HIV treatment as prevention among people who inject drugs - a re-evaluation of the evidence
HIV treatment as prevention among people who inject drugs - a re-evaluation of the evidence
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DOI：
10.1093/ije/dyw180
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发表时间：
2017-04-01
影响因子：
7.7
通讯作者：
Vickerman, Peter
中科院分区：
文献类型：
--
作者：
Fraser, Hannah;Mukandavire, Christinah;Vickerman, Peter
背景：HIV病毒载量和HIV发病率的社区测量之间的人口水平相关性被解释为HIV抗逆转录病毒治疗(ART)作为注射吸毒者(PWID)预防的证据。然而，对同时发生的丙型肝炎病毒和艾滋病毒发病率趋势的调查，可以检验艾滋病毒发病率下降的其他解释。我们评估了抗逆转录病毒疗法和降低注射风险对降低1996年至2007年温哥华艾滋病发病率的贡献。方法：根据温哥华艾滋病病毒和丙型肝炎病毒流行基线(1996年)，对艾滋病和丙型肝炎病毒在温哥华艾滋病患者中传播的确定性模型进行校准。在加入参数不确定性的同时，该模型预测了什么水平的ART保护和注射风险的降低可以重现1996-2007年观察到的艾滋病毒和丙型肝炎发病率的下降，那么仅使用ART或仅仅降低注射风险会产生什么影响。结果：模型预测表明，估计1996-2007年丙型肝炎发病率的降低(84%)需要注射风险降低59%(2.5-97.5个百分位数范围49-76%)，这占了观察到的HIV发病率下降的9/10；其余的在降低性艾滋病毒感染性(70%，51-89%)和降低注射相关艾滋病毒传染性(44%，0-96%)方面取得了中等的抗逆转录病毒药物疗效。尽管存在这种不确定性，但预测表明，注射风险的降低使HIV发病率降低了76%(63-85%)，ART将HIV发病率进一步降低了8%(2-19%)，或单独降低了3%(-34-37%)。结论：1996年至2007年温哥华HIV发病率的下降应被视为密集减少危害的成功，而ART可能起到了很小的作用。
Background: Population-level associations between community measures of HIV viral load and HIV incidence have been interpreted as evidence for HIV anti-retroviral treatment (ART) as prevention among people who inject drugs (PWID). However, investigation of concurrent HCV and HIV incidence trends allows examination of alternative explanations for the fall in HIV incidence. We estimate the contribution of ART and reductions in injecting risk for reducing HIV incidence in Vancouver between 1996 and 2007.Methods: A deterministic model of HIV and HCV transmission among PWID was calibrated to the baseline (1996) HIV and HCV epidemic among PWID in Vancouver. While incorporating parameter uncertainty, the model projected what levels of ART protection and decreases in injecting risk could reproduce the observed reduction in HIV and HCV incidence for 1996-2007, and so what impact would have been achieved with just ART or just reductions in injecting risk.Results: Model predictions suggest the estimated reduction (84%) in HCV incidence for 1996-2007 required a 59% (2.5-97.5 percentile range 49-76%) reduction in injecting risk, which accounted for nine-tenths of the observed decrease in HIV incidence; the remainder was achieved with a moderate ART efficacy for reducing sexual HIV infectivity (70%, 51-89%) and an uncertain ART efficacy for reducing injection-related HIV infectivity (44%, 0-96%). Despite this uncertainty, projections suggest that the decrease in injecting risk reduced HIV incidence by 76% (63-85%) and ART further reduced HIV incidence by 8% (2-19%), or on its own by 3% (-34-37%).Conclusions: Observed declines in HIV incidence in Vancouver between 1996 and 2007 should be seen as a success for intensive harm reduction, whereas ART probably played a small role.