暴露前预防的变革；从临床试验到项目实施。
The preexposure prophylaxis revolution; from clinical trials to programmatic implementation.
作者信息
Mugo Nelly R, Ngure Kenneth, Kiragu Michael, Irungu Elizabeth, Kilonzo Nduku
机构信息
aCenter for Clinical Research, Kenya Medical Research Institute, Nairobi, Kenya bDepartment of Global Health, University of Washington, Seattle, WA, USA cPartners in Health Research and Development, Thika dDepartment of Public Health, Jomo Kenyatta University of Agriculture and Technology, Juja eLVCT-Health fNational AIDS Control Council, Nairobi, Kenya.
出版信息
Curr Opin HIV AIDS. 2016 Jan;11(1):80-6. doi: 10.1097/COH.0000000000000224.
PURPOSE OF REVIEW
An investment in preexposure prophylaxis (PrEP) delivery must have public health impact in reducing HIV infections. Sustainable delivery of PrEP requires policy, integration of services, and synergy with other existing HIV prevention programs. This review discusses key policy and programmatic considerations for implementation and scale up of PrEP in Africa.
RECENT FINDINGS
PrEP delivery has been delayed by concerns about adherence and delivery in 'real world' settings. Demonstration projects and clinical service delivery models are providing evidence of PrEP effectiveness with an impact much higher than that found in randomized clinical trials. Data confirm that PrEP uptake, adherence, and retention has been high, more so by persons who perceive themselves at high risk for HIV infection, and PrEP is well tolerated. PrEP delivery is more than dispensation of a pill and programs should address other risk drivers, which differ by population. In Africa, barriers to PrEP uptake and adherence include stigma among MSM and low HIV risk perception among young women. Additional data have provided insight into optimal points of service delivery, provider training requirements and quality assurance needs. Of the 2 million new HIV infections in 2014, 70% were in Africa. PrEP use is not lifelong, and use limited to periods of risk may be both effective and cost-effective for the continent.
SUMMARY
HIV prevention programs should determine strategies to identify those at substantial risk for HIV infection, formulate and deliver PrEP in combination with interventions that target social drivers of HIV vulnerability specific to each population. Policy guidance for optimal combination of interventions and service delivery avenues, clinical protocols, health infrastructure requirements are required. Cost-effectiveness and efficiency data are essential for policy guidance to navigate ethical questions over use of antiretroviral therapy for HIV-negative individuals when treatment coverage has not been attained in many parts of Africa. Countries need to invest in purposeful advocacy at both local and global forums. Failure to implement PrEP will be a failure to protect future generations.
综述目的
对暴露前预防（PrEP）实施的投入必须对减少艾滋病毒感染产生公共卫生影响。PrEP的可持续实施需要政策支持、服务整合以及与其他现有艾滋病毒预防项目协同作用。本综述讨论了在非洲实施和扩大PrEP的关键政策及项目考量因素。
最新研究发现
由于对“现实世界”环境中服药依从性和药物发放的担忧，PrEP的实施有所延迟。示范项目和临床服务提供模式正在提供PrEP有效性的证据，其影响远高于随机临床试验中的发现。数据证实，PrEP的接受度、依从性和持续性都很高，那些认为自己感染艾滋病毒风险较高的人更是如此，而且PrEP耐受性良好。PrEP的实施不仅仅是发放药丸，项目还应解决其他风险驱动因素，这些因素因人群而异。在非洲，接受和坚持PrEP的障碍包括男男性行为者中的污名化以及年轻女性中艾滋病毒低风险认知。更多数据为最佳服务提供点、提供者培训要求和质量保证需求提供了见解。2014年200万新发艾滋病毒感染病例中，70%在非洲。PrEP并非终身使用，对于非洲大陆而言，仅在风险期使用可能既有效又具有成本效益。
总结
艾滋病毒预防项目应确定策略，以识别那些感染艾滋病毒风险极高的人群，结合针对特定人群中艾滋病毒易感性社会驱动因素的干预措施来制定和实施PrEP。需要关于干预措施和服务提供途径的最佳组合、临床方案、卫生基础设施要求的政策指导。成本效益和效率数据对于政策指导至关重要，以便在非洲许多地区尚未实现治疗覆盖的情况下，应对使用抗逆转录病毒疗法治疗艾滋病毒阴性个体的伦理问题。各国需要在地方和全球论坛上进行有针对性的宣传。不实施PrEP将是未能保护后代。
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