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世卫组织:艾滋病毒耐药性激增,鼓励全球向度鲁特韦过渡

2019-08-02 贺梨萍 澎湃新闻

抗菌素耐药性(AMR)的增加是当今对人类健康的最大威胁之一。如果不紧急处理,耐药性问题可能导致数百万人死亡,并增加新的难以治疗的感染,从而推升更高的治疗成本。对全球主要公共卫生问题艾滋病来说,耐药性问题也不例外。世界卫生组织(WHO)在最近发布的《2019版艾滋病毒耐药性报告》中指出,两种关键的抗艾滋病毒药物依法韦伦(Efavirenz)、奈韦拉平(Nevirapine)的耐药性激增,令人震惊。报

抗菌素耐药性(AMR)的增加是当今对人类健康的最大威胁之一。如果不紧急处理,耐药性问题可能导致数百万人死亡,并增加新的难以治疗的感染,从而推升更高的治疗成本。

对全球主要公共卫生问题艾滋病来说,耐药性问题也不例外。世界卫生组织(WHO)在最近发布的《2019版艾滋病毒耐药性报告》中指出,两种关键的抗艾滋病毒药物依法韦伦(Efavirenz)、奈韦拉平(Nevirapine)的耐药性激增,令人震惊。

报告中指出,与包括耐药艾滋病毒造成的威胁在内的抗菌素耐药性作斗争是全球社会的一项主要目标。

艾滋病毒耐药性(HIVDR)是由艾滋病毒中的一种或多种突变等引起,这种变化影响药物或药物组合阻止病毒复制的能力。目前,艾滋病毒感染者通常会接受鸡尾酒疗法,即抗逆转录病毒疗法。报告称,由于耐药病毒的出现,目前所有抗逆转录病毒(ARV)药物,包括较新的药物类别,都有部分或完全失效的风险。

值得注意的是,不仅接受抗逆转录病毒治疗的人会产生耐药性,其他人群也会感染已经具有耐药性的艾滋病毒。

世卫组织的调查结果显示,在过去4年时间里,世卫组织在18个国家随机选择的诊所中进行了调查,并检查了在此期间开始接受艾滋病毒治疗患者的耐药性水平。

其中,在在12个国家(埃斯瓦蒂尼、纳米比亚、乌干达、南非、津巴布韦、阿根廷、古巴、危地马拉、洪都拉斯、尼加拉瓜、巴布亚新几内亚和尼泊尔)中,超过10%的艾滋病病毒感染成年人被发现对依法韦伦、奈韦拉平具有耐药性。

一般来说,超过这个10%阈值,就认为给其他人群开同样的艾滋病毒药物是不安全的,因为耐药性可能会增加。

总部位于华盛顿的泛美卫生组织(PAHO)传染病专家Massimo Ghidinelli说,“我认为现在已经超过阈值了。”

报告还提到,尤其令人担忧的是,撒哈拉以南非洲地区感染艾滋病毒的婴儿的耐药水平也很高。2012年至2018年间,在该地区9个国家中,约有一半新确诊的婴儿感染了对依法韦伦、奈韦拉平其中一种或对两者都具有耐药性的艾滋病毒。

该报告的作者之一、世卫组织传染病内科医生Silvia Bertagnolio说,耐药性的原因仍然难以捉摸。但她提到,当人们中断治疗时,耐药艾滋病毒可能会发展。

举例来说,许多携带病毒的妇女可能在怀孕期间服用了抗逆转录病毒药物以防止其婴儿感染,但在分娩后停止服用。2015年,世卫组织建议孕妇和哺乳期妇女终生使用药物。

数据显示,中断治疗后重新使用依法韦伦和奈韦拉平的人群中出现耐药性概率(21%)远远高于首次使用的人群(8%)。

至于携带艾滋病毒的人为何会停药,Bertagnolio说,“耻辱感”是很大一部分原因,他们可能不想被人看到去拿他们的药。报告还指出,诊所药品短缺也可能是原因之一。

值得注意的是,世卫组织日前已建议,根据新的收益和风险证据,推荐将抗艾滋病毒药物度鲁特韦(dolutegravir)作为包括孕妇和有生育潜力人群在内的所有人群的首选一线和二线治疗药物。
 
世卫组织认为,虽然曾有研究结果显示,怀孕时使用度鲁特韦的妇女可能会造成其婴儿的神经管缺陷(导致脊柱裂等问题的大脑和脊髓天生缺陷)。但大型临床试验比较得出,这种药物比其他疗法更有效、更耐受性更强。

位于西班牙巴塞罗那的德国特里亚斯普约尔大学医院传染病医生Roger Paredes说,与其他抗逆转录病毒药物相比,度鲁特韦产生变异并最终产生耐药性的可能性更低。他补充道,“我们必须鼓励全球向多鲁特格拉韦过渡。”

世卫组织统计显示,2019年,82个低收入和中等收入国家报告称正向使用度鲁特韦的艾滋病毒治疗方案过渡。

Bertagnolio对此表示同意,但呼吁谨慎行事。如果治疗实施不佳或不全面,就可能出现新的耐药性。“我们不希望最后再次处于同样的境地。”

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