Baggaley Rachel, Dalal Shona, Johnson Cheryl, Macdonald Virginia, Mameletzis Ioannis, Rodolph Michelle, Figueroa Carmen, Samuelson Julia, Verster Annette, Doherty Meg, Hirnschall Gottfried
HIV Department, World Health Organization, Geneva, Switzerland;
HIV Department, World Health Organization, Geneva, Switzerland.
J Int AIDS Soc. 2016 Dec 19;19(1):21348. doi: 10.7448/IAS.19.1.21348. eCollection 2016.
The remarkable expansion in availability of antiretroviral therapy (ART) over the past two decades has transformed HIV infection into a manageable chronic condition. People with HIV infection now live long and healthy lives on treatment that is simpler, safer and cheaper. According to UNAIDS estimates, the global coverage of ART reached 46% in 2015, resulting in a 26% decrease in annual HIV-related deaths since 2010. Such success has positioned treatment access at the centre of the global HIV response as a way to prevent mortality, morbidity and HIV transmission through a "Treat All" approach. Continuing expansion of treatment is needed to further reduce HIV-related mortality. This progress with treatment, however, masks a stagnation in the estimated annual number of new HIV infections. Continuing levels of HIV incidence despite treatment scale-up stem from several factors, which should be addressed in order to prevent new infections and decrease the numbers of people requiring treatment in the future.
ART can only reach those already diagnosed, and although it is unclear what proportion of new infections occur during acute and early infection prior to treatment initiation, phylogenetic studies suggest that it might be substantial. Thus, better testing approaches to reach the 40% of people with undiagnosed HIV infection as early as possible are critical. New approaches to reach men, young people and key populations, where HIV risk is highest and HIV prevention, testing and treatment coverage is lowest, are also needed. Overall coverage of effective prevention interventions remains low, enabling HIV transmission to occur, or time is required to show population-level effects. For example, the full impact of the medical male circumcision intervention will be seen once a larger proportion of men in age cohorts with high incidence are circumcised. Finally, strategically focused pre-exposure prophylaxis interventions have the potential to prevent HIV acquisition among populations at substantial risk, averting treatment costs in coming years.
The United Nations (UN) targets to end AIDS include the "90-90-90" targets for HIV diagnosis, treatment and viral suppression. While 90-90-90 has been widely emphasized and adopted by countries and international funders, the focus thus far has largely been on increasing access to ART - the second "90." A similar emphasis on achieving UN HIV prevention targets and adequate funding for meeting these is essential, alongside treatment, in order to reduce population-level incidence and change the trajectory of the HIV epidemic over the long term.
在过去二十年中，抗逆转录病毒疗法（ART）的可及性显著提高，已将艾滋病毒感染转变为一种可控制的慢性病。感染艾滋病毒的人现在依靠更简单、更安全、更便宜的治疗方法过着长寿且健康的生活。据联合国艾滋病规划署估计，2015年抗逆转录病毒疗法的全球覆盖率达到46%，自2010年以来与艾滋病毒相关的年度死亡人数减少了26%。这一成功使治疗可及性成为全球应对艾滋病毒行动的核心，以此通过“全面治疗”方法预防死亡、发病和艾滋病毒传播。需要持续扩大治疗范围以进一步降低与艾滋病毒相关的死亡率。然而，这一治疗方面的进展掩盖了新艾滋病毒感染估计年数的停滞不前。尽管扩大了治疗规模，但艾滋病毒感染率持续居高不下源于多种因素，必须加以解决，以预防新感染并减少未来需要治疗的人数。
抗逆转录病毒疗法只能惠及已确诊的患者，虽然尚不清楚在开始治疗前的急性感染期和早期感染阶段发生的新感染占比多少，但系统发育研究表明这一比例可能相当大。因此，尽早发现40%未被诊断出感染艾滋病毒的人群的更好检测方法至关重要。还需要采用新方法覆盖男性、年轻人和重点人群，这些人群感染艾滋病毒的风险最高，而艾滋病毒预防、检测和治疗的覆盖率最低。有效预防干预措施的总体覆盖率仍然很低，使得艾滋病毒得以传播；或者需要时间才能显现出对人群层面产生的影响。例如，一旦更多高发年龄组的男性接受包皮环切手术，男性包皮环切干预措施的全面影响将会显现。最后，有针对性的暴露前预防干预措施有可能预防高风险人群感染艾滋病毒，避免未来几年的治疗费用。
联合国终结艾滋病的目标包括艾滋病毒诊断、治疗和病毒抑制方面的“90-90-90”目标。虽然“90-90-90”目标已得到各国和国际资助者的广泛强调和采纳，但迄今为止重点主要放在增加抗逆转录病毒疗法的可及性——第二个“90”。除治疗外，同样重视实现联合国艾滋病毒预防目标并为实现这些目标提供充足资金，对于降低人群层面的感染率并长期改变艾滋病毒流行趋势至关重要。
