HIV 暴露前預防 (PrEP) 和病毒性肝炎：整合的獨特機會
資料來源：www.thelancet.com/hiv Vol 9 November 2022 / 財團法人台灣紅絲帶基金會編譯
Amir M Mohareb 及其同事強調，HIV 暴露前預防 (PrEP) 提供了與病毒性肝炎服務整合的獨特機會。 可以從 PrEP 中受益的個人通常攜帶或有感染B型肝炎病毒 (HBV) 和C型肝炎病毒 (HCV) 的風險。 為獲得 PrEP 的個人提供 HBV 和 HCV 服務解決了幾個公共衛生問題，並提供以人為本的照護。
基於替諾福韋的口服 PrEP (Tenofovir-based oral PrEP) 可對抗 HBV 並預防 HIV。 Mohareb 及其同事指出，在服務可及性不佳的情況下，擴大 PrEP 可以擴大獲得 HBV 照護的機會。他們同樣注意到 HBV 感染者普遍被排除在 PrEP 計畫之外，並且缺乏向 HBV 感染者提供 PrEP 的指引。2022 年 7 月，世衛組織發布了關於 PrEP 和病毒性肝炎的最新指引。該指引強調了在 PrEP 開始後 3 個月內檢測 HBV 並提供 HBV 治療評估的公共衛生益處。同樣，強烈鼓勵在向 HCV 風險人群提供服務的地方進行 HCV 檢測和治療評估。這種整合有助於消除病毒性肝炎並提高衛生系統的效率。
世衛組織指出，可以向 HBV 或 HCV 患者提供每日和事件驅動的口服 PrEP 劑量。B肝病毒感染者停止治療後病毒學和臨床復發的風險很小； 然而，復發很少見，通常是良性的，並且風險取決於替諾福韋暴露持續時間；每日和事件驅動的 PrEP 都存在風險，因為 PrEP 的開始、停止和重新開始很常見。對於 HBV 患者，口服 PrEP 的風險和益處都應該考慮到，且監測很重要，特別是對於已有肝病的人。實施研究應評估最佳方法，包括治療停止後的追蹤。
在同一期《刺胳針愛滋病毒》中，ANRS PREVENIR 研究強調了事件驅動 PrEP 的好處。消除慢性 HBV 禁忌症可以使事件驅動的 PrEP 成為更容易獲得的 HIV 預防選擇（特別是在更新的 WHO 指引的背景下，事件驅動的 PrEP 可以提供給所有出生時被指定為男性且未服用性別肯定激素的性接觸者）。
達匹韋林 (dapivirine) 陰道環沒有 HBV 復發的風險。但是，鼓勵選擇此選項來解決 HBV 問題（包括垂直傳播）的人們進行 HBV 檢測。鑑於數據有限，需要針對 HBV 或 HCV 患者進行注射型卡博特韋 (cabotegravir) 實施之研究，但基於替諾福韋的口服 PrEP 可能更適合 HBV 患者，因為它可以抑制 HBV。
我們聲明沒有競爭利益。 Unitaid 和 Bill & Melinda Gates Foundation 向 WHO 提供資助，使這篇文章成為可能。 我們單獨對本文表達的觀點負責，它們不一定代表其所屬機構的觀點、決定或政策。 © 2022 世界衛生組織。 由 Elsevier Ltd. 出版。保留所有權利
*Robin Schaefer、Heather-Marie A Schmidt、Michelle Rodolph、Olufunmilayo Lesi、Rachel Baggaley、Niklas Luhmann schaeferr@who.int
全球愛滋病毒、肝炎和性傳播感染計畫，世衛組織，瑞士日內瓦（RS、H-MAS、MR、RB、OL、NL）； 聯合國愛滋病規劃署亞洲及太平洋區域辦事處，泰國曼谷 (H-MAS)
HIV PrEP and viral hepatitis: a unique opportunity for integration
www.thelancet.com/hiv Vol 9 November 2022
Amir M Mohareb and colleagues1 highlight that HIV pre-exposure prophylaxis (PrEP) offers unique opportunities for integration with viral hepatitis services. Individuals who could benefit from PrEP commonly live with or are at risk of acquiring hepatitis B virus (HBV) and hepatitis C virus (HCV). Providing individuals accessing PrEP with HBV and HCV services addresses several public health issues and provides person-centred care.
Tenofovir-based oral PrEP acts against HBV and prevents HIV. Mohareb and colleagues note that PrEP scale-up could expand access to HBV care where access to services is suboptimal. They equally note the common exclusion of people with HBV from PrEP programmes and scarcity of guidelines on offering PrEP to people with HBV. In July, 2022, WHO released updated guidance on PrEP and viral hepatitis. The guidance stresses the public health benefits of testing for HBV within 3 months of PrEP initiation and providing HBV treatment evaluation. Similarly, HCV testing and treatment evaluation is strongly encouraged where services are provided to populations at HCV risk. Such integration can contribute to viral hepatitis elimination and generate health system efficiencies.
WHO noted that both daily and event-driven oral PrEP dosing can be offered to people with HBV or HCV. There are small risks of virological and clinical relapse in people with HBV when withdrawing therapy; however, relapse is rare, commonly benign, and risks depend on tenofovir exposure duration, existing for daily and eventdriven PrEP as starting, stopping, and restarting of PrEP is common. For people with HBV, risks and benefits of oral PrEP should be considered, and monitoring is important, particularly for people with pre-existing liver disease. Implementation research should evaluate best approaches, including for follow-up after treatment cessation.
In the same issue of The Lancet HIV, the ANRS PREVENIR study highlighted the benefits of eventdriven PrEP. Removing the chronic HBV contraindication can make eventdriven PrEP a more accessible HIV prevention choice (particularly in the context of updated WHO guidance that event-driven PrEP can be offered to all people assigned male at birth with sexual exposure not taking gender-affirming hormones).
There is no risk of HBV relapse with the dapivirine vaginal ring. However, HBV testing is encouraged for people choosing this option to address HBV, including vertical transmission. Implementation research is needed on injectable cabotegravir for people with HBV or HCV given that data are limited, but tenofovir-based oral PrEP could be preferred for people with HBV because it suppresses HBV.
We declare no competing interests. Unitaid and the Bill & Melinda Gates Foundation awarded grants to WHO that enabled this article. We alone are responsible for the views expressed in this article and they do not necessarily represent the views, decisions or policies of the institutions with which they are affiliated. © 2022 World Health Organization. Published by Elsevier Ltd. All rights reserved
*Robin Schaefer, Heather-Marie A Schmidt, Michelle Rodolph, Olufunmilayo Lesi, Rachel Baggaley, Niklas Luhmann schaeferr@who.int
Global HIV, Hepatitis and STIs Programmes, WHO, Geneva, Switzerland (RS, H-MAS, MR, RB, OL, NL); UNAIDS Regional Office for Asia and the Pacific, Bangkok, Thailand (H-MAS)