重點族群的整合式愛滋預防及照護

 

重點族群的整合式愛滋預防及照護

資料來源:剌胳針滋病毒醫學雜誌,www.thelancet.com/hiv Vol 6 May 2019,財團法人台灣紅絲帶基金會編譯

在全球範圍內,愛滋病毒流行主要集中在關鍵族群,包括男男間性行為者(MSM)和注射藥癮者(PWID)。從歷史上來看,這些群體的成員在獲取愛滋病預防和照護相關服務上面臨著根本性結構和人際上的巨大障礙,增強了他們得到愛滋病毒的風險。

例如,將吸毒或同性間性行為定為刑事犯罪,可能會限制其獲得醫療服務。在愛滋病預防上採整合的方式或綜合的方法可以集中提供服務,並可以減少污名或後勤障礙。因此,提供具有文化能力的綜合照護可以改善對愛滋病毒檢測的吸收,並允許簡化進入預防(對於那些檢測為陰性的人)和治療(對於那些檢測呈陽性的人)。在剌胳針滋病毒雜誌中,Sunil Solomon及其同事報告了一項雄心勃勃的世代隨機試驗的結果,該試驗旨在評估印度整合式照護中心在增加HIV之檢測和進入男男間性行為者和注射藥癮者照護上的成效。在整個次大陸的地點,Solomon及其同事發現整合式照護中心的愛滋病毒檢測與常規照護中心相比沒有顯著增加,亦對愛滋連續性照護的結果沒有影響。該試驗的一個重要發現是,暴露在整合式照護中心的人群並不是最理想的(注射藥癮者為40%和男男間性行為者為24%),這可能會影響了整體成效。介入的低外顯率可能歸咎於缺乏人口水平的影響。這一發現強調了估算人口規模大小的重要性,以便服務的可用性可適切的足以去支持最多數人口。雖然可靠地去估計隱藏人口的規模是眾所周知的挑戰,在愛滋預防活動上去達成人口水平之影響,在阻止傳播上仍是最終的需要,亦需要加強努力去估計承擔最大疾病負擔人口之規模。儘管整合式照護對人群水平沒有顯著影響,但在個人層面當評估暴露於整合式照護中心造成的影響時顯示,這些中心的使用率之提升可以改善預後。與愛滋病毒檢測有關的調查結果特別引人注目;曾經訪問過綜合醫療中心的人與未檢測愛滋病毒的人相比,檢測愛滋病毒的可能性大約是其3.5倍(調整後的盛行比為3.46, 2.94 – 4.06)。鑑於愛滋病毒檢測是治療和照護的重要切入點,這一發現顯示,這些中心對於他們所原被規劃耍去服務的對象族群,亦即男男間性行為者和注射藥癮者,其HIV相關結果的改善是可接受的和有效的。這些結果顯示,人口覆蓋率的提高最終可能轉化為人口水平的影響。除了進入愛滋病毒治療外,綜合性設施提供的愛滋病毒檢測還可以讓其進入愛滋病毒預防服務。訪問過綜合照護中心的參與者更有可能意識到他們的HIV血清狀況。對血清狀況的認識是愛滋病預防階層中的重要的一步。儘管綜合照護中心對男男間性行為者或注射藥癮者之風險行為沒有影響,但在綜合照護環境中增加的HIV檢測可以促進其進入預防性服務中,例如 - pre-exposure prophylaxis(暴露前預防性投藥)。透過綜合性照護中心提供暴露前預防性投藥,潛在著可能與愛滋病毒自我檢測等其他愛滋病預防介入措施相結合,亦可能呈現出在人口水平上降低愛滋病毒傳播的另一個機會。同樣地在連結到愛滋病照護上亦相似,暴露前預防投藥的提供亦可能會受益於一種綜合性的方法,使用者可以透過這種方法獲得共存於一處之多項服務,包括定期的愛滋病毒和性傳染病之測試。綜合式的整合性照護服務,可以在完整連續的愛滋治療和預防的多項選擇上改善關鍵族群的連結。該研究顯示,整合式照護中心可以在疫情集中的疫情中心之環境下,為重點族群在提供非歧視性綜合照護方面上發揮重要的作用。某些證據中的一些落差仍有待解決。例如,需要尋找出有效地將個人層面上之影響轉化為人口水平上之影響的策略。整合式照護中心的數量和覆蓋範圍能否擴增並達到充分地利用,從而導致人口水平上的變化?如何在關鍵族群的不同的成員中滿足其優先考慮,以增加他們在現有綜合性照護中心獲得和接受照護服務的機會?

結構性介入措施中嚴謹的證據對於回答目前和未來在執行面上的問題是必要的,本研究提供了至關緊要的第一步。

凱瑟琳·奧登堡,Francis I Proctor基金會,美國加州舊金山大學眼科、以及流行病學和生物統計學系。

 

 

Integrated HIV prevention and care for key populations

Globally, the HIV epidemic is concentrated in key populations, including men who have sex with men (MSM) and people who inject drugs (PWID).1,2 Historically, members of these groups have faced substantial structural and interpersonal barriers to accessing HIV prevention and care services, potentiating their risk of HIV acquisition.

For example, criminalisation of drug use or same-sex behaviour can limit access to care.Integrated or combination

approaches to HIV prevention centralise service provision and may reduce stigma or logistical barriers. As a result, provision of culturally competent integrated care can improve uptake of HIV testing and allow for streamlined entry into prevention (for those who test negative) and treatment (for those who test positive). In The Lancet HIV, Sunil Solomon and colleagues4 report the results of an ambitious cluster randomized trial designed to evaluate the effectiveness of integrated care centres for increasing HIV testing and entry to care among MSM and PWID in India. At sites across the

subcontinent, Solomon and colleagues found a nonsignificant increase in HIV testing in integrated care centres compared with usual care centres, and no effect on HIV care continuum outcomes. An important finding of the trial was that population exposure to the integrated care centres was suboptimal (40% of PWID and 24% of MSM), which might have affected overall efficacy. Low penetrance of the intervention might be to blame for the absence of a population-level effect. This finding underscores the importance of estimating population sizes so that the availability of services is adequate to support most of the population. Although reliably estimating the size of hidden populations is notoriously challenging, achieving population-level effects of HIV prevention activities, which will ultimately be necessary to stop transmission, might require improved efforts to estimate the size of populations that bear the greatest burden of disease. Despite integrated care having no significant effect at the population level, evaluation of the effect of exposure to integrated care centres at the individual level showed that increased utilisation of such centres led to improved outcomes. Findings related to HIV testing were particularly striking; individuals who had ever visited an integrated care centre were about 3·5 times more likely to test for HIV compared with those who had not (adjusted prevalence ratio 3·46, 2·944·06). Given that HIV testing is an essential entry point into treatment and care, this finding suggests that the centres are acceptable and effective for improving HIV related outcomes in the MSM and PWID populations they were designed to serve. These results suggest that improved population coverage could eventually translate to population-level effects. In addition to entry into HIV treatment, HIV testing at integrated facilities offers entry into HIV prevention services. Participants who had visited an integrated care centre were more likely to be aware of their HIV serostatus. Awareness of serostatus is an important step in the HIV prevention cascade.6,7 Although integrated care centres had no effect on HIV risk behaviours for PWID or MSM, increasing HIV testing in an integrated care setting could facilitate entry into preventive services, such as pre-exposure prophylaxis.8,9 Offering pre-exposure prophylaxis, potentially in combination with other HIV prevention interventions, such as HIV self-testing, through integrated care centres might represent an additional opportunity to reduce population-level HIV transmission. Similar to engagement in HIV care, provision of pre-exposure prophylaxis will likely benefit from an integrated approach where users can access colocalisation of services, including regular HIV and sexually transmitted infection testing. Integrating care services might improve engagement with the full continuum of HIV treatment and prevention options for key populations. This study shows that integrated care centres could play a major role in providing non-discriminatory comprehensive care for members of key populations in concentrated epidemic settings. Some gaps in the evidence remain to be addressed. For example, identification of strategies to effectively translate individual-level effects to the population level are required. Will expansion of the number and coverage of integrated care centres allow for adequate uptake to lead to changes at the population level? How can we meet priorities for diverse members of key populations to increase their access and uptake of care services at existing integrated care centres?

Rigorous evidence from structural interventions is necessary to answer these and future implementation questions, and this study presents a crucial first step.

Catherine E Oldenburg

Francis I Proctor Foundation, Department of Ophthalmology, and Department of Epidemiology & Biostatistics, University of California, San Francisco, CA 94143, USA