迪安街診所正在為倫敦的男男間性行為者之愛滋疫情奮鬥

 

迪安街診所正在為倫敦的男男間性行為者之愛滋疫情奮鬥

資料來源:刺胳HIV醫學期刊,www.thelancet.com/hiv Vol 5 May 2018.財團法人台灣紅絲帶基金會編譯

雖然在整個倫敦均可獲得愛滋檢測和治療之服務,但在英國首都對男男間性行為者(MSM) 而言可能沒有任何一間診所能較迪安街56號所提供之快速服務更知名。由主要負責醫師Alan McOwan所領導的診所,由其所提供服務之數字可為它自己說話。“我們兩家診所大約診斷出全倫敦三分之一的男男間性行為者之愛滋新感個案“,他解釋說。這數字意味著全英國所有MSM新診斷個案的20%由其檢出。然而,該診所不光只是專門針對MSM患者提供服務-其中男男間性行為者約佔其顧客的60%,還有多達25%的女性和15%的男異性戀顧客。

“在去年,我們努力在減少男男間性行為者愛滋新感個案的檢出比率已經開始顯現成果,而且倫敦與英國自疫情開始以來首次出現疫情反轉下降“,McOwan解釋說。“這歸因於針對MSM族群提供暴露前預防投藥與快速檢測並針對新感染者立即開始進行抗反轉錄病毒治療之結合- 再加上已建置成熟之預防方法如保險套 - 這整體的結合是革命性的愛滋預防,“約有75%的感染者確診後首次就診時就已開始了抗反錄病毒藥物之治療,其開始治療之中位時間為7天。

那麼迪安街診所的成功秘訣是什麼呢?它所在的位置是一個關鍵因素,位處倫敦Soho地區的心臟,更是位處它所服務社區的門口。從2014年開張的迪安街快速篩檢服務提出後,診所已經隨著成長而學習,推出步入便即時提供之HIV檢測和性傳染病(STI)之測試,其檢測結果透過手機通訊在6小時內提供。患者步入、自行擦拭取樣,並提供一個尿液樣本用於檢測披衣菌和淋病,如果需要的話在此之前他們的血液檢體會被護士用於梅毒、愛滋病毒和C型肝炎之檢測。“這種最快速的轉變亦為我們的顧客所喜歡McOwan說。該診所每月整體篩檢約12 ,500名患者。

透過藥物支持服務之經理David Stuart和他的團隊,迪安街診所亦協助人們處理從偶爾之問題用藥到發展成熟的藥物成癮之所有事情,主要針對俱樂部藥物如G水(以伽瑪-羥基丁酸酯的形式或伽瑪-丁內酯)、4-甲基甲基卡西酮(喵喵)、和甲基安非他命(冰毒)。該診所的CODE服務(由McOwan所創建)用於管理最嚴重案件,以及那些伴隨著問題用藥者所產生而Stuart已觀察到之全面的症狀,包括妄想症、精神病、喪失自尊,以及高風險的性行為和其他後續健康上的行為。“我們也非常活躍於社交媒體以及透過社區活動,例如在當地酒吧舉行之「讓我們談談同志和藥物」 - 向人們展示他們並不孤單,並鼓勵他們如果需要時應去尋求協助”,Stuart表示。“我們成功地減少了愛滋病毒新感個案主因係集中於針對風險最高的族群展開外展服務”,迪安街診所臨床經理Leigh Chislett解釋道。

“進入診所接受進行暴露後預防投藥的人、梅毒治療者、以及直腸感染衣原體患者或淋病患者,這些人在一年內將有10%的機會會成為HIV陽性。包括使用西班牙文、葡萄牙文和其他語言的教材去接觸這些人,因為該族群中的一些人英語並不是他們的母語 -這個群體新感染的比例已經下降到1%,形成了新感染個案數巨大的降低”。倫敦的跨性別社區受益於位於迪安街56號稱為cliniQ的特別服務,其專門設計為跨性別界社區及其合作夥伴提供服務,並由跨性別人士管理。“這是跨性別人士的一個安全空間”,一位cliniQ的共同創始人Michelle Ross-Turner解釋說。“跨性別族群顯然面臨著一個不同類型的歧視並約有一半的人曾企圖自殺。這家診所現在已經提供了六年的服務。我們有瑜伽、針灸和其他針對跨性別人士的整體福祉的活動,支持和協助他們在感受到自在的社區環境和族群中面對圍繞在愛滋和性病的相關問題”。

診所中有一個專門的健康顧問諮詢團隊解決所有與性健康交織在一起的問題。“我們處理所有因透過身體和情感的攻擊所導致嚴重的精神病,確保病人的安全是我們的首要任務 -當然有時會涉及和合作夥伴等服務團隊如心理健康信託機構和警察一起工作“,資深健康顧問Annette Colcutt解釋。

迪安街診所在管理有愛滋感染風險人們上的成功是顯而易見的,診所中所有新的HIV診斷從20156月的72例高峰下降到20179月的11例。但與英國其他的預防服務一樣,做好的工作有被取消的風險,英國中央政府在各地的商議用於資助愛滋和性傳染病預防的公共衛生補助不斷地被削減。“我們擔心的是較特殊的像cliniQ這種和其他的服務將受到威脅“,McOwan說。像全國其他服務一樣,迪安街診所將在繼續提供步入即時式服務時面臨到需要在線上先進行優先順序之分類和改採郵寄自我篩檢套組的壓力。

“這將是一個困難的平衡”,他解釋說。“當巴黎和紐約的診所正在根據我們的模式建立服務時“,他說。“尤其當我們第一次在英國看到愛滋的新感個案正減少時,這些經費削減的威脅將傷害或扭轉我們的進步。“

 

Dean Street clinics—battling London’s MSM HIV epidemic

Tony KirbyMichelle Thornber-Dunwell. www.thelancet.com/hiv Vol 5 May 2018

Although HIV testing and treatment services are available across London, probably no clinics in the UK capital are better known to men who have sex with men (MSM) than those at 56 Dean Street and Dean Street Express.

 Led by chief clinician Alan McOwan, the clinics numbers speak for themselves. We diagnose around a third of all new HIV infections in London in MSM in our two clinics, he explains. This translates to 20% of all new diagnoses in MSM in England. Yet the clinic is not exclusively for MSMpatientsMSM are 60% of their clients, with a further 25% women and 15% heterosexual men.

In the last year, our efforts to reduce new HIV diagnosis rates among MSM have begun to bear fruit, with London and the UK seeing their first decreases since the epidemic began, explains McOwan.This has been due to a combination of pre-exposure prophylaxis plus rapid testing and immediate initiation of antiretroviral treatment of newly infected MSMin addition to more established methods of prevention such as condomswhich are revolutionising HIV prevention. Around 75% of people start antiretroviral treatment at their first appointment after diagnosis, with a median time to starting treatment of 7 days.

So what is the secret of Dean Streets success? Location is a key factor, in the heart of Londons Soho, on the doorstep of the community it serves. The clinic has learnt as it has grown, with Dean Street Express (opened in 2014) offering walk-in instant HIV test and sexually transmitted infection (STI) testing for which the results are delivered by SMS within 6 hours. Patients enter, self-swab, and provide a urine sample for chlamydia and gonorrhoea testing before having their blood taken by a nurse for syphilis testing and HIV and hepatitis C testing if required. Its the fast turnaround that our patients like, says McOwan. The clinics together screen approximately 12 500 patients each month.

Through the drugs support services manager, David Stuart, and his team, Dean Street are there to help people cope with everything from occasional problematic use of drugs to full blown addiction, mostly to the club drugs G (in the form of gammahydroxybutyrate or gamma-butyrolactone), mephedrone, and methamphetamine (crystal meth). The clinics CODE service (created by McOwan) manages the most serious cases, and Stuart has seen the full gamut of symptoms that accompany problem users, including paranoia, psychosis, loss of self-esteem, and high-risk sexual and other health behaviours that follow. Weve also been very active both on social media and through community events such as lets talk about gay sex and drugs’—held at local barsthat show people they are not alone and encourage them to seek help if they need it, says Stuart.

Our success in reducing new HIV diagnoses has centred on us targeting patients at highest risk for outreach, explains Leigh Chislett, Dean Street Clinic Manager.People coming in for post-exposure prophylaxis, syphilis treatment and those who had rectal chlamydiaor gonorrhoea, each had a 10% chance of becoming HIV positive within a year. By reaching out to these groupsincluding using materials in Spanish, Portuguese and other languages since some patients in this group did not have English as their first languagethe new infection rate in this group has fallen to 1%, making a huge dent in new infections.

The London trans community benefits from a specialised service called cliniQ based at 56 Dean Street, serving the trans community and their partners. It is managed by trans people. This is a safe space for trans people, explains Michelle Ross-Turner, who is acofounder of cliniQ. Trans patients obviously face a different type of stigma and around half have attempted suicide. This clinic has now been delivering services for six years. We have yoga, acupuncture and other holistic  wellbeing activities for trans people, supporting and helping them face the issues surrounding HIV and STIs in a group and community environment where they feel comfortable.

The clinics have a dedicated counselling team of health advisors who address all the issues intertwinedwith sexual health. We deal with anything from serious psychosis through to physical and motional assault, ensuring the patients safety is our first prioritywhich of course sometimes involves working with partner services such as mental health trusts and the police, explains Annette Colcutt, Senior Health Advisor.

Dean Streets success in managing those at risk of HIV infection is evident, with their clinics new HIV diagnoses dropping from a peak of 72 cases in June 2015 to 11 in September 2017. But like other prevention services in the UK, the good work being done risks being undone by the continual cuts to the public health grant from central government that councils across England use to fund HIV and STI prevention. Our worry is that specialist services such as cliniQ and others will be under threat, says McOwan. Like other services nationwide, Dean Street will be under pressure to offer online triage and postal self-testing kits while continuing to offer walk-in services.It will be a difficult balance, he explains. Clinics in Paris and New York are setting up services based on our model, he says. Just as we are reducing new HIV diagnoses in England for the first time, these cuts threaten to harm or reverse our progress.