HIV病毒抑制是健康長壽的關鍵

資料來源：ww.thelancet.com/hiv Vol 9 October 2022 / 財團法人台灣紅絲帶基金會編譯

自 UNAID 發佈到 2020 年 HIV 治療目標的挑戰已過去十年：90% 的 HIV 感染者知道自己的狀況，90% 的 HIV 感染者接受抗反轉錄病毒治療，90% 接受抗反轉錄病毒治療的人受到病毒抑制。 儘管雄心勃勃，但這些目標並挑戰了 HIV 計畫以監測接受治療的患者之病毒載量。

在《剌胳針愛滋病毒》中，Collin Payne 和同事根據南非 INDEPTH 社區的一項以人群為基礎的研究，基於感染者之HIV 狀況和 HIV病毒載量的抑制，報告了預期壽命和無殘疾預期壽命差異的結果。該研究具有許多重要優勢，包括透過血斑分析直接測量病毒載量和抗反轉錄病毒效度，女性多於男性，以及使用兩種方法評估殘疾——自我報告和客觀測量。研究人員發現，到 45 歲時，未感染 HIV 的人將比病毒載量無法檢測的 HIV 感染者多活 3 年，而未感染 HIV 的人將比病毒載量不受抑制的 HIV 感染者多活 10 年。在 65 歲時，病毒載量無法檢測之愛滋病毒感染者和未感染愛滋病毒者的預期壽命差異估計更小。當他們使用兩種不同的殘疾方法來考慮無殘疾的預期壽命並分別考慮男性和女性時，結果是相似的。研究人員得出的結論是，只要病毒受到抑制，愛滋病病毒感染者就可以過上與未感染者相似的無殘疾生活。

這些結果令人鼓舞。愛滋病毒藥物的廣泛普及導致全球愛滋病毒感染者人數大幅增加，特別是在愛滋病毒負擔高的撒哈拉以南非洲地區。確保人們不僅壽命更長，而且生活得更健康至關重要。對於已經在努力實現聯合國愛滋病規劃署目標的醫療保健系統來說，管理與老齡化相關的殘疾的負擔可能是巨大的。幾乎可以肯定的是，在其他條件相同的情況下，抑制病毒的人比沒有抑制病毒的人活得更長、更健康。

在我們最近關於調整愛滋病毒感染者照護的論文中，我們強調需要定制的照護以滿足這一人群的需求。我們呼籲醫療保健提供者應比普通人群更早地去篩查 HIV 感染者與年齡相關的疾病。除了病毒抑制之外，健康長壽也很重要，因此需要與多個提供者以及有服用多種藥物風險的人進行協調。最後，我們呼籲在聯合國愛滋病規劃署的目標中增加第四個 90（哈里斯及其同事和拉撒路及其同事也提出），這將要求愛滋病毒計畫追踪與生活質量（健康長壽）相關的指標。在我們更好好地協調年齡和與愛滋病毒相關的非愛滋病的其他狀況(nonAIDS conditions)之前，與社會人口和行為上相似的未感染愛滋病毒之老年人相比，愛滋病毒感染者的壽命和生活質量可能會降低。

目前，提出病毒抑制患者的預期壽命和無殘疾預期壽命與未感染愛滋病毒的人相似可能還為時過早。 Collins 和 Armstrong 的一項研究將 HIV 感染者與非 HIV 感染者進行了比較，發現儘管預期壽命的差異多年來有所下降，但它確實持續存在著HIV 感染者其無合併症之預期壽命並沒有改善。愛滋病毒獨立地增加了與老齡化相關的疾病的風險，愛滋病毒感染者比未感染愛滋病毒的人提早了 16 年，強調了愛滋病毒感染者在老齡人口生活中共同管理愛滋病毒和非傳染性疾病的重要性。

Payne 及其同事研究中的三組人  ——那些病毒受抑制的HIV 感染者、那些病毒未抑制的 HIV 感染者和那些沒有 HIV 的人——可能在更多方面的差異而不是病毒感染狀態。該研究僅限於愛滋病毒照護存留率低和該國病毒抑制率最低的人群。總體樣本的預期壽命也低於全國平均水平。在這種情況下，那些獲得病毒抑制的人（41% 對全國 59%）可能是非常健康的個體：與可檢測到病毒的人相比，他們擁有更多的社會經濟資源、更好的營養、更少的酒精消耗和更少的結核病。並且，可能，甚至比那些沒有愛滋病毒的人）。該研究可能將存活率和無殘疾存活率的差異部分歸因於可檢測病毒與不可檢測病毒的這些共病因素。此外，正如 Payne 及其同事所指出的，他們的研究無法解釋自 HIV 感染以來的時間。大多數感染愛滋病毒的老年人可能是長期倖存者，他們也是經過挑選的群體。

總之，這項研究為我們帶來了希望，未來愛滋病毒可以被認為是一種可控制的慢性疾病，很少傳播給他人。但我們不應該自滿。我們需要做的事情還很多。

我們聲明沒有競爭利益。 *Jepchirchir Kiplagat, Amy Justice jkiplagat@ampath.or.ke 

肯亞埃爾多雷特Moi 大學健康科學學院 (JK)；美國康乃狄克州紐黑文耶魯大學醫學院和退輔醫療保健系統 (AJ) 。

HIV viral suppression is key to healthy longevity

ww.thelancet.com/hiv Vol 9 October 2022

A decade has passed since UNAIDs issued its target challenge for HIV treatment by 2020: 90% of all people living with HIV know their status, 90% of people diagnosed with HIV are treated with antiretrovirals, and 90% of those receiving antiretrovirals are virally suppressed. Although ambitious, these targets challenged HIV programmes to monitor viral loads among their patients in treatment. 

In The Lancet HIV, Collin Payne and collegues report findings on differences in life expectancy and disabilityfree life expectancy, on the basis of HIV status and viral load suppression for those living with HIV, from a population-based study nested in the INDEPTH community in South Africa. The study had many important strengths, including direct measurement of viral load and antiretroviral titres via blood spot analysis, inclusion of more women than men, and use of two approaches to assess disability—self-report and objective measures. The researchers found that by age 45 years, a person without HIV will live 3 years longer than a person living with HIV whose viral load is undetectable, and a person without HIV will live 10 years longer than a person living with HIV whose viral load is unsuppressed. At age 65 years, estimated differences in life expectancy for people with suppressed HIV and those without HIV were even smaller. When they considered disability-free life expectancy using two different approaches to disability, and considered men and women separately, results were similar. The researchers concluded that people living with HIV can live a disabilityfree life similar to that of people who are not infected, as long as they remain virally suppressed. 

These results are encouraging. Wide access to HIV medication has resulted in a substantial increase in the number of people ageing with HIV globally, especially in sub-Saharan Africa, where HIV burden is high. Ensuring that people are not only living longer, but healthier, lives is critical.3 The burden of managing ageing-associated disabilities can be overwhelming for health-care systems already struggling to achieve UNAIDS targets. It is almost certainly true that people who have viral suppression live longer and healthier lives than those who do not, all else equal. 

In our recent paper on adapting care for people ageing with HIV, we emphasised the need to tailor care to meet the needs of this population. We called on health-care providers to screen age-related conditions among people living with HIV earlier than in the general population. Beyond viral suppression, healthy longevity is important, hence the need to coordinate from multiple providers and for those who are at risk of polypharmacy. We concluded with a call to add a fourth 90 to the UNAIDS targets—as also raised by Harris and colleagues and Lazarus and colleagues —which will require HIV programmes to track metrics related to quality of life (healthy longevity). Until we achieve better coordination of age and HIV-associated nonAIDS conditions, those ageing with HIV are likely to have decreased length and quality of life compared with demographically and behaviourally similar people who are ageing without HIV. 

For now, it is probably premature to suggest that those with viral suppression have life expectancy and disability-free life expectancy similar to those people living without HIV. A study by Collins and Armstrong matched individuals living with HIV with those without and found that, although the difference in life expectancies has decreased over the years, it did persist, with non-improvement in comorbidity-free life expectancy for people with HIV. HIV independently increased the risk of ageing-related conditions, with this occurring up to 16 years earlier in those with HIV than in their HIV-uninfected counterparts, emphasising the importance of co-management of HIV and non-communicable diseases in the ageing population living with HIV. 

The people in the three groups in Payne and colleagues’ study —those with HIV with suppressed virus, those with HIV with unsuppressed virus, and those without HIV—probably differ from each other in more ways than viral status. The study was limited to a population with low retention rates in HIV care and the lowest rates of viral suppression in the country. Life expectancy in the overall sample was also lower than the national average. In this context, those treated who achieved viral suppression (41% vs 59% in the country as a whole) might be exceptionally healthy individuals: with more socioeconomic resources, better nutrition, lower alcohol consumption, and less tuberculosis than those with detectable virus (and, possibly, even than those without HIV). The study might be attributing differences in survival and disability-free survival partly due to these comorbid factors to detectable virus versus undetectable virus. Also, as noted by Payne and colleagues, their study was not able to account for time since HIV infection. Most of the older people with HIV were probably longerterm survivors, who are also a select group. 

In conclusion, this study gives us hope for a future in which HIV can be considered a manageable chronic disease that is rarely transmitted to others. But we should not be complacent. There is much we need to do.

We declare no competing interests.

*Jepchirchir Kiplagat, Amy Justice jkiplagat@ampath.or.ke 

Moi University College of Health Sciences, Eldoret, Kenya (JK); Yale University, School of Medicine and VA Connecticut Healthcare System, New Haven, CT, USA (AJ)