將人們視為百分比

將人們視為百分比

聯合國愛滋病規劃署90-90-90」目標,為全球愛滋社群提供了明確的執行目標。自2014設下這目標以來,當時雖然只有37%的愛滋感染者接受抗反轉錄病毒治療(ART),同時暴露前預防投藥(PrEP)和U = U(無法檢測到=不會造成傳播)等知識仍處於萌芽的嬰兒期,在都取得了實質性儘管有這些明顯的進步,但仍然無法實現2020年「90-90-90」的目標。這些目標近期最終數字還沒統計完成,但從2019年以來的最新估計,在所有愛滋感染者中,有81%的人知道自己的感染狀況,有67%的人正在接受抗反轉錄病毒療法,59%的人已測不到病毒。

 

當因為SARS-CoV-2大流行威脅,使得世界目前應對HIV停滯不前的時候,現在更重要的目標是繼續力減少新的HIV感染,並確保感染者可以獲得足夠的照顧並持續接受治療。聯合國愛滋病規劃署的新報告以人為中心對抗病毒大流行〉(Prevailing against pandemics by putting people at the centre)剛好提出了目前的問題。報告中突顯了目應對HIV的計畫裡有著令人震驚不足之處。例如,只41的HIV高發地區,針對少女和年輕婦女制定了全面性的愛滋預防計劃,然而她們始終是一個特別脆弱的族群還有,儘管目標是要達到300萬人,但目前全球只有59萬人正在使用PrEP生物醫學的進步,有望為這些不足提供一些解決途徑。例如最近獲得了WHO預審資格的新工具,帶有dapivirine藥物的陰道可做為PrEP替代形式,還有cabotegravir長效注射劑的臨床試驗也有正面的結果但是由於污名、歧視和結構性障礙持續影響愛滋病毒照護的各個面,單純的生物醫學進步無法解決所有問題

 

除了檢驗、預防和治療的目標外,值得稱讚的是聯合國愛滋病規劃署的報告中明確定義了關於推動社會進步的目標2025的新10-10-10」目標是指,少於10%的國家有懲罰性的法律政策以拒絕或限制服務愛滋感染者,少於10愛滋感染者和關鍵人群遭受到污名化與歧視,少於10婦女、女孩、愛滋感染者和關鍵人群會遭受到性別不平等和暴力侵害。這些是遠大的目標,而且必須在接下來的5年中持續增長並取得進展。

 

為了實現第一個「10」的目標,必須解決常被認為是犯罪的四個關鍵領域:性工作擁有少量毒品同性性行為以及HIV的傳播、暴露或不公開。在HIV政策實驗室的資料中顯示,同時也是剌胳針11份的愛滋期刊社論上所強調的,全世界沒有一個國家的法律能完全無罪化這四個領域。雖然無法達到所有目標在各個領域上還是有著不同程度的成功

在撰寫本文時,HIV政策實驗室統計在194個國家中有112個國家沒有將同性性行為定為犯罪。同時值得高興的是不丹廢除了該國刑法中將同性性行為定為刑事犯罪的部份,意味著同性性行為無罪的國家將上升到113個。然而,自2014年以來,包括不丹在內的只有十個國家將同性性行為除罪化,這表2025年以前很難實現175個國家(佔90%)將同性性行為無罪化的目標。另外需要警惕的20196波札納由女同性戀者、男同性戀者和雙性戀者組織所倡導的同性性關係合法化,正受到被起訴的威脅。

其他目標似乎更加難以實現,例如,只有維德角共和國、海地、洪都拉斯、紐西蘭、紐埃和巴拿馬六個國家,採取了將性工作無罪化

而關於HIV除罪化的議題,喬納森·梅敏(Jonathan Mermin)及其同事強調,美國目前有37個州制定了有關愛滋病毒犯罪的法律,他們同時提供了有力的方案在進行法律改革上。

 

2020年本來可以成為對抗愛滋里程碑的一年,但過去十年全球愛滋病主要計畫「90-90-90」的目標還沒實現。這並不代表這目標已經失敗了,與2014確定目標時相比,目前正在接受治療的人數有所增加,並且在實現這些目標的過程中得到了重要的一課。儘管還沒達到「90-90-90目標,但仍然取得了很多的,這凸顯了人們在過去40年來知道要如何應對HIV如果想要實現診斷、治療和病毒抑制百分比的目標,必須給予感染者鼓勵和能力,讓他們可以獲取他們所需要的資源。

畢竟,「人」還是比「百分比」重要。

 

剌胳針愛滋病毒醫學期刊

資料來源:www.thelancet.com/hiv Vol 8 January 2021,財團法人台灣紅絲帶基金會編譯

 


Seeing the people in the percentages

The UNAIDS 90-90-90 targets have provided clear targets to the global HIV community. Since their inception in 2014, when only 37% of people living with HIV were receiving antiretrovial therapy (ART) and tools such as pre-exposure prophylaxis (PrEP) and knowledge of U=U (undetectable=untransmissible) were in their infancy, there has been substantial progress. However, despite these gains, the 90-90-90 targets for 2020 will not be met. Although we await the final numbers the most recent estimates, from 2019, suggest that among all people living with HIV 81% were aware of their status, 67% were accessing ART, and 59% were virally suppressed.

At a time when the SARS-CoV-2 pandemic threatens to derail a stalling HIV response it is more important than ever to remain focused on the global goals of reducing new HIV infections and ensuring that people with HIV have access to care and are receiving treatment. The new UNAIDS report Prevailing against pandemics by putting people at the centre comes at a welcome time. Some current shortcomings highlighted in the report are startling. For example, only 41% of high-incidence locations have comprehensive HIV prevention programmes for adolescent girls and young women, despite this being a particularly vulnerable group. Only 590 000 people worldwide are accessing PrEP, although the target is 3 million people.

Biomedical innovations such as alternative forms of PrEP with the dapivirine ring, which recently received WHO prequalification, and positive results from trials on cabotegravir injections, will hopefully go some way to addressing this shortfall. However, advances in biomedical tools are not enough while stigma, discrimination, and structural barriers continue to affect every aspect of HIV care. Alongside targets for testing, prevention, and treatment, the inclusion of clearly defined goals around societal enablers in the UNAIDS report is to be applauded. New 10-10-10 targets state that by 2025 less than 10% of countries should have punitive legal and policy environments that deny or limit access to services, less than 10% of people living with HIV and key populations will experience stigma and discrimination, and less than 10% of women, girls, people living with HIV, and key populations will experience gender inequality and violence. These are ambitious targets and progress will have to be substantial in the next 5 years.

To achieve the first 10 target, four key areas of criminalisation must be addressed: sex work, possession of small amounts of drugs, same-sex sexual behaviour, and HIV transmission, exposure, or non-disclosure. But data from HIV Policy Lab, which we highlighted in our November Editorial, show that not a single country worldwide has laws that refrain from criminalising all four. Success in the individual areas is mixed. At the time of writing, same-sex sexual behaviour was not criminalised in 112 of the 194 countries listed in HIV Policy Lab. The welcome news that Bhutan has repealed sections of the country’s penal code that criminalized same-sex sexual behaviour means this number will rise to 113 countries. However, since 2014 only ten countries, including Bhutan, have decriminalised samesex sexual behaviour, suggesting that it will be hard to meet the target of 175 countries (90%) by 2025. Gains must also be closely guarded. Botswana’s legalisation of same-sex sexual relationships in June, 2019, led by the advocacy group Lesbians, Gays & Bisexuals of Botswana, has been threatened by appeal. Other targets seem even harder to reach; non-criminalisation of sex work, for example, has been adopted by only six countries— Cape Verde, Haiti, Honduras, New Zealand, Niue, and Panama. In a Comment in this issue, Jonathan Mermin and colleagues highlight that 37 states in the USA currently have HIV criminalisation laws, and make a strong case for legal reform.

2020 could have been a milestone year in the fight against HIV, but the 90-90-90 targets that have dominated the global HIV response in the past decade have not been met. This does not mean the targets have failed. Many more people are now on treatment than were in 2014 when the targets were adopted, and many lessons have been learned in the efforts to achieve them. The failure to reach the targets despite all the advances highlight what those who have followed the HIV response for the past 40 years already know—to achieve ambitious goals for diagnosis, treatment, and viral suppression individuals must be empowered, enabled, and encouraged to access the resources they need. The people matter more than the percentages.

■ The Lancet HIV

www.thelancet.com/hiv Vol 8 January 2021