van Griensven Frits, Guadamuz Thomas E, de Lind van Wijngaarden Jan Willem, Phanuphak Nittaya, Solomon Sunil Suhas, Lo Ying-Ru
Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, California, USA.
Department of Society and Health, Mahidol University, Nakorn Pathom, Thailand.
Sex Transm Infect. 2017 Aug;93(5):356-362. doi: 10.1136/sextrans-2016-052669. Epub 2017 Jul 20.
In Asia Pacific, most countries have expanded HIV treatment guidelines to include all those with HIV infection and adopted antiretroviral treatment for prevention (TFP) as a blanket strategy for HIV control. Although the overall epidemic development associated with this focus is positive, the HIV epidemic in men who have sex with men (MSM) is continuing unperturbed without any signs of decline or reversal. This raises doubt about whether TFP as a blanket HIV prevention policy is the right approach. This paper reviews currently available biomedical HIV prevention strategies, national HIV prevention policies and guidelines from selected countries and published data on the HIV cascade in MSM. No evidence for efficacy of TFP in protecting MSM from HIV infection was found. The rationale for this approach is based on assumptions about biological plausibility and external validity of latency-based efficacy found in heterosexual couples. This is different from the route and timing of HIV transmission in MSM. New HIV infections in MSM principally occur in chains of acutely HIV-infected highly sexually active young men, in whom acquisition and transmission are correlated in space and time. By the time TFP renders its effects, most new HIV infections in MSM will have already occurred. On a global level, less than 6% of all reports regarding the HIV care cascade from 1990 to 2016 included MSM, and only 2.3% concerned MSM in low/middle-income countries. Only one report originated from Asia Pacific. Generally, HIV cascade data in MSM show a sobering picture of TFP in engaging and retaining MSM along the continuum. Widening the cascade with a preventive extension, including pre-exposure prophylaxis, the first proven efficacious and only biomedical HIV prevention strategy in MSM, will be instrumental in achieving HIV epidemic control in this group.
在亚太地区，大多数国家已扩大了艾滋病毒治疗指南，将所有艾滋病毒感染者纳入其中，并采用抗逆转录病毒治疗以预防（TFP）作为艾滋病毒控制的全面战略。尽管这种重点关注所带来的总体疫情发展是积极的，但男男性行为者（MSM）中的艾滋病毒疫情仍在持续，没有任何下降或逆转的迹象。这引发了人们对TFP作为全面艾滋病毒预防政策是否正确的质疑。本文回顾了目前可用的生物医学艾滋病毒预防策略、部分国家的国家艾滋病毒预防政策和指南，以及关于男男性行为者艾滋病毒防治流程的已发表数据。未发现TFP在保护男男性行为者免受艾滋病毒感染方面有效的证据。这种方法的理论依据基于对异性恋夫妇中基于潜伏期疗效的生物学合理性和外部有效性的假设。这与男男性行为者中艾滋病毒传播的途径和时间不同。男男性行为者中的新艾滋病毒感染主要发生在急性艾滋病毒感染的高性活跃年轻男性群体中，在这些人中，感染和传播在空间和时间上相互关联。在TFP产生效果时，男男性行为者中的大多数新艾滋病毒感染可能已经发生。在全球范围内，1990年至2016年所有关于艾滋病毒防治流程的报告中，涉及男男性行为者的不到6%，而涉及低收入/中等收入国家男男性行为者的仅为2.3%。只有一份报告来自亚太地区。总体而言，男男性行为者的艾滋病毒防治流程数据显示了TFP在整个连续过程中吸引和留住男男性行为者方面令人清醒的情况。通过包括暴露前预防在内的预防性扩展来扩大防治流程，暴露前预防是首个被证明有效的、也是男男性行为者中唯一的生物医学艾滋病毒预防策略，这将有助于实现该群体的艾滋病毒疫情控制。
