估算关键人群对塞内加尔达喀尔地区 HIV 传播的贡献。
Estimating the contribution of key populations towards the spread of HIV in Dakar, Senegal.
机构信息
Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK.
Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.
出版信息
J Int AIDS Soc. 2018 Jul;21 Suppl 5(Suppl Suppl 5):e25126. doi: 10.1002/jia2.25126.
INTRODUCTION
Key populations including female sex workers (FSW) and men who have sex with men (MSM) bear a disproportionate burden of HIV. However, the role of focusing prevention efforts on these groups for reducing a country's HIV epidemic is debated. We estimate the extent to which HIV transmission among FSW and MSM contributes to overall HIV transmission in Dakar, Senegal, using a dynamic assessment of the population attributable fraction (PAF).
METHODS
A dynamic transmission model of HIV among FSW, their clients, MSM and the lower-risk adult population was parameterized and calibrated within a Bayesian framework using setting-specific demographic, behavioural, HIV epidemiological and antiretroviral treatment (ART) coverage data for 1985 to 2015. We used the model to estimate the 10-year PAF of commercial sex between FSW and their clients, and sex between men, to overall HIV transmission (defined as the percentage of new infections prevented when these modes of transmission are removed). In addition, we estimated the prevention benefits associated with historical increases in condom use and ART uptake, and impact of further increases in prevention and treatment.
RESULTS
The model projections suggest that unprotected sex between men contributed to 42% (2.5 to 97.5th percentile range 24 to 59%) of transmissions between 1995 and 2005, increasing to 64% (37 to 79%) from 2015 to 2025. The 10-year PAF of commercial sex is smaller, diminishing from 21% (7 to 39%) in 1995 to 14% (5 to 35%) in 2015. Without ART, 49% (32 to 71%) more HIV infections would have occurred since 2000, when ART was initiated, whereas without condom use since 1985, 67% (27 to 179%) more HIV infections would have occurred, and the overall HIV prevalence would have been 60% (29 to 211%) greater than what it is now. Further large decreases in HIV incidence (68%) can be achieved by scaling up ART in MSM to 74% coverage and reducing their susceptibility to HIV by two-thirds through any prevention modality.
CONCLUSIONS
Unprotected sex between men may be an important contributor to HIV transmission in Dakar, due to suboptimal coverage of evidence-informed interventions. Although existing interventions have effectively reduced HIV transmission among adults, it is crucial that further strategies address the unmet need among MSM.
介绍
包括女性性工作者（FSW）和男男性行为者（MSM）在内的重点人群感染艾滋病毒的负担不成比例。然而，将预防工作重点放在这些群体上以减少一个国家的艾滋病毒流行的做法存在争议。我们使用人群归因分数（PAF）的动态评估来估计在塞内加尔达喀尔，FSW 和 MSM 之间的艾滋病毒传播对整体艾滋病毒传播的影响。
方法
使用基于贝叶斯框架的参数化和校准，建立了 FSW、其客户、MSM 和低风险成人人群之间艾滋病毒的动态传播模型，使用 1985 年至 2015 年特定于环境的人口统计学、行为、艾滋病毒流行病学和抗逆转录病毒治疗（ART）覆盖数据。我们使用该模型估计了 1995 年至 2005 年期间，FSW 与客户之间的商业性性行为和男性之间的性行为对整体 HIV 传播的 10 年 PAF（当去除这些传播途径时，可预防的新感染百分比）。此外，我们估计了与历史上 condom 使用和 ART 覆盖率增加相关的预防益处，以及进一步增加预防和治疗的影响。
结果
模型预测表明，1995 年至 2005 年期间，男性之间无保护的性行为导致 42%（2.5 到 97.5 百分位范围 24 到 59%）的传播，到 2015 年至 2025 年期间增加到 64%（37 到 79%）。商业性行为的 10 年 PAF 较小，从 1995 年的 21%（7 到 39%）下降到 2015 年的 14%（5 到 35%）。如果没有 ART，自 2000 年开始使用 ART 以来，将有 49%（32 到 71%）更多的 HIV 感染发生，而如果自 1985 年以来没有 condom 使用，将有 67%（27 到 179%）更多的 HIV 感染发生，总体 HIV 流行率将比现在高 60%（29 到 211%）。通过将 MSM 中的 ART 覆盖率提高到 74%，并通过任何预防方式将他们对 HIV 的易感性降低三分之二，可以进一步大幅降低 68%的 HIV 发病率。
结论
由于缺乏对循证干预措施的充分覆盖，男性之间无保护的性行为可能是达喀尔艾滋病毒传播的一个重要因素。尽管现有的干预措施已有效降低了成年人中的 HIV 传播，但至关重要的是，进一步的策略应解决 MSM 中的未满足需求。
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