18 個非洲國家的多項愛滋病毒指標明顯存在社會經濟上的不平等
資料來源：Krishen Samuel / 2022 年 4 月 6 日 /aidsmap news
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完整圖片來源：巴門達瀑布；圖片由 rairdpccam 提供。知識共享許可。
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根據最近發表在《愛滋病》上的一項多國研究，許多非洲國家最富有的人使用保險套的可能性是最貧窮的人的五倍，同時對愛滋病毒感染者也表現出更積極的態度。
撒哈拉以南非洲佔全球愛滋病毒感染總數的三分之二。社會經濟不平等加劇了該地區在滿足愛滋病毒檢測、治療和病毒抑制目標方面的差距；聯合國愛滋病規劃署強調這些差異需要緊急關注。來自巴黎國家工藝美術學院的 Mohamed Hamidouche 博士及其同事進行了研究，以調查多個撒哈拉以南非洲國家在多項愛滋病毒指標上的社會經濟不平等。
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研究
研究人員使用了於 2010 年至 2018 年間在 18 個撒哈拉以南非洲國家（布吉納法索、喀麥隆、象牙海岸共和國、剛果民主共和國、衣索比亞、幾內亞、肯亞、賴索托、賴比瑞亞、馬拉威、馬利、尼日、盧旺達、塞內加爾、獅子山共和國、坦桑尼亞、尚比亞和辛巴威）之社會人口及健康家庭調查資料。值得注意的是，該分析忽略了愛滋病毒流行最嚴重的國家——南非。社會、經濟和健康訊息是透過使用標準化的面對面訪談調查所收集的。這包括對家庭財富的估計，根據所擁有的資產和設施的存在，例如衛生設施。
調查還從受訪者那裡收集了愛滋病毒相關訊息，包括愛滋病毒相關知識、對愛滋病毒感染者的態度、性伴侶的數量、保險套的使用、包皮環切術（在七個東部和南部非洲國家）、最近的愛滋病毒檢測和懷孕期間的檢測。在某些情況下，匿名愛滋病毒檢測是調查的一部分，15 至 24 歲青年的愛滋病毒盛行率被用作愛滋病毒發生率的代表。
研究人員使用了兩種衡量不平等的方法——不平等之相對指數（在這裡，指數或 RII 為 2 意味著在一個國家中最富有的人其報告結果可能是最貧窮的人的兩倍）和不平等的斜率指數，即不平等的絕對衡量標準（在這裡，指數或 SII 為 0.2 意味著測量的結果在最富有的人中比在最貧窮的人中高 20%）。
研究期間收集了 18 個國家的 358,591 名參與者（66% 為女性）的數據。調查的參與率很高，從 90% 到 100% 不等。
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愛滋病毒特異性指標
西非和中非國家對愛滋病毒相關的知識最低——十分之八的國家中只有不到 20% 的人對所有七個知識問題都給出了正確答案。喀麥隆和布吉納法索是例外，有 30% 和 23% 的抽樣調查者顯示出對 HIV 傳播和預防有很好的了解。相比之下，東非和南部非洲國家的知識水平更高（辛巴威和盧旺達最高，分別為 40% 和 43%）。同樣地，在西非和中非國家中除了一個國家以外，只有不到 50% 的人對愛滋病毒感染者表示積極態度，然而在東非和南部非洲之八個國家中的六個國家，則有超過 70% 的人表示對愛滋病毒感染者持積極態度。
在所有國家中的大多數參與者報告在過去一年中都沒有多個性伴侶；盧旺達和衣索比亞的這一比例最高（98%）。然而，據報導，在賴索托最後一次性活動中使用保險套的比例最高為 51%，降至最低的尼日為1%。
過去一年，所有東非和南部非洲國家有超過 20% 的人接受了 HIV 檢測，但在西非和中非十個國家中，有九個國家的這一比例低於 20%。據報導，在大多數東非和南部非洲國家，懷孕期間的檢測水平高於 95%（但衣索比亞較低，為 57%），惟據報導，在西非和中非則低於 90%（從馬利的 23% 到89% 在喀麥隆）。男性包皮環切術則僅在東非和南部非洲進行測量，從馬拉威的 9% 到盧旺達的 85% 不等。
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愛滋病毒指標中的社會經濟不平等
在 HIV 指標方面，相對不平等和絕對不平等指標上都存在顯著差異，社會上最富有的人在 HIV 相關知識、對 HIV 感染者的積極態度、最後性行為時使用保險套、最近的 HIV 檢測、懷孕期間的檢測、和男性割包皮上均遠遠地更佳。有趣的是，最貧窮的人報告的性伴侶數量較低，愛滋病毒感染率也較低。愛滋病毒發生率缺乏社會經濟梯度可能顯示流行模式正在發生變化，隨著時間的推移，更高的風險會從最富有的人轉移到最貧窮的人。
在相對不平等方面，保險套使用的差異最大，最富有的人使用保險套的可能性是最貧窮的人的五倍（RII = 5.02；95% 信賴區間，CI，2.79-9.05）。在愛滋病毒相關知識、積極態度、保險套使用、近期愛滋病毒檢測和懷孕期間檢測方面，西非和中非的相對不平等明顯高於東非和南部非洲。
就絕對不平等而言，最富有和最貧窮之間的最大差距是對愛滋病毒感染者的積極態度，差異為 32%（SII=0.32；95% CI 0.26-0.39）——最富有的人更有可能表現出積極或非污名化的態度。西非和中非的絕對不平等程度再次上升，尤其是在懷孕期間的愛滋病毒檢測和最近的愛滋病毒檢測方面。衣索比亞在相對和絕對指標上的不平等程度最高。大多數指標（除了保險套使用和包皮環切術外）顯示出在相對和絕對不平等指標之間存在顯著的正相關。
在解釋不同地區與財富相關的不平等時，作者提供了西非和中非國家中不平等程度較高的一些原因。一是私營醫療保健部門較突出，因此使用費可能是貧困人口獲得醫療服務的障礙。此外，總體上愛滋病毒的流行程度較小，導致最富有和最貧窮之間的不平等程度更高，並減低了對這些國家一般人口之介入上的捐助資金水準。
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結論
作者總結說：「總體而言，在缺乏知識和對愛滋病毒感染者的污名化態度方面，仍然存在鉅大的絕對和相對不平等，這可能會破壞對愛滋病毒的預防、照護和治療」。「在保險套使用、預防母嬰傳播、醫療上男性自願包皮環切術和愛滋病毒檢測方面觀察到不平等現象，特別是在西非和中非國家。這尤其值得關注，因為這些介入措施可以預防新的感染，直接透過保險套使用和自願性的男性包皮環切術，或者在預防母嬰傳播和愛滋病毒檢測上與照護和治療相關聯。保險套使用方面上的鉅大不平等可能反映了免費保險套獲取上的困難」。
參考文獻：
Hamidouche M 等人。監測 18 個撒哈拉以南非洲國家在愛滋病毒知識、態度、行為和預防方面的社會經濟不平等。 AIDS，2022 年 2 月 21 日線上提供。
https://doi.org/10.1097/qad.0000000000003191
Pronounced socio-economic inequalities across multiple HIV indicators in 18 African countries
Krishen Samuel / 6 April 2022 / aidsmap news
Image by rbairdpccam. Creative Commons licence.
The richest people in many African countries were five times more likely to use condoms than the poorest, while also displaying more positive attitudes towards people living with HIV, according to a recent multi-country study published in AIDS.
Sub-Saharan Africa accounts for two-thirds of all HIV infections globally. Socio-economic inequalities contribute towards gaps in meeting HIV testing, treatment and viral suppression targets in this region; these disparities have been highlighted by UNAIDS as requiring urgent attention. Dr Mohamed Hamidouche and colleagues from the National Conservatory of Arts and Crafts in Paris undertook research to investigate socio-economic inequalities for different HIV indicators in multiple sub-Saharan African countries.
The study
The researchers used data from Demographic and Health household sample surveys conducted in 18 sub-Saharan African countries (Burkina Faso, Cameroon, Côte d’Ivoire, the Democratic Republic of Congo, Ethiopia, Guinea, Kenya, Lesotho, Liberia, Malawi, Mali, Niger, Rwanda, Senegal, Sierra Leone, Tanzania, Zambia, and Zimbabwe) between 2010 and 2018. Notably, the country with the largest HIV epidemic – South Africa – was omitted from this analysis. Social, economic and health information was collected through face-to-face interviews using standardised surveys. This included estimates of household wealth, based on assets owned and the presence of facilities, such as sanitation.
The surveys also collected HIV-specific information from respondents, including HIV-related knowledge, attitudes towards people living with HIV, number of sexual partners, condom use, circumcision (in seven east and southern African countries), recent HIV testing and testing during pregnancy. In certain instances, anonymous HIV testing was conducted as part of the surveys and HIV prevalence among youth aged 15 to 24 was used as a proxy for HIV incidence.
The researchers used two ways of measuring inequalities – the relative index of inequality (here, an index or RII of 2 would mean that the richest were twice as likely to report an outcome than the poorest in a country) and the slope of index inequality, an absolute measure of inequality (here, an index or SII of 0.2 would mean that the outcome measured was 20% higher among the richest than among the poorest).
Data were collected on 358,591 participants for the study period (66% women) in the 18 countries. Participation rates for the surveys were high, ranging from 90% to 100%.
HIV-specific indicators
HIV-related knowledge was lowest in west and central African countries – less than 20% in eight out of ten countries gave correct answers to all seven knowledge questions. Cameroon and Burkina Faso were exceptions, as 30% and 23% of those sampled demonstrated good knowledge of HIV transmission and prevention. In contrast, knowledge was higher in east and southern African countries (highest in Zimbabwe and Rwanda at 40% and 43% respectively). Similarly, less than 50% expressed positive attitudes towards people living with HIV in all but one of the west and central African countries, whereas over 70% did so in six of the eight east and southern African countries.
Most participants reported having not having multiple sexual partners in the past year across all countries; this was highest in Rwanda and Ethiopia (98%). However, reported condom use for last sexual activity was highest in Lesotho at 51%, falling to as low as 1% in Niger.
Over 20% in all East and Southern African countries had taken an HIV test in the past year, but this fell below 20% in nine out of ten West and Central African countries. Testing during pregnancy was reported at levels above 95% in most East and Southern African countries (it was lower in Ethiopia at 57%), but it was reported at less than 90% in West and Central Africa (ranging from 23% in Mali to 89% in Cameroon). Male circumcision was only measured in East and Southern Africa and ranged from 9% in Malawi to 85% in Rwanda.
Socio-economic inequalities in HIV indicators
There were significant differences in both relative and absolute inequalities in terms of HIV indicators, with the richest in society faring better on HIV-related knowledge, positive attitudes to people with HIV, condom use at last sex, recent HIV testing, testing during pregnancy, and male circumcision. Interestingly, the poorest reported lower levels of sexual partners and had lower rates of HIV infection. This lack of a socio-economic gradient in terms of HIV incidence could indicate a changing epidemic pattern, with higher risk moving from the wealthiest to the poorest over time.
In terms of relative inequalities, the highest difference was observed for condom use, with the richest being five times more likely to use condoms than the poorest (RII = 5.02; 95% confidence interval, CI, 2.79-9.05). Relative inequalities were significantly higher in West and Central Africa than in East and Southern Africa for HIV-related knowledge, positive attitudes, condom use, recent HIV testing and testing during pregnancy.
In terms of absolute inequalities, the largest gap between the richest and poorest was noted for positive attitudes towards people living with HIV, with a 32% difference (SII=0.32; 95% CI 0.26-0.39) – the richest were more likely to display positive or non-stigmatising attitudes. Absolute levels of inequalities were once again higher in West and Central Africa, especially for HIV testing during pregnancy and recent HIV testing.
Ethiopia had the highest levels of inequalities on both the relative and absolute measures. Most indicators (apart from condom use and circumcision) showed significant positive correlations between relative and absolute inequality metrics.
In terms of explaining the wealth-related inequalities noted for different regions, the authors provide a few reasons for the higher levels of inequalities in West and Central African countries. One is that the private healthcare sector is more prominent and thus user fees may be a barrier to poorer people accessing care. Additionally, HIV epidemics are smaller overall, leading to greater levels of inequality seen between the richest and poorest and reduced levels of donor funding for general population interventions in these countries.
Conclusion
“Large absolute and relative inequalities, overall, remain regarding lack of knowledge and stigmatizing attitudes toward people living with HIV, and this may undermine HIV prevention, care and treatment,” the authors conclude. “Concerning inequalities are observed in condom use, prevention of mother-to-child transmission, voluntary medical male circumcision and HIV testing, especially in West and Central African countries. This is of particular concern because these are interventions that can prevent new infections, directly for condom use and voluntary male medical circumcision, or when linked to care and treatment for prevention of mother-to-child transmission and HIV testing. Large inequalities in condom use may reflect difficulties to access condoms free of charge.”
References
Hamidouche M et al. Monitoring socioeconomic inequalities across HIV knowledge, attitudes, behaviours and prevention in 18 sub-Saharan African countries. AIDS, available online 21 Feb 2022.
https://doi.org/10.1097/qad.0000000000003191