摘要:依據聯合國愛滋病組織(UNAIDS)發表的最新報告顯示愛滋病毒(HIV) 感染人數逐年創新高,截至2013年為止,現今全球人類免疫不全病毒(human immunodeficiency virus,簡稱HIV) 的感染者約有3,500萬 (3,320~ 3,720萬),亞洲地區(東亞及東南亞)則約有480萬(410~550萬),而每天約有6,200名新感染者產生。其中性行為與毒品是最主要的感染途徑,全球男女感染比率目前已趨近1:1,因懷孕導致小孩垂直感染的案例日增,亦即可能有更多愛滋寶寶將由母親處感染到愛滋病毒。世界衛生組織將103年世界愛滋病日主題訂為「Close the gap」,就是希望能朝消弭各項愛滋預防、治療及照護上的障礙而努力,讓大家都能有機會且無差異的接受到完善的醫療照護。我國愛滋防治策略近年成效顯著,截至103年8月底止感染者就醫人數計20,477人,就醫率達87.17%,且新通報個案3個月內就醫率達91.58%;服用抗愛滋病毒藥物之患者近80%均能規律回診,服藥一年後病毒量亦大幅降低,顯見規律治療成效良好,相對也呼應「Close the gap」的目標。一直以來的愛滋病毒傳染途徑90%係經由性行為傳染,毒品施用者因共用針具注射行為造成愛滋病毒感染長久以來為個位數,但自民國92年毒癮者感染人數首次突破十位數達74人,至96年6月已累積至5,488名,佔總感染人數38.94%,顯示疫情逐漸飆升,面對此一新挑戰,幸賴行政院核定「愛滋病減害計畫」以因應毒癮愛滋個案的遽增,94年8月由台北市、台北縣、桃園縣、台南縣進行「毒品病患愛滋減害試辦計畫」;並於95年7月起擴大辦理清潔針具計畫,全國23縣市共計設置清潔針具及愛滋衛教諮商輔導站427處;於95年8月擴大辦理替代療法計畫,全國22縣市設置替代療法醫療執行機構,使得毒品注射群體愛滋病盛行率顯著下降,但男同性戀族群間的愛滋病毒感染率仍然每年新增比例都超過15%。再者,台灣與東南亞國家和中國大陸等高感染盛行率地區的交流頻繁,更加速HIV感染的擴散。政府於79年11月30日經立法院三讀通過「後天免疫缺乏症候群防治條例」,同年12月17日由總統公布實施,中間歷經數次修訂施行細則以符合實際需求。90年年底衛生福利部疾病管制署(前行政院衛生署)為有效推動愛滋病防治計畫,減少感染人口,維護國人健康和確保青壯人口生產力,以防範愛滋病流行造成社會和經濟動盪,故凝聚各部會之力量共同推動,以統籌落實各項因應措施,特別設置了「愛滋病防治推動委員會」,將愛滋病防治提昇至中央跨部會之層級。為確保對愛滋病防治的重視,行政院承諾將愛滋病防治經費列為國家預算優先編列項目,加強跨部會協調與合作,盡一切努力,積極推動防治工作,全面對抗愛滋病漫延。台大醫院充分瞭解政府相關單位打擊愛滋病的決心,故結合本院與北區熱心同仁一起籌組「愛滋病防治中心」,以全體之力與政府共同對抗愛滋病帶來的挑戰。「人類免疫缺乏病毒傳染防治及感染者權益保障條例」部分條文修正草案,103年4月3日經行政院第3392次院會決議通過,將送請立法院審議。此次修法,將為我國愛滋防治政策與國際社會之接軌開創新頁。衛生福利部疾病管制署表示,此次修法重點在於取消非本國籍感染者之入境及停居留限制,與國際人權趨勢接軌。另調整感染者醫療費用由公務預算支應之原則,以符合愛滋病已經成為慢性疾病之現況,將感染者醫療費用調整為防疫為重的「醫療轉銜期」由公務預算補助,維持為重的「治療維持期」回歸健康保險給付。修正草案中另一重點為考量醫療之必要性或急迫性,增訂無需取得受檢查人或其法定代理人同意,即得採集檢體進行愛滋病毒檢測之情形,俾利進行預防性投藥評估及後續治療等相關醫療處置。WHO/UNAIDS為了達成防治愛滋目標,於2015年提出「90-90-90」的新策略,希望能在2020年時,達到「90%愛滋病毒感染者知道自己病況」、「90%知道病況者服用抗愛滋病毒藥物」、以及「90%服用藥物者成功抑制病毒量」的目標。根據疾病管制署於2016年5月公布資料,目前台灣這三項數據分別為75%、79%、85%;因此台灣目前仍面臨著愛滋病毒感染診斷與治療上的挑戰,防治政策亦朝向「90-90-90」的木目標邁進。目前國內已有多家醫療院所提供PrEP,但尚不清楚目前自費市場接受PrEP者,其服藥期長短、順從性、副作用及陰轉陽發生率。在自覺有暴露愛滋病毒風險而尋求愛滋預防性投藥之民眾中,使用成癮性藥物者可能有較高的風險重複尋求PEP或持續其風險行為。醫院除了預防其感染傳染病外,應評估其與身心科、精神科等醫療服務整合,提供完整的傳染病防治照護模式對愛滋防治之效益。由國內具愛滋病毒暴露預防性投藥經驗之醫師提供專線諮詢,答覆國內醫事人員有關愛滋病毒暴露前、後之預防性投藥問題,並分析諮詢內容,製作Q&A供醫事人員參考。為降低愛滋延遲診斷及愛滋患者死亡之比率,應提供民眾友善便利之就診環境,讓民眾篩檢後可即刻獲得就診資源,並因就診環境讓民眾可以不須過分擔心隱私暴露問題,因而提高就醫及服藥順從性。疾管署已於105年5月公布新版處方使用規範,搭配感染者診斷即刻服藥政策,預估可減少其他愛滋併發症的發生,更有助於愛滋疫情的長期控制。當下應對新發現並依新版處方規範服藥病人之治療效益進行評估。抗反轉錄病毒療法的使用,使愛滋患者的健康結果大幅改善,但部分藥物的副作用仍會對感染者的生活與工作造成影響。藉由監測服藥感染者之藥物血中濃度、療效及副作用等,並參考WHO之愛滋治療準則,提供改善國內愛滋病治療指引之依據,使國內感染者獲得更好的治療品質。愛滋抗藥性病毒株的出現及傳播增加了治療失敗的風險。WHO 於2012年針對HIV抗藥性情形公布早期警示指標(early warning indicators),建議各國應監測HIV抗藥性流行情形。期望本研究建立國內HIV感染者使用抗病毒藥物治療前與後之HIV抗藥性情況,監視重要的早期警示指標以監測 HIV 抗藥性,提供政策參考。現今愛滋感染者存活率大幅提升,感染者發生糖尿病、高血壓及其他心血管疾病等慢性疾病的機會也大幅提升,為提升愛滋照護品質,臨床醫師提供感染者ART同時,應一併考量感染者老化及其他慢性共病的影響,如藥物交互作用研究。台大醫院「愛滋病防治中心」於86年6月間成立以來,全體同仁積極參與防治與臨床工作,陣容愈來愈強化,不但責無旁貸地照護住院病患,亦主動且積極地派遣醫護人員前往各家醫療院所支援。本中心19年來在衛生福利部疾病管制署(前行政院衛生署)大力資助下已達到初期的成果,不論是臨床醫療服務或是研究工作皆成果豐碩,在人事訓練及佈局都已漸穩定,中心實驗室已稍具規模,將踏實地邁入繼往開來承先啟後的關鍵期。我們責無旁貸將繼續擔負起愛滋病防治與醫療的重要責任,所以向衛生福利部疾病管制署提出申請「愛滋病防治中心」106年度計畫,因為愛滋病毒的傳播涉及社會文化、性行為改變,實是一社會改造運動,而非單純醫療衛生問題,所以除了愛滋病醫療照護外,本中心將結合教育、文化、社會各體系共同合作推動防治計畫,尤其注重教育訓練,預定將以本中心及北區各個醫院之現有資源,開辦一系列衛教課程及研討會,因為普及防治教育和宣導,是打破HIV感染惡性循環的最佳方法。自73年通報第1例愛滋病毒感染者以來,截至105年7月累計本國籍通報個案數為33,457人,其中存活個案數為27,051人,約佔通報個案之83.42%。自抗愛滋病毒雞尾酒療法(HAART,Highly-Active Anti-Retroviral Therapy)治療問世以來,感染者生活品質提高,存活時間大大延長,但存活之感染者將日益增加,新感染者仍不斷產生的情形下,與感染HIV相關醫療問題,如相關合併感染症、治療副作用及抗藥性等醫療照護問題,需持續透過相關臨床研究與監測及醫事人員培訓與教育等,以提升治療成效與照護品質,並加強感染者衛教諮詢服務及行為介入措施,以避免其感染他人。「愛滋病防治中心」106年度計畫的實施重點如下列:總計畫名稱:愛滋病防治整合型研究計畫─愛滋病防治中心研究重點:本研究重點為愛滋高風險族群介入措施與其他預防策略,及提升愛滋照護品質整合性策略二大研究方向,共含研究重點如下:1.我國暴露愛滋病毒前口服預防性投藥(Pre-exposure prophylaxis, PrEP)之自費病人臨床實證研究2.使用nPEP或PrEP且合併成癮藥物使用對象之戒治整合性照護服務研究。3.針對診斷即刻服藥個案之服藥成效評估4.接受抗病毒療法愛滋感染者之藥品動態學和基因學研究5.愛滋個案開始服藥前與服藥後之抗藥性發生率追蹤研究6.國內愛滋感染者老化與其他慢性病共病之相關研究研究目標:1.瞭解愛滋預防性投藥及整合預防服務介入措施,對國內愛滋防治成效之影響。2.瞭解新治療、照護與個案追蹤模式,對感染者治療照護成效及防治愛滋感染之效益。3.瞭解藥物與個案治療結果之相關性,以提升個案治療品質效果和品質。
Abstract: The latest report presented by the Joint United Nations Program on HIV/AIDS (UNAIDS) showed a new record high in the population of HIV infections. As of 2012, 34 million people were living with HIV/AIDS, and among which 23.5 million people are in sub-Saharan Africa. Some 14.8 million people require medical treatment, but only 8 million people have availed of proper treatment. It was also noted that sex practices and prohibited substance use are the essential routes of infection. The global gender ratio of people living with HIV/AIDS is now gradually approaching 1:1 since cases of direct infection of fetus during pregnancy are also gradually rising. It is therefore possible that more babies may be born with HIV infection by their mothers. In Taiwan, HIV/AIDS infection spreads somewhat late; however, its infection rate likewise manifested a gradual annual growth. As of end of July 2016, a total of 33,457 Taiwan nationals had been reported to be HIV infected; the disease had already caused the death of 5,334 people; that is, an average of 6 persons being infected with HIV per day. The problem posed a toll to the society and economy of the nation. In September 2013, the Taipei International Conference on HIV/AIDS, sporting the motto “turning the tide on AIDS starting with me”, hopes to control epidemic through the personal behavior of each person. It is also hoped that people learn to protect themselves, thereby protecting others as well. The seminar especially underscores the importance of “personal responsibility”. Regardless of people being acquainted with HIV/AIDS or living with HIV/AIDS, each person should take on more responsibility in the fight against AIDS. According to the Centers for Disease Control, in the period from 2008 to 2012, three quarters of the men infected with HIV/AIDS acquired the infection through MSM (men who have sex with men). Young people are sexually active, and MSM is the main route of infection in this age group. In the period from 1984 to 2012, the HIV infected people between the ages of 15 and 24 took up 18.5% of the infected population. Ever since, 90% of the HIV/AIDS infection has been acquired through sexual intercourse. Syringe sharing among drug dependents had long been a factor in of HIV infection but the number had remained a single-digit figure until 2003 when, for the first time, the population of syringe-related infections broke the barrier and rose to 74 persons; by June 2007, the number had risen to 5,488 persons, comprising 38.94% of the total infected population. This development indicates the emergence of a new challenge in the gradual growth of the epidemic. Consequently, the Executive Yuan ratified the AIDS Harm Reduction Program to cope with the drastic rise of HIV infection among the drug dependent population. In August of 2005, Taipei City, Taipei County, Taoyuan County, and Tainan County organized the AIDS Harm Reduction Program for Drug Dependents; thereafter, a clean syringe campaign was launched in July 2006. There were 427 syringe sterilization and AIDS health information and counseling stations established throughout 23 cities and counties of Taiwan. In the massive campaign for the use of alternative therapy launched in August 2006, the alternative therapy program implementing facilities established throughout the 22 cities and counties of Taiwan resulted in the significant decrease of AIDS prevalence rate among intravenous drug users; unfortunately, the ratio of new HIV infections reported annually remained to post 15% and above among the male heterosexuals. Furthermore, exchanges between Taiwan and Southeast Asian countries and China having high HIV prevalence rates are quite common, a factor that further hastened the spread of HIV infectionOn November 30, 1990, the Legislative Yuan passed the third reading of the Acquired Immune Deficiency Syndrome Control Act, and on December 17 of the same year, the President decreed its ratification and implementation. In the process of its legislation, the enforcement rules of the bill had undergone a series of amendment before it finally met the society’s requirements. In the yearend of 2001, in an effort to effectively implement the HIV/AIDS control plan, reduce the HIV infections, protect the public health, and preserve the reproductive health of the young generation, thereby preventing the AIDS epidemic from causing any serious social and economic impacts, the Centers for Disease Control of the Ministry of Health and Welfare (formerly the Department of Health) consolidated the resources of all concerned departments and agencies in the implementation and preparation of the necessary countermeasures for the organization of the HIV/AIDS Control Committee (愛滋病防治推動委員會). The move elevated HIV/AIDS control operations to the central inter-agency operations level. To ensure that the government keeps serious attention on HIV/AIDS control operations, the Executive Yuan promised to include the budget for HIV/AIDS control in the priority budget list of the government and to enhance inter-agency coordination and cooperation for an all-out aggressive implementation of control measures and full-scale mitigation of the HIV contagion. Fully understanding the government’s determination in stemming HIV communication, the National Taiwan University Hospital organized the dedicated NTU Hospital staff and medical workers of northern Taiwan for the establishment of the HIV/AIDS Control and Study Center, thereby combating the challenges of the disease through concerted effort and government assistance.Currently, several hospitals are providing PrEP services, however it is unclear about duration of treatment, compliance, side-effects and seroconversion among PrEP users in the self-pay market. Among people who are conscious of their risk exposure to HIV and seeking for HIV prophylaxis, addictive drugs users may be at higher risk of repeatedly seeking PEP services or continuing high-risk behavior. In addition to prevention of other infectious transmissible diseases, hospitals should evaluate and consider mental health and psychiatric department integrated services care and therefore providing holistic infectious disease control and prevention to effectively HIV/AIDS disease control.Through counseling line answered by Taiwanese physicians with experience in PrEP, questions related to pre-and post-exposure prophylaxis will be answered. Content will be analyzed and Q&A sheet will be developed for healthcare professionals’ reference. In order to reduce the rates of HIV/AIDS late diagnosis and AIDS-related mortality, a friendly and convenient environment for public to access medical services should be provided. After screening, people would be able to immediately obtain medical services information. Such environment will be prone so that people will not worry too much about disclosure of their status, ultimately increasing clinic visit and drug compliance. Since May 2016, Center for Disease Control (CDC) has announced new recommendations on prescription use of antiretroviral agents along with the “Test and treat” strategy, which are estimated to reduce the incidence of AIDS related co-morbidities but also help long-term control of HIV/AIDS epidemic.We should evaluate the treatment benefits in ART treated patients according to new discoveries and the new version of regulations. The use of antiretroviral therapy significantly improve health outcomes of HIV/AIDS patients, but some drug side effects may still impact on the life and work of infected people.By monitoring drug blood concentrations, efficacy and side effects, and with reference to the WHO HIV treatment guidelines, to provide an improved basis for national HIV/AIDS treatment guidelines, infected people in Taiwan will get better quality of care. The emergence and transmission of drug-resistant strains of HIV virus increases the risk of treatment failure.In 2012, WHO has issued early warning indicators of HIV drug resistance and recommended each country to monitor the prevalence of HIV drug resistance.We expect this research will establish the national prevalence of HIV resistance in HIV-infected people prior and after initiation of antiretroviral treatment, monitor the important early warning indicators to conduct surveillance of HIV resistance and provide policy reference.Nowadays, the survival rate of HIV infected people has greatly improved, the chances of chronic diseases as diabetes, hypertension and other cardiovascular diseases have increased dramatically, to enhance the quality of HIV care, clinicians providing ART to patients should also consider influence of aging and other chronic co-morbidities, such as drug interactions. Since the establishment of the NTU Hospital HIV/AIDS Control and Study Center in June 1997, the entire NTU hospital staff aggressively participated in the preventive and clinical medicine work, allowing the team to develop greater proficiency. In addition to untiring dedication to the care of hospital patients, NTU Hospital also proactively and aggressively dispatches medical workers to aid other hospitals. For the past 19 years, the HIV/AIDS Control and Study Center, under the full support of the Centers for Diseases Control of the Ministry of Health and Welfare (formerly the Department of Health) has already achieved preliminary results of its efforts. The center was able to reap a wealth of outcomes both in its clinical medical services and research work. Under a stable personnel training and deployment, the center laboratory has reached a certain level of scale and is steadily plodding towards a highly promising and pioneering key phase. We shall continue to shoulder the heavy responsibility of HIV/AIDS control and medical treatment work; in light of which, the center filed an application for the 2017 Annual Program of the HIV/AIDS Control and Study Center with the Centers for Disease Control. Since communication of HIV involves changes in social, cultural, and sexual behaviors, it may be said that the program is a social reform movement in substance and not just a simple medical and health issue. Hence, in addition to AIDS treatment and medical care, the center s hall consolidate the academic, cultural, and social sectors for the concerted implementation of related control programs, with special attention to the education and training. The plan is to employ the existing resources of the center and the respective hospitals in north Taiwan for organizing a series of health orientation classes and seminars, since a widespread disease control education and information promotion campaign is the best way to combat the vicious cycle of HIV communication.We have become quite aware that AIDS is not only a fatal disease, but also a disease that could seriously dent social development, weaken productivity, ward off foreign investments, downgrade the living standards of the nation, and even diminish government and social forces. The entire medical staff of the center will provide people with HIV/AIDS the most suitable antiviral drug and medical treatment for opportunistic infection. Medicine administration regulations are updated every year; moreover, test items and test time intervals are evaluated for the definition of the principles governing test items, thereby equipping clinical physicians with the right materials for reference in the provision of medical care to patients. The center also earnestly endeavors to conserve the health insurance resources and studies more economical treatment procedures for the welfare of HIV patients and enhancement of the medical care system; thus, patients, patients’ families, and their communities may be able to avail of proper support. Nationwide inter-hospital HIV clinical epidemiology related studies were conducted for the upgrade and consolidation of the medical resources and infected people related information of the designated AIDS treatment hospitals in the country. Moreover, assistance was provided in the related clinical epidemiology research, such as, monitoring study of the clinical symptoms of people with HIV/AIDS, prevention and treatment of opportunistic infection, health seeking inclination, high-risk behaviors, and drug resistance and side effects of treatments; results will be provided for the reference of future therapy and control policy making and amendment endeavors. Furthermore, the HIV/AIDS Control and Study Center should take on the role of leading the domestic treatment and control related work and provide the appropriate educational training program for resource planning. Also, the center shall establish and implement Post Exposure Prophylaxis (PEP) procedures. Essentials of the implementation of the 2017 annual program of the HIV/AIDS Control and Study Center are as follows:Study Subject: Integrated Plan for the Control of HIV/AIDS Focal Point of the Study: This research focuses on two major research streams; interventional processes and other preventive strategies in HIV/AIDS high-risk populations and integrated approaches to enhance HIV quality care, with a total of 10 priorities described as follows:1.National clinical study on pre-exposure prophylaxis (PrEP) in self-pay subjects.2.Research related to integrated care of patients with abuse substance undertaking drug replacement therapy using PrEP or non-occupational PEP (post-exposure prophylaxis).3.Effectiveness of counseling line for pre- and post-exposure prophylaxis questions.4.Assessment of the benefits of implementing designated clinics for adult HIV/AIDS.5.Evaluation of the treatment effectiveness in cases treated immediately after diagnosis.6.Pharmacodynamics and genetic study in HIV-infected patients receiving antiretroviral therapy.7.Cohort study on resistance profile in HIV/AIDS clients before and after initiation of treatment.8.Research related to ageing and other co-morbidities in Taiwanese HIV-infected subjects.Research objectives:1. To understand the effectiveness of HIV prophylaxis and integrated interventional preventive services, and its impact on the national HIV/AIDS prevention and control.2. To understand the effectiveness of new therapies, care and case follow-up model in patient treatment care and HIV/AIDS disease prevention and control.3. To understand the relationship between drug treatment and health outcomes in cases to improve patient treatment care and quality of life.