Fenway Health and Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA.
Ann Intern Med. 2012 Feb 21;156(4):312-4. doi: 10.7326/0003-4819-156-4-201202210-00383. Epub 2012 Jan 16.
During the past 2 years, several pivotal clinical trials have proven that the use of antiretrovirals by HIV-infected and at-risk uninfected persons can decrease the probability of HIV being transmitted sexually. The initial chemoprophylaxis studies evaluated tenofovir administered topically or orally (with or without emtricitabine). However, several questions remain. Some subsequent primary prevention studies did not replicate the results of the initial studies, raising questions about differences in the behaviors of participants in each study (in particular about medication adherence), as well as whether pharmacologic or local mucosal factors might explain the variable efficacy estimates. Other antiretrovirals and delivery systems are being evaluated to maximize the efficacy of primary chemoprophylactic approaches. At present, increasing access to antiretroviral treatment globally is a priority, because expanding access to medication that can prevent morbidity and mortality is itself an important public health goal and may reasonably be expected to decrease HIV incidence. However, for treatment as prevention to be maximally effective, increases in HIV testing, health care workers, and infrastructure are needed, in addition to medications and laboratory support for clinical monitoring. A combination of approaches is needed to most quickly decrease the current trends in HIV incidence, including early diagnosis and initiation of treatment for HIV-infected persons. These approaches can be coupled with appropriately tailored interventions for populations at greatest risk for infection (for example, men who have sex with men and sex workers), including male circumcision, behavioral interventions, and chemoprophylaxis. However, a substantial gap exists between current expenditures and unmet needs, which suggests that mobilization of political will is needed for this combination approach to be successful.
在过去的 2 年中，几项关键的临床试验证明，HIV 感染者和高危未感染者使用抗逆转录病毒药物可以降低性传播 HIV 的概率。最初的化学预防研究评估了局部或口服给予替诺福韦（联合或不联合恩曲他滨）。然而，仍有几个问题悬而未决。一些后续的初级预防研究未能复制最初研究的结果，这引发了对每个研究中参与者行为差异的质疑（特别是关于药物依从性），以及是否药理学或局部黏膜因素可能解释了可变的疗效估计。其他抗逆转录病毒药物和给药系统正在被评估，以最大限度地提高初级化学预防方法的疗效。目前，在全球范围内增加获得抗逆转录病毒治疗的机会是当务之急，因为扩大获得可预防发病率和死亡率的药物的机会本身就是一个重要的公共卫生目标，并且可以合理地预期会降低 HIV 的发病率。然而，为了使治疗成为预防措施达到最大效果，还需要增加 HIV 检测、卫生保健工作者和基础设施，以及用于临床监测的药物和实验室支持。需要结合多种方法来最快地降低当前 HIV 发病率的趋势，包括对 HIV 感染者进行早期诊断和开始治疗。这些方法可以与针对感染风险最大的人群（例如男男性行为者和性工作者）的适当定制干预措施相结合，包括男性包皮环切术、行为干预和化学预防。然而，目前的支出与未满足的需求之间存在巨大差距，这表明需要调动政治意愿才能成功实施这种综合方法。
