我国实现艾滋病防治策略三个90％的进展与挑战

诊断90％、治疗90％和有效90％是联合国艾滋病规划署确定全球终结艾滋病流行的三个90％防治策略.该策略以传染源为核心,通过发现和治疗感染者,“消灭”传染源,控制艾滋病流行.到2015年底,我国这三项目标已经分别达到68％、67％和91％.今年,治疗标准调整为对所有感染者提供治疗,为实现治疗90％目标提供了政策保障.诊断90％则成为实现三个90％策略目标最重要和最难的.该防治策略与针对易感人群的防治措施互补,联合使用才能更好地控制艾滋病流行.     

经治艾滋病患者免疫恢复 和免疫无应答相关研究进展

[摘要]　有效的抗反转录病毒治疗（antiretroviral therapy, ART）可以持续抑制HIV-1复制,同时促进HIV-1感染者的免疫恢复。然而不同疾病阶段的艾滋病患者经ART后的预后不同,大部分HIV-1感染者免疫恢复较好,但仍有15%～30%左右的HIV-1感染者无法实现有效的免疫重建,即免疫无应答者（immunological non-responders, INRs）。本文重点介绍了免疫恢复的分类及定义,导致INRs的可能原因以及针对INRs治疗的临床试验进展,以期为INRs的诊断和治疗寻找潜在的方向     

情绪状态对男男性行为HIV新诊断感染者睡眠紊乱及治疗行为影响

基于国际大规模流行病学研究结果,联合国艾滋病规划署对艾滋病防治提出三个90%策略,全球主要国家均积极推动,但因对新诊断感染者接受和持续治疗行为研究不足,在推动新诊断感染者实现治疗90%目标上有较大差距。国内外研究报道新诊断感染者在压力作用下会产生情绪问题,男男性行为人群HIV感染者因性取向和感染双重影响所承受压力高于一般人群,70.7%人群存在抑郁、焦虑等情绪,情绪波动和心理状态不佳易影响该人群的睡眠状况和治疗行为等方面。情绪状态与睡眠紊乱之间的相互影响已被证明,但情绪状态对HIV感染者接受和持续治疗的相关研究开展有限且作用机制尚不清晰。本文重点回顾了该人群抗病毒治疗行为现状,以及情绪对睡眠和感染者治疗行为影响的相关研究,分析并一定程度上解释了情绪状态与睡眠紊乱的作用关系,以期为我国重点人群艾滋病防控工作和感染者的治疗关怀提供新思路而奠定基础。     

义乌市2007年艾滋病自愿咨询检测人群感染情况调查

自愿咨询检测（VET）是艾滋病预防与关怀工作的切人点和枢纽。VCT广泛有效的开展,有利于及时发现艾滋病病毒（HIV）感染者和艾滋病病人,使更多的感染者了解自己的感染现状,得到及时治疗、关怀等必要的服务;同时通过咨询和转介服务的提供,有利于降低危险行为,避免新感染发生,减少HIV的传播,控制艾滋病的流行。义乌市从2005年开始,首先在市疾病预防控制中心开设艾滋病自愿咨询检测室,提供免费咨询和检测服务。     

湖北省艾滋病流行趋势及防治策略

艾滋病是由人类免疫缺陷病毒引起的一种传染性疾病,最先在美国发现。感染该病毒后经过5～8年潜伏期,感染者由于免疫系统遭破坏而出现免疫缺陷症状,并伴机会性感染或恶性肿瘤发生,目前尚无有效治疗方法,病死率极高。该病主要通过血液途径、性途径和母婴途径传播。该病是一种目前尚无有效治愈方法但完全可以预防的严重传染病。湖北省于1988年首次发现艾滋病感染者,其后每年均有新的艾滋病感染者发现,且每年发现的感染者数量逐年上升,并已出现艾滋病死亡病例。艾滋病感染的高危人群如吸毒、卖淫嫖娼人群数量呈上升趋势,尤其是性病患者数量每年…     

抗艾滋病病毒药物的使用近况

目前，艾滋病仍缺乏有效的根治药物，临床上多采用综合治疗，其中以抗艾滋病病毒治疗为主。抗艾滋病病毒药物联合应用后作用在艾滋病病毒复制的各个阶段，以最大限度抑制艾滋病病毒在CD4细胞内的复制，使病人免疫功能的损伤降低到最小程度或使免疫功能逐渐恢复，这样，就可以推迟感染艾滋病病毒后发展到艾滋病的时间。进行性免疫缺陷是艾滋病病毒感染的特征，抗艾滋病病毒治疗可以使这一过程逆转，     

503名艾滋病自愿咨询检测者调查分析

艾滋病自愿咨询检测（VCT）是指人们在经过咨询后对于艾滋病病毒（HIV）抗体检测做出的明智的选择过程。VCT工作广泛有效的开展可以使更多的感染者了解自己的感染现状并及时得到治疗、关怀服务,同时自觉降低危险行为,为控制和预防艾滋病工作发挥重要作用。VCT不仅仅是提供咨询和检测,还是对HIV感染者和艾滋病患者进行干预、治疗和关怀的切入点,是目前艾滋病防治工作的一个重要服务体系。     

艾滋病潜伏期研究进展

获得性免疫缺陷综合征(Acquire Immunodeficiency Syndrome,AIDS),简称"艾滋病",是人类免疫缺陷病毒(Human Immunodeficiency Virus,HIV)感染人的免疫系统,进行性损害人的免疫系统,使免疫功能低下的HIV感染者感染其他机会性感染,并最终导致艾滋病病人死亡的传染性疾病.艾滋病作为一种目前尚无有效治愈方法的慢性传染病,其病程分为3个阶段:窗口期、潜伏期和临床发病期.其中艾滋病的潜伏期是指从人体感染HIV后出现血清学HIV抗体阳性起,到感染者出现艾滋病相关临床症状和体征为止的这段时间.国内外对艾滋病潜伏期开展了大量的研究,对了解艾滋病的自然史、评价治疗效果、预测艾滋病疫情趋势和艾滋病的流行特征以及病人的生存率有着重要的意义.现将其综述如下.     

高效抗逆转录病毒治疗与HI/AIDS相关机会性感染

高效抗逆转录病毒治疗(HAART)显著降低了人免疫缺陷病毒(HIV)感染者和艾滋病(AIDS)患者的机会性感染发生率,接受治疗者的CD4 T细胞计数增加表明其免疫功能已有提高.HAART使HIV/AIDS相关的真菌感染率由90年代中期的25%下降到现在的20%,耐咪唑类药的白色念珠菌和曲霉菌引起的机会性感染很少出现于HIV感染者,而HIV合并真菌感染者在接受HAART后也不需要超长时间的抗真菌治疗.随着HAART的有效应用,HIV/AIDS相关机会性感染将得到显著的控制.     

艾滋病抗病毒治疗“一站式”服务模式的实践与探索

艾滋病抗病毒治疗能有效降低机体内病毒载量,降低病死率。昆山市自2017年起试点开展艾滋病抗病毒治疗"一站式"服务项目,即将已确诊的艾滋病感染者直接转诊至艾滋病抗病毒治疗定点医院,定点医院提供专业的抗病毒治疗、结核病筛查、抗机会性感染等综合干预服务,提高了艾滋病抗病毒治疗时效性、可及性及服务满意度。本文就艾滋病抗病毒治疗"一站治式"服务模式工作开展相关情况进行探讨,以供其他地区参考和借鉴。     

The HIV Care Cascade Before,During, and After Incarceration: A Systematic Review and Data Synthesis

We conducted a systematic literature review of the data on HIV testing, engagement in care, and treatment in incarcerated persons, and estimated the care cascade in this group.We identified 2706 titles in MEDLINE, EBSCO, and Cochrane Library databases for studies indexed to January 13, 2015, and included 92 for analysis. We summarized HIV testing results by type (blinded, opt-out, voluntary); reviewed studies on HIV care engagement, treatment, and virological suppression; and synthesized these results into an HIV care cascade before, during, and after incarceration.The HIV care cascade following diagnosis increased during incarceration and declined substantially after release, often to levels lower than before incarceration. Incarceration provides an opportunity to address HIV care in hard-to-reach individuals, though new interventions are needed to improve postrelease care continuity.The 2010 National HIV/AIDS Strategy outlines 3 interdependent goals: (1) reducing HIV incidence, (2) increasing access to care and improving health outcomes for persons living with HIV, and (3) reducing HIV-related disparities and health inequities.1 To meet these goals, it is essential to measure and improve performance at every stage in the HIV care continuum (also known as the HIV treatment cascade) as supported by a 2013 executive order by President Obama2: diagnosis, linkage to care, retention in care, receipt of antiretroviral therapy (ART), and virological suppression.3Evaluation of this cascade in the general US population according to 2008 data determined that only 80% of HIV-infected individuals were aware of their diagnosis, 62% were linked to care, 41% were retained in routine HIV care, 36% were receiving ART, and 28% had an undetectable viral load.4 Although more recent measures based on surveillance data indicate somewhat higher proportions achieving success in the steps in the cascade,5 significant gaps in the HIV care continuum remain, particularly in vulnerable subgroups. For example, African Americans and younger individuals (aged 25–34 years) are less likely than their counterparts to be aware of their diagnosis, engaged in care, receiving ART, or to have a suppressed viral load.6 These health disparities highlight the need for new approaches to HIV testing, linkage to care, and treatment, especially in hard-to-reach populations.Because 1 in 7 HIV-infected individuals passes through correctional facilities every year,7 and most inmates come from minority and medically underserved communities, including many people younger than 35 years, jails and prisons are critical settings to address the HIV care continuum and health disparities.8,9 Among African American men aged 18 years or older, 1 in 15 is incarcerated, whereas this statistic is 1 in 36 for Hispanic men and 1 in 106 for White men.9 Incarceration provides a unique opportunity to offer HIV testing, linkage to HIV care, and antiretroviral treatment to individuals who may not be accessing medical services in the community. In addition to affecting individual outcomes by identifying and treating HIV, interventions in the correctional setting have the potential to affect community health by reducing HIV transmission to others through reduction of an HIV patient’s viral load, known as treatment as prevention.10Although there have been multiple, well-conducted studies of HIV testing, linkage to care, and treatment in incarcerated individuals, there has been less focus on the HIV care continuum as a whole in this group or on how this cascade changes as an individual passes through the correctional system and back to the community. An improved understanding of the course of HIV identification, care, and treatment in this population will allow us to better direct resources to major gaps in the care continuum and to come closer to achieving the goals of the national HIV/AIDS strategy.Therefore, we sought to perform a systematic literature review to (1) summarize HIV testing, treatment, and linkage to care efforts in the incarcerated and recently released population; (2) determine the estimates in the cascade of care for HIV-infected individuals before, during, and after incarceration; and (3) identify research gaps and targets for future interventions to improve outcomes in the HIV-infected population involved in the criminal justice system.     

Assessing the Effect of Recent Incarceration in Prison on HIV Care Retention and Viral Suppression in Two States

The prevalence of HIV among people in correctional facilities remains much higher than that of the general population. Numerous studies have demonstrated the effectiveness and acceptability of HIV treatment for individuals incarcerated in US prisons and jails. However, the period following incarceration is characterized by significant disruptions in HIV care. These disruptions include failure to link in a timely manner (or at all) to community care post-release, as well as not being retained in care after linking. We used a retrospective, propensity-matched cohort design to compare retention in care between HIV-positive individuals recently released from prison (releasees) who linked to care in Ryan White HIV/AIDS Program (RWHAP) clinics and RWHAP patients without a recent incarceration history (community controls). We also performed analyses comparing viral load suppression of those retained in both groups. This study shows that even for those who do successfully link to care after prison, they are 24 to 29 percentage points less likely to be retained in care than those already in community care. However, we found that for those who did retain in care, there was no disparity in rates of viral suppression. These findings provide valuable insight regarding how best to address challenges associated with ensuring that HIV-positive individuals leaving prison successfully move through the HIV care continuum to become virally suppressed.     

Differences in Selected HIV Care Continuum Outcomes Among People Residing in Rural,Urban, and Metropolitan Areas—28 US Jurisdictions

Purpose

The HIV care continuum is used to monitor success in HIV diagnosis and treatment among persons living with HIV in the United States. Significant differences exist along the HIV care continuum between subpopulations of people living with HIV; however, differences that may exist between residents of rural and nonrural areas have not been reported.

Methods

We analyzed the Centers for Disease Control and Prevention's National HIV Surveillance System data on adults and adolescents (≥13 years) with HIV diagnosed in 28 jurisdictions with complete reporting of HIV‐related lab results. Lab data were used to assess linkage to care (≥1 CD4 or viral load test ≤3 months of diagnosis), retention in care (≥2 CD4 and/or viral load tests ≥3 months apart), and viral suppression (viral load <200 copies/mL) among persons living with HIV. Residence at diagnosis was grouped into rural (<50,000 population), urban (50,000‐499,999 population), and metropolitan (≥500,000 population) categories for statistical comparison. Prevalence ratios and 95% CI were calculated to assess significant differences in linkage, retention, and viral suppression.

Findings

Although greater linkage to care was found for rural residents (84.3%) compared to urban residents (83.3%) and metropolitan residents (81.9%), significantly lower levels of retention in care and viral suppression were found for residents of rural (46.2% and 50.0%, respectively) and urban (50.2% and 47.2%) areas compared to residents of metropolitan areas (54.5% and 50.8%).

Conclusions

Interventions are needed to increase retention in care and viral suppression among people with HIV in nonmetropolitan areas of the United States.     

Role of complement in the control of HIV dynamics and pathogenesis

In all ex vivo preparations of HIV tested so far, C3 fragments and, after seroconversion, antibodies were detected on the viral surface. This indicates that HIV survives complement-mediated lysis. The virus has adopted different protection mechanisms to keep complement activation under the threshold necessary to induce virolysis. Among them are complement regulatory proteins that remain functionally active on the surface of HIV and turn down the complement cascade and serum proteins with complement regulatory activities. Therefore, opsonized virions accumulate in HIV-infected individuals, and subsequently adhere to complement receptor (CR) expressing cells. Among them are B cells, which bind opsonized virus. Such bound virus is efficiently transferred to autologous T cells, which subsequently are infected. Other cells interacting via CR with opsonized HIV are follicular dendritic cells (FDC). As shown by ex vivo experiments, up to 80% of virus is bound to follicular dendritic cells through C3-CR interactions. In the brain, HIV is not only interacting with complement proteins, but is able to induce their expression. Thus, interaction of HIV with the complement system is a main mechanism for pathogenesis to AIDS, since retention of (complement-resistant) opsonized viral particles on cell surfaces via CRs occurs in different compartments in HIV-infected individuals, thereby promoting transmission of virus to other permissive cells.     

HIV risk screening for high-yield community testing services for orphans and vulnerable children: a literature review

This systematic literature review focuses on the identification of risk and protective factors – sociodemographic, behavioral and structural – associated with orphans’ and vulnerable children’s (OVC) likelihood of being or becoming HIV infected to inform the development of a high-yield community screening tool to identify at-risk OVC and link them to HIV testing services. The review examines the state of the evidence regarding HIV risk, protective factors and screening for HIV testing, including algorithms used in OVC and youth community and clinical program settings to identify those already infected with HIV and those at risk of acquiring HIV. A total of 26 studies were found eligible for abstraction, encompassing 428,501 participants. The literature is sparse and inadequate related to screens for HIV testing among OVC, and only seven distinct screens were identified. Overall, it is clear that it is critical to identify children and youth most at risk of being HIV positive in community settings, while being mindful of risks associated with stigma and discrimination. Identifying these children and youth is critical to reaching the first and second UNAIDS targets – 90% of people living with HIV diagnosed and 90% of those with diagnosed HIV infection on treatment – and ultimately achieving viral suppression, leading to an AIDS-free generation.     

Reaching the 90–90–90 UNAIDS treatment target for people who inject drugs receiving integrated clinical care at a drug-use outpatient treatment facility

Background

People who inject drugs (PWID) experience more gaps at each stage of the HIV care continuum than others living with HIV. The study aimed to describe the effectiveness of an integrated care model to reach the UNAIDS 90–90–90 target.

Methods

This cross-sectional study included PWID who met the criteria for DSM-5 substance use disorder. They received a multidisciplinary comprehensive program, including medical HIV care, substance use treatment, and psychosocial support, at a drug-use treatment outpatient facility during 2019. The percentage of patients reaching the 90–90–90 UNAIDS target was the main study variable.

Results

Two hundred and twenty-one PWID were monitored at the facility during a median follow-up of 98 months (IQR: 61–143). Current HIV status was established in all PWID, of whom 84/221 (38.0%) tested HIV-positive. All the 84 patients (100%) received antiretroviral therapy, and 76(90.5%) had RNA HIV-1?<?20 copies/ml during a median of 74 months (IQR: 36–115). The UNAIDS goals were: 84/84 (100%) for the HIV testing, 84/84 (100%) for patients on antiretroviral therapy, and 76/84 (90.5%) for viral suppression.

Conclusions

Integrated clinical care provided at a drug-use treatment facility is a useful strategy to sustain a long-term HIV care continuum among PWID.

     

A brief history of antiretroviral therapy of HIV infection: success and challenges

Unprecedented efforts in the fields of biology, pharmacology and clinical care have contributed to progressively turn HIV infection from an inevitably fatal condition into a chronic manageable disease, at least in the countries where HIV infected people have full access to the potent antiretroviral drug combinations that allow a marked and sustained control of viral replication. However, since currently used treatments are unable to eradicate HIV from infected individuals, therapy must be lifelong, with the potential for short- and long-term, known and unknown, side effects, and high costs for health care systems. In addition, different patterns of unexpected systemic complications involving heart, bone, kidney and other organs are emerging. Although their pathogenesis is still under debate, they are likely to originate from chronic inflammation and immune dysfunction associated to HIV infection. A final consideration regards the dishomogenous pattern of HIV disease worldwide. In fact, access to HIV diagnosis, treatment and care are seriously limited in the geographical areas that are most affected, like Africa, which sustains 70% of the global burden of the infection. This is one of the greatest challenges that international institutions are asked to face today.     

Perspectives on the Role of Patient-Centered Medical Homes in HIV Care

To strengthen the quality of HIV care and achieve improved clinical outcomes, payers, providers, and policymakers should encourage the use of patient-centered medical homes (PCMHs), building on the Ryan White CARE Act Program established in the 1990s.The rationale for a PCMH with HIV-specific expertise is rooted in clinical complexity, HIV’s social context, and ongoing gaps in HIV care. Existing Ryan White HIV/AIDS Program clinicians are prime candidates to serve HIV PCMHs, and HIV-experienced community-based organizations can play an important role.Increasingly, state Medicaid programs are adopting a PCMH care model to improve access and quality to care. Stakeholders should consider several important areas for future action and research with regard to development of the HIV PCMH.Combination antiretroviral therapy (ART) is critical to the management of HIV/AIDS because it improves survival of HIV-infected persons1,2 and reduces rates of both sexual and mother-to-child transmission of disease.3,4 Adherence to ART decreases the average mortality rate in people living with HIV (PLWH) by one half,2 reduces sexual transmission of HIV-1 in serodiscordant couples by 96%,4 and reduces the frequency of mother-to-child transmission to below 2%.3 Because of these clinical and preventive benefits, increasing access to ART and retention in care remains an important public health strategy.Unfortunately, the Centers for Disease Control and Prevention estimates that of the 1.1 million people living with HIV disease in the United States in 2012, only 37.0% were retained in HIV care.5 Only 25.0% of PLWH have achieved viral suppression (defined as a sustained viral load of ≤ 50 copies per mL).5,6 The Centers for Disease Control and Prevention considers ART with durable viral suppression key to a comprehensive HIV prevention strategy.7,8 Recent estimates show that increasing the HIV diagnosis rate (i.e., the percentage of individuals aware of their infection) to 90.0%, achieving 80.7% viral suppression in care, and obtaining full funding of behavioral interventions for PLWH could avert nearly 180 000 new infections by 2020.9Difficulties in accessing ART and achieving viral suppression stem from delayed diagnosis and other challenges to engagement and retention in care, such as substance use, unstable housing or homelessness, psychiatric disorders, language barriers, and incarceration.10,11 Regular adherence is crucial for long-term viral suppression, and missed doses or significant variation in dosage timing can lead to viral resistance that may portend treatment failure.12,13Serving PLWH through a patient-centered medical home (PCMH) may be a successful strategy for increasing the number of people who remain in care and achieve viral control. PCMH models, which have evolved over decades, focus on whole person care coordinated across all the elements of the health care system and the patient’s community.14 Both the National HIV/AIDS Strategy and the Patient Protection and Affordable Care Act include the PCMH as a valued strategy for accomplishing key goals of improving quality of care and cost containment.15–17The national rate of 25% viral suppression reflects a need for development and refinement of the PCMH specifically designed for PLWH, or the HIV PCMH. Stakeholders across the health care system—including providers and payers—should ensure that a growing proportion of PLWH enroll in a PCMH with specific HIV expertise that comprehensively meets their needs. An alternative policy direction would be to enroll PLWH into traditional PCMHs that address the full spectrum of primary care, although that alternative is suboptimal.     

Racial and socioeconomic disparities in viral suppression among persons living with HIV in New York City

PurposeTo examine differences in racial disparities across levels of neighborhood poverty and differences in socioeconomic disparities by race/ethnicity in viral suppression among persons living with HIV (PLWH).MethodsUsing HIV surveillance data, we categorized and geocoded PLWH who were in care in New York City (NYC). Multilevel binomial regression techniques were used to model viral suppression with a two-level hierarchical structure, by including age, transmission risk, year of diagnosis, race/ethnicity, census tract poverty, and an interaction term of race/ethnicity and census tract poverty in the model.ResultsThere were 30,638 Blacks, 22,921 Hispanics, and 11,695 Whites living with HIV and retained in care in NYC, 2014. Compared with Blacks living in the most impoverished neighborhoods (≥30% residents living below the federal poverty level) who had the lowest proportion of viral suppression, with 75% in males and 76% in females, Whites living in the least impoverished neighborhoods (<10% residents living below the federal poverty level) had the highest, with 92% in males (prevalence ratio = 1.16; 95% confidence interval: 1.13, 1.18) and 90% in females (PR = 1.14; 95% CI: 1.09, 1.19).ConclusionsBy examining racial and socioeconomic disparities simultaneously, we were able to detect both disparities in viral suppression among PLWH in NYC.     

Understanding HIV viral load: implications for counselling

This paper provides an overview of HIV viral loads in blood and genital fluids and how these relate to HIV transmission during sexual activity. Current knowledge around HIV viral loads and transmission are then discussed in relation to HIV disclosure laws in Canada. HIV counsellors and health care workers should ensure that their clients/patients are aware that blood viral load is not necessarily equivalent to genital tract viral load and that the development of drug resistance within the two compartments may be unrelated. This is an important factor in preventing the spread of HIV as well as for HIV-positive individuals in not unintentionally exposing themselves to potential legal repercussions.