of these men are often violated. Anti-LGBT discrimination creates barriers to implementing effective HIV research, policy and health programmes along with disruption of services provided by community and non-governmental organisations.

Professor Marie-Claude Boily of Imperial College London, UK says: “Nearly one million people living with HIV still die annually because they cannot or do not get tested and engage in treatment. Our results suggest that despite improvements in recent years in Africa, engagement in HIV testing and treatment among men who have sex with men is still low, and additional efforts are urgently needed. With an estimated 67% of men who have sex with men in Africa surveyed after 2011 having ever tested for HIV, we are still a long way off achieving the UNAIDS 90-90-90 targets.” [1]

The review used 75 independent studies conducted between 2004 and 2017 from 28 African countries to estimate HIV testing, status awareness, engagement in care, antiretroviral therapy use, and viral suppression in the men.

Over all studies conducted after 2011, the estimated proportion of participants ever tested for HIV was 67%, which was 1.3 times higher than before 2011, and was highest in southern Africa (80%) and lowest in northern Africa (34 %). In comparison, the proportion of men tested in the last 12 months was 50% in studies after 2011, which was 1.6 times higher than before 2011, and again was highest in southern but lowest in eastern Africa (67% vs 40%).

The proportion of men who have sex with men who are HIV positive and aware of their status was much lower at just 19%, and was particularly low in eastern Africa even after 2011 (9%). Overall, less than 24% of men living with HIV were currently on antiretroviral therapy, and an estimated 25% of men living with HIV were currently virally suppressed. It was not possible to look at changes over time as there was not enough data in the studies on these outcomes.

Levels of HIV testing ever, in the past 12 months, and HIV status awareness were lower in countries with the most severe anti-LGBT legislation, compared with countries with the least severe legislation. Men were more likely to have ever been tested for HIV in countries with more protective and progressive legislation and no LGBT-related arrests from 2014-17.

The authors note some limitations, including that there were no studies in 26 African countries, including 13 countries where same-sex relations are illegal, so the new findings may not apply to the entire African continent and results may be worse in countries with more severe anti-LGBT legislation. Despite a substantial increase in the number of studies on testing for HIV, treatment and viral suppression, data remains scarce for all outcomes except HIV testing, especially from central and northern Africa. This means the study may underestimate or overestimate engagement, especially for antiretroviral therapy use and viral suppression. The authors note that this reflects the challenges of doing research among key populations that face substantial stigma.

The anti-LGBT legislation index used in the study only includes information about legislation, not how it is implemented so may not have captured the full picture. Because most of the studies included were self-reported and used non-confidential interview methods, underreporting and reporting biases are possible.

In a linked Comment article, Dr Jean Joel Bigna of the Centre Pasteur of Cameroon, Yaoundé, Cameroon, says: “Stannah and colleagues have provided important updates on the current situation regarding the HIV care cascade among men who have sex with men in Afric