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保健關懷
Health Concerns

愛滋病剖析

In Focus — HIV/AIDS

Anatomy of a Pandemic

隨著愛滋病不斷擴展其破壞力,扶輪社員也遭逢新的挑戰

As AIDS extends its ruinous reach, Rotarians confront new challenges.

作者:佛克Rebecca Voelker

(THE ROTARIAN-Dec. 2003 扶輪月刊2004/1 )


截至2002

12月為止,全球有4200萬人感染愛滋病 

不到30年的時間,愛滋病已經橫行全世界各個角落。自1981年美國的公共衛生專家首度辨識出這個新疾病至今,愛滋病已經成為全球第四大死亡原因,也是非洲大陸的頭號殺手。

In less than three decades, AIDS has run a deadly marathon around the globe. Since 1981, when public health experts in the United States first identified it as a new disease, AIDS has become the fourth-leading cause of death worldwide and the leading killer on the African continent.

全球估計有4,200萬人是愛滋病患者或帶原者。去年,每天有14,000人感染愛滋病毒,一整年有310萬人死於愛滋病。

An estimated 42 million people throughout the world are living with either AIDS or HIV, the virus that causes the disease. Last year, 14,000 new HIV infections occurred each day, and 3.1 million people died of AIDS.

在這個疾病邁向第三個10年之際,印度醫療協會愛滋病防制計劃全國協調人,同時也是德里南區都會(Delhi South Metropolitan)扶輪社社員坦頓醫師(Dr. Rajiv Tandon)說:「全球沒有一個洲、沒有一個國家、沒有一個社區可以倖免於難。」

As the disease enters its third decade, "no continent, no country, no community has escaped its vicious trail," says Dr. Rajiv Tandon, national coordinator of the Indian Medical Association's AIDS Control Program and a member of the Rotary Club of Delhi South Metropolitan.

愛滋病的悲劇發生在社會各個階層,破壞經濟與社會結構。因為愛滋病主要是透過性接觸來傳播,因此對正值生產力巔峰的年輕人殺傷力也最大。亞特蘭大艾莫里大學公共衛生系系主任兼愛滋病研究中心主任的庫博士(Dr. James Curran)說:「我們在非洲看到大部份的勞動力量都病患垂危。」

The tragedy of AIDS touches society at every level, eroding economic and social structures. Because it spreads primarily through sexual contact, AIDS kills young adults in what would otherwise be their most productive years. "What we see in Africa are large portions of the work force becoming ill and dying," says Dr. James Curran, dean of public health and director of the Center for AIDS Research at Emory University in Atlanta.

身為亞特蘭大(Atlanta)扶輪社員的庫蘭解釋說:「愛滋病往往會摧毀整個家庭。收入來源的人死亡,或雙親都去世。」結果:撒哈拉沙漠以南的非洲有超過1,100萬名兒童因愛滋病成為孤兒。

"AIDS tends to devastate whole families," explains Curran, a member of the Rotary Club of Atlanta. "The wage earner dies, or both [parents] die." The result: More than 11 million children in sub-Saharan Africa are AIDS orphans.在開發中國家各地,提供愛滋病帶原者的醫療照顧十分缺乏,或根本付之闕如。聯合國愛滋病計劃署監督與評估組主任德雷博士表示,在需要抗逆轉性濾過性病毒藥物來遏止愛滋病毒繁殖,延緩愛滋病發作的600萬人當中,只有30萬人可以取得藥物。其中只有5萬人居住在撒哈拉沙漠以南的非洲,而這裡有近3000萬人感染愛滋病毒。開發中國家缺乏藥物、實驗室、診所、及受過訓練的人員來照顧愛滋病患者/帶原者。

Throughout the developing world, medical care for HIV infection is scarce or nonexistent. Dr. Paul De Lay, director of monitoring and evaluation with UNAIDS (Joint United Nations Programme on HIV/AIDS), says that of the six million people who need treatment with antiretroviral drugs, which keep HIV from reproducing and can significantly slow the development of AIDS, only 300,000 receive it. Only 50,000 of those are in sub-Saharan Africa, where nearly 30 million are HIV-infected. Developing nations lack the drugs, laboratories, clinics, and trained staff to care for those with HIV/AIDS.

要徹底消滅愛滋病毒,必須研發出有效的愛滋病疫苗或治療法。政府的堅強決心在資源缺乏的國家也十分重要。德雷表示,沒有上述重要的因素配合,「即使是再50年或100年,在許多國家我們仍然要面對艱鉅的難題。」

Vanquishing HIV ultimately hinges on the development of an effective vaccine or a treatment to cure AIDS. Strong government commitment also is needed in countries with scant resources. Without these vital elements, says De Lay, "we will be facing major problems in many countries 50 to 100 years from now."

愛滋病在世界各地有不同的發展。可是在2003121日,受到愛滋病波及的社區、組織、機構將以肅穆和決心來紀念世界愛滋病日。在這個第16屆的世界愛滋病日前夕,我們將依區域來看愛滋病在全球所造成的問題與挑戰。我們也將展現扶輪社員如何努力防止該病毒的蔓延,及如何協助受愛滋病影響的人。

The AIDS pandemic is at varying stages throughout the world. But on 1 December 2003, communities, organizations, and institutions affected by HIV/AIDS will observe World AIDS Day with common solemnity and resolve. On this 16th annual World AIDS Day, we take a region-by-region look at the issues and challenges posed by HIV and AIDS worldwide. We also show how Rotarians are working to prevent the virus from spreading and how they are helping those affected by the disease.

 

撒哈拉以南的非洲

Sub-Saharan Africa

在全世界疫情最嚴重的區域──撒哈拉沙漠以南的非洲,目前有2940萬人是愛滋病患者或帶原者。在去年全球500萬件新增的感染病例中,有350萬件發生在這裡。近9%的成年人感染愛滋病毒,其中58%是女性,因為愛滋病毒在此地主要是透過異性間的性接觸來傳播。光是去年,愛滋病在此地便奪走240萬人的性命。成年人的愛滋病盛行率因地而異,從波札那的38.8%到塞內加爾的低於1%不等。

The most severely affected region in the world, sub-Saharan Africa is home to 29.4 million people living with HIV or AIDS. Of the world's five million new HIV infections last year, 3.5 million occurred here. Nearly 9 percent of adults are HIV-positive, and 58 percent of those infected are women, since HIV spreads here mainly by heterosexual contact. AIDS claimed 2.4 million lives in the region last year alone. Adult prevalence rates swing erratically, from a staggering 38.8 percent in Botswana to less than 1 percent in Senegal.

撒哈拉沙漠以南的非洲情況非其他區域可比。這裡的國家多數遭受戰爭、貧窮、乾旱、飢荒、和洪水的破壞,往往再加上政治貪污的迫害,愛滋病在這裡不僅是醫療問題還是社會與經濟發展的問題。在南非,因該國政府處理愛滋病問題的腳步太慢,使得世界銀行發出警告說除非該國民選的領導人能夠採取更有力的行動,否則經濟將在三個世代內崩潰。因為年輕人大量凋零,農業與工業也搖搖欲墜。稅收銳減,讓公共預算更加吃緊。在盛行率高的國家,政府可能比較不願支持教育,因為年輕人的高死亡率意味著教育投資無法回收。

Conditions in sub-Saharan Africa are comparable to no other region in the world. With nations ravaged by war, poverty, drought, famine, and floods and too often hamstrung by political corruption, the calamity of AIDS here is as much an issue of social and economic development as of medical care. In South Africa, where the government has been slow to react to HIV, the World Bank has warned of economic collapse within three generations unless elected leaders take more forceful action. As young adults die, agriculture and industry falter. Tax revenue falls, putting more stress on public budgets. In countries with high infection rates, governments may be less likely to support education because high death rates among young adults mean they won't see a return on the investment.

 

儘管情況十分悲慘,還是有樂觀的理由,在烏干達普及的防治計畫讓成年人盛行率從1999年的8.3%降低至2001年的5%。在波札那有5,000人在服用藥物,在該國迷你的150萬人左右的人口中,佔相當高的比例。在南非,公共衛生官員表示政治的潮流正在轉向。該國政府在20038月宣佈將訂定計畫在全國各地發放藥物。

Despite the grim picture, there is cause for some optimism. In Uganda, widespread prevention programs have helped roll back the adult HIV prevalence rate from 8.3 percent in 1999 to 5 percent in 2001. And in Botswana, 5,000 people are receiving antiretroviral drugs, a large proportion given the country's relatively small population of about 1.5 million. In South Africa, public health officials say the political tide is turning: The government announced in August 2003 that it will develop plans to distribute antiretroviral drugs nationally.

德雷表示,即使如此,衣索比亞與奈及利亞某些區域盛行率上升,引起相當的關注。他警告說儘管非洲愛滋病感染人數已經高得驚人,但仍然可能會有大規模、新的流行病產生。

Even so, De Lay says rising prevalence in areas of Ethiopia and Nigeria is cause for great concern. He cautions that despite the continent's already overwhelming HIV statistics, Africa could continue to see massive, new epidemics.

 

拉丁美洲和加勒比海

Latin America and the Caribbean

  加勒比海的愛滋病盛行率-此地有2.4%的成年人感染(1,840萬人中有44萬人感染)-僅次於撒哈拉沙漠以南的非洲 

拉丁美洲和加勒比海區域大約有190萬人為愛滋病患者或帶原者。而加勒比海本身的愛滋病盛行率──此地有2.4%的成年人感染(1840萬人中有44萬人染)──僅次於撒哈拉沙漠以南的非洲。海地和巴哈馬群島成年人的盛行率在加勒比海區域排名最高,分別是6%3.5%。海地人的平均壽命因為愛滋病已經減少6年,降低為51歲。

About 1.9 million people in Latin America and the Caribbean have HIV or AIDS. The Caribbean itself — where 2.4 percent of adults are infected (440,000 infections in a population of 18.4 million) — is second only to sub-Saharan Africa in HIV/AIDS prevalence. Haiti and the Bahamas have the highest adult prevalence rates in the Caribbean, at 6 percent and 3.5 percent, respectively. Life expectancy in Haiti has dropped six years to about 51 because of AIDS.

除了靜脈注射藥物、社經地位不平等、和高危險的性行為之外,南北美洲國家之間的移民遷徙也助長此地的疫情。社會不齒同性戀與雙性戀也妨礙公共衛生行動,讓病毒得以在該區域的許多地方快速散播。在中南美洲,男性受感染的情形較為嚴重;加勒比海人口的二性罹病率比例大約是一比一。專家表示預防工作應該要集中在同時與男性和女性有性關係的男性。最近針對宏都拉斯二個城市的一項調查結果顯示需要有效的防治計劃。當地的愛滋病盛行率大約13%,一夫一妻制並不普遍,可是保險套的使用率甚低,對於不安全的性行為會增加愛滋病毒傳播的風險普遍一無所知。

Migration between North and South American countries helps drive the epidemic here, as do intravenous drug use, socioeconomic inequality, and high-risk sexual behavior. Social stigmas attached to homosexuality and bisexuality stymie public health efforts and allow the virus to spread rapidly in many parts of the region. Men continue to be more seriously affected in Central and South America; the gender breakdown in the Caribbean is now about fifty-fifty. Experts say heightened prevention efforts should focus on men who have sex with both men and women. The need for effective prevention programs was illustrated by the results of a recent study in two cities in Honduras. HIV prevalence rates were about 13 percent and monogamy was not generally practiced, but condom use was low and there was little recognition that unsafe sex increases the risk of HIV transmission.

該區域最成功的例之是巴西。這個收入中等的國家比撒哈拉沙漠以南的貧窮國家較能挹注更多資源。德雷表示,藉由自行生產抗逆轉性濾過性病毒藥物、強化醫院系統、快速訓練醫師與其他醫療人員等措施,巴西已經能夠提供治療給近10萬人,此數字與總人口的比例已經接近美國。他將巴西的成功歸功於該國政府處理這項問題的強烈決心。

The region's biggest success story is Brazil, a middle-income country better able to marshal resources than the hard-hit countries of sub-Saharan Africa. By manufacturing its own antiretroviral drugs, strengthening its hospital system, and quickly training doctors and other health-care professionals, Brazil has been able to provide treatment for almost 100,000 infected people, a per capita rate comparable to the United States, says De Lay. He credits the country's success to the Brazilian government's strong commitment to addressing the problem.

 

亞洲和太平洋

Asia and the Pacific

愛滋病盛行率在亞洲與太平洋地區相對而言較低,可是公共衛生人員擔心大型的風暴正在醞釀。據估計此地目前有720萬名愛滋病病患或帶原者,這個數字在20012002年之間增加了10%。在這些國家,愛滋病毒藉由性接觸與動脈注射毒品二種途徑來傳播。2002年,此區域有近50萬人死於愛滋病。

HIV prevalence rates remain relatively low in Asia and the Pacific region, but public health officials fear major storms are brewing. An estimated 7.2 million people here currently live with HIV or AIDS, a figure that increased 10 percent between 2001 to 2002. In these countries, HIV spreads through both sexual contact and intravenous drug use. In 2002, nearly 500,000 people in the region died of AIDS.

最引人關切的區域是中國和印度,二者的人口總計佔全球三分之一強。如果區域性的流行蔓延至一般大眾,專家擔心會有大規模的發病與死亡。印度的愛滋病毒盛行率為1%,可是這個數字表示有400萬人為愛滋病毒,專家預測到2010年時這個數字將激增為10倍。在中國,人口遷徙和高低收入階層的差距日益擴大,都會增加愛滋病毒散播到靜脈注射毒品使用者與其他高危險群之外的風險。

Areas of greatest concern are China and India, which together hold more than a third of the world's population. If localized epidemics reach the general public, experts fear widespread illness and death. India's HIV prevalence is less than 1 percent, but that figure represents four million people living with HIV or AIDS. In China, where about one million people have HIV, experts project a tenfold increase in infections by the end of the decade. In both countries, migration and growing gaps between low- and high-income groups heighten the risk that HIV will spread beyond intravenous drug users and other high-risk groups.

在印度,由於大眾宣導運動的普及,很高比例的成年人知道如何防止愛滋病毒傳播。可是坦頓指出一個警訊:在南部的坦米爾納度,母子垂直感染在1999年到2002年之間幾乎增加為7倍。他說,在印度與其他地方,愛滋病毒的控制工作必須集中在對抗病人為人所齒、動員政府與私人的力,並仰賴以科學為基礎的防治計劃。德雷說,若沒有有效的控制措施,「印度的情況將遠超過我們所能想像。」

In India, a large proportion of adults know how to prevent HIV transmission, thanks to widespread public awareness campaigns. But Tandon points to a danger sign: In the southern state of Tamil Nadu, mother-to-child transmission increased almost sevenfold from 1999 to 2002. In India and elsewhere, he says, HIV control efforts must focus on fighting stigmas, mobilizing public and private sectors, and relying on science-based prevention programs. Without effective control measures, says De Lay, "India will be unlike anything else we've seen."

專家預測印尼和新幾內亞的疫情將因靜脈注射毒品和性交易而日益擴大。然而,高棉和泰國的愛滋病毒盛行率因全面性的防治計劃與對抗汙名的行動而降低。此外,泰國也主動自行生產抗逆轉性濾過性病毒藥物,並訓練衛生醫療人員來投藥。

Experts forecast growing epidemics in Indonesia and Papua New Guinea, as a result of intravenous drug use and commercial sex. However, HIV prevalence has fallen in Cambodia and Thailand due to comprehensive prevention programs and efforts to fight stigma. What's more, Thailand took the initiative to manufacture its own antiretroviral drugs and train health-care workers to administer them.

 

東歐和中亞

Eastern Europe and Central Asia

這個區域是全球愛滋病毒/愛滋病成長最快速的區域。在東歐和中亞有120萬名愛滋病帶原者和患者,意味著盛行率只有0.6%。可是據估計光是去年此區域便新增25萬人感染。

This region is home to the world's most rapidly escalating HIV/AIDS epidemic. In Eastern Europe and Central Asia, the 1.2 million people with HIV or AIDS represent an adult prevalence rate of only 0.6 percent. But an estimated 250,000 HIV infections occurred in the region last year alone.

德雷說:「俄羅斯是最主要的問題。」該國快速的社會變遷、高失業率、和貧窮正構成流行病滋生的溫床。從1998年底到去年年中,俄羅斯的愛滋病感染驟增近20倍,從大約11,000人增加為超過20萬人。絕大多數都是因為靜脈注射毒品造成,且大多數感染的人在30歲以下。在人口100萬的陶里亞帝市所做的調查顯示,參與研究的靜脈注射毒品使用者當中,有56%感染了愛滋病毒;可是絕大多數不知道自身已經感染。公共衛生官員害怕因為通報率嚴重偏低,實際的情況可能比記錄的統計數字更為嚴重。

"Russia is of major concern," says De Lay. There, rapid social change, high unemployment, and poverty set the stage for a flourishing epidemic. From the end of 1998 to the middle of last year, HIV infections in Russia increased by nearly 2000 percent, from about 11,000 to more than 200,000. The vast majority are attributed to intravenous drug use, and most of those infected are under age 30. A survey in Togliatti, a city of one million, showed that 56 percent of intravenous drug users who took part in the survey were HIV-positive; the majority didn't know they had the virus. Public health officials fear that because of vast underreporting, recorded statistics foreshadow much more severe conditions.

德雷解釋說:「疫情正由集中在注射毒品使用者蔓延至一般大眾。」這恐怕已經是事實,烏克蘭成人的1%盛行率在全歐洲是最高的。在中亞,對愛滋病毒與愛滋病的認識相當缺乏。然而,愛滋病毒的盛行率在全國宣導計劃完善的捷克、匈牙利、波蘭、和斯洛伐克則一直維持相當低的水準。

"Concentrated epidemics in injection-drug users are spilling into the general public," explains De Lay. Already, Ukraine's 1 percent adult prevalence rate is the highest in all of Europe. In Central Asia, awareness of HIV and AIDS is extremely low. However, HIV prevalence has remained at very low levels in the Czech Republic, Hungary, Poland, and Slovenia, which have strong national awareness programs.

 

北非和中東

North Africa and the Middle East

愛滋病毒直到1980年代末期才入侵這個區域。2002年通報的新病例有83000件,使北非和中東愛滋病帶原者和病患的人數增加為55萬人。其中有超過半數55%是女性。異性性行為和靜脈注射是愛滋病毒在此地的主要傳播途徑。然而此地公共衛生的疫情監視工作極度缺乏,使疫情判定也相當困難。專家表示政治不穩定、移民和貧富差異,促成愛滋病毒滋生的成熟條件。非政府組織已經在伊朗和黎巴嫩展開防治行動。

HIV and AIDS didn't arrive in this region until the late 1980s. In 2002, 83,000 new infections were reported, bringing the number of people living with HIV or AIDS in North Africa and the Middle East to 550,000. More than half, 55 percent, are women. Heterosexual contact and intravenous drug use are the primary HIV transmission routes here, though determining trends in the region is difficult because of woefully inadequate public health surveillance. Experts say political instability, migration, and gaps between the rich and poor create conditions ripe for HIV to gain a foothold. Nongovernmental organizations have begun prevention efforts in Iran and Lebanon.

 

「愛滋病仍然無藥可治,可是愛滋病毒帶原者可以過著健康、有貢獻的生活。」"AIDS still is not curable, but people [with HIV] are living healthy, productive lives,"──庫蘭Curran博士

 

高收入國家

High-income countries

澳洲、紐西蘭、以及北美洲和西歐的國家大約有160萬人是愛滋病帶原者與患者。去年,上述國家總計有76000人通報感染,23000人因愛滋病喪生1990年代中期至末期開始使用抗逆轉性濾過性病毒藥物,因愛滋病死亡的人數已經大幅減少。

Some 1.6 million people are living with HIV and AIDS in Australia, New Zealand, and countries in North America and Western Europe. Last year, a total 76,000 new HIV infections and 23,000 AIDS deaths were reported in these countries. Since the introduction of antiretroviral drugs in the mid- to late-1990s, AIDS deaths have fallen dramatically.

庫蘭說:「愛滋病仍然無藥可治,可是愛滋病毒帶原者可以過著健康、有貢獻的生活。」高收入國家大約有50萬人接受抗逆轉性濾過性病毒藥物的治療。

"AIDS still is not curable, but people [with HIV] are living healthy, productive lives," says Curran. About 500,000 individuals in high-income countries receive antiretroviral treatment.

然而,美國疾病控制及預防中心今年稍早提出警告表示,2002年美國的愛滋病毒新病例在10年來首度增加,而同性戀與雙性戀的男性愛滋病帶原者增加,也意味著疫情正在復發。其他性傳染疾病也有增加情形的報告顯示歐洲與澳洲也呈現同樣的趨勢。在數個西歐國家,愛滋病正在異性戀與低收入人口之間快速蔓延。

However, the U.S. Centers for Disease Control and Prevention warned earlier this year that new AIDS cases in the United States rose in 2002 for the first time in a decade and that increased HIV infection among gay and bisexual men could mean a resurgence is underway. Reports of increases in other sexually transmitted infections indicate similar trends in Europe and Australia. In several Western European countries, the epidemic is spreading more rapidly among heterosexuals and in low-income populations.

公共衛生專家強調有必要在各個層面-社會、經濟、文化、和醫療-同時持續對抗愛滋病。儘管已開發國家整體來說防疫工作相當成功,可是庫蘭警告說:「我們無法忽視一個對社會造成如此重大衝擊的問題。」

Public health experts emphasize the continuing need to tackle HIV/ AIDS on all fronts — social, economic, cultural, and medical. Despite the overall successes in developed nations, Curran cautions: "We can't ignore a problem that has had such an enormous impact on society." 

2002年愛滋病最嚴重五個區域的新病例數目

New HIV infections in 2002 in the five most-affected regions

2002年各區域估計的愛滋病死亡人數

Estimated AIDS deaths by region in 2002

北非及中東

North Africa & the Middle East

83,000

北美

North America

15,000

拉丁美洲及加勒比海

Latin America & the Carribean

210,000

加勒比海

Carribbean

42,000

東歐及中亞

Eastern Europe & Central Asia

250,000

拉丁美洲

Latin America

60,000

亞洲及太平洋

Asia & the Pacific

970,000

北非及中東

North Africa & Middle East

37,000

撒哈拉以南的非洲

Sub-Saharan Africa

3.5 million

撒哈拉以南的非洲

Sub-Saharan Africa

2,400,000

 

 

西歐

Western Europe

8,000

 

 

東歐及中亞

Eastern Europe & Central Asia

25,000

 

 

東亞及太平洋

East Asia & Pacific

45,000

 

 

南亞及東南亞

South & Southeast Asia

440,000

 

 

澳洲及紐西蘭

Australia & New Zealand

<100

※五百萬人在2002年感染愛滋病

310萬人在2002年死於愛滋病

Source: UNAIDS/WHO, AIDS Epidemic Update, December 2002

 

作者:佛克(Rebecca Voelker )為芝加哥的衛生與醫療題材自由作家。

Rebecca Voelker is a freelance health and medical writer based in Chicago