資料來源：http://www.thelancet.com/hiv/ Vol 10 June 2023 /財團法人台灣紅絲帶基金會編譯

 

英國在實現聯合國愛滋病規劃署 95-95-95 目標方面取得了長足進步：有95% 的感染者得到診斷

，其中99% 的人接受了治療，接受治療者中有98% 的人病毒得到抑制。 雖然疫情主要集中在男男

性行為者（MSM）中，但近年來異性戀人群的新增確診比例已超過MSM。 此外，雖然 MSM 中的 HIV

檢測已恢復至 COVID-19 之前的水平，但其他群體中的檢測則尚未恢復。 到 2030 年，涵蓋 5% 的未

確診愛滋病毒感染者對於阻止愛滋病毒傳播和結束愛滋病及愛滋病毒相關死亡至關重要。2021 年，

英國政府的零愛滋病毒行動計畫建議在關鍵領域轉向選擇性退出之愛滋病毒檢測服務。在愛滋病毒

感染率最高的地區，並撥款 2,000 萬英鎊用於 3 年內進行選擇性退出之檢測。 2022 年 4 月，英國

布萊克浦、布萊頓、倫敦和曼徹斯特等城市的事故和急診部門啟動了選擇性退出之愛滋病毒檢測。

英國愛滋病毒協會 (BHIVA) 4 月份的春季會議上報告了該計畫前 9 個月推出後的結果。

33個事故和急救部門參與了該計畫，其中不僅包括愛滋病毒檢測，還包括B型肝炎病毒和C型肝炎

病毒檢測。 醫院內相關部門會聯繫診斷呈陽性的人，為他們提供照護服務。 在該計畫的前 9 個月

中，57% 的急診科就診者進行了愛滋病毒血液檢測，18% 的患者進行了B型肝炎病毒檢測，24% 的

患者進行了C型肝炎病毒檢測（實施肝炎篩查的地點較少）。 在 HIV 陽性檢測中，282 例為新診斷

（3,664 例陽性結果中的 7·7%），144 例（3·9%）則為失去照護追蹤者，3,238 例（88·4%）為先

前診斷出的患者。 從事照護工作。 220 例 (78%) 新診斷者成功地與照護聯繫起來，54 例 (38%) 失

去照護追蹤的患者則重新參與其中。 對於一個新被診斷出或失去照護追蹤的人，需要檢測的人數為

1,562 人。 根據目前的檢測率估計，到該計劃的前 12 個月結束時，將完成 900,000 次 HIV 檢測，

這與該計畫實施前 於2019 年在英國急診室進行的 114,000 次檢測形成鮮明對比。

第一組結果清楚地顯示，選擇性退出之策略正在發揮作用，可識別出新病例和失去照護追蹤的人

。 然而，這些數字還顯示，並非所有人都接受檢測，這可能是由於人們真的選擇了退出或急診室工

作人員過度勞累而沒有下令進行檢測。 對兩個選擇退出站點的急診科工作人員的調查顯示，需要採

取介入措施來幫助工作人員與患者進行篩查討論，特別是與女性、老年人和黑人進行討論，這些人

都不太可能接受篩查。 此外，所提供的數字顯示，需要採取更多措施將人們與照護體系聯繫起來，

特別是重新參與到照護體系者。

在英國，所有新診斷中有 46% 是晚期診斷（診斷後 91 天內 CD4 計數 < 350 個細胞/μL），晚

期診斷的人在診斷後一年內死亡的可能性高出 13 倍，因此需要更早地確定是那些人勢在必行。 英

國的選擇性退出之測試對於識別那些受到晚期診斷影響尤其嚴重的人特別有效，包括婦女、老年人

和來自非洲黑人社區的人，這些群體都不太可能獲得性健康服務。 此外，選擇性退出之策略為 NHS

節省的長期成本也並非微不足道。 選擇性退出測試的前 100 天給 NHS 帶來了 200 萬英鎊的費用，

但估計至少可以節省 600至800 萬英鎊的照護費用。

在之前的社論中，我們質疑僅在盛行率非常高的地區選擇性地實施此一計畫。 初步結果顯示，

選擇性退出之計畫不僅是一項良好的公共衛生策略，而且具有成本效益。 選擇性退出之方法有助於

消除愛滋病毒檢測的污名並使之正常化，並解決獲得愛滋病毒照護方面的不平等之問題。 選擇性退

出可以在那些認為自己沒有感染愛滋病毒風險的人中發現病例，其中許多人永遠不會尋求性健康服

務。 此外，還有可能讓已經脫離照護體系的人們重新回到照護體系中，了解自己的狀況。 及早發現

愛滋病毒可以節省大量費用，因為晚期愛滋病毒感染者的照護費用要高得多。 在對抗愛滋病毒的鬥

爭中已經取得了如此大的進展，為了讓英國以公平的方式走完最後一哩路，並不讓任何人掉隊，選

擇性退出之愛滋病毒檢測現在應該擴大到愛滋病毒盛行率更高的其他地區，並且也許是所有的急診

部門。 ■ 刺胳針愛滋病毒

 

Opt-out HIV testing in the UK

http://www.thelancet.com/hiv Vol 10 June 2023

 

The UK has made great strides in achieving the UNAIDS 95-95-95 targets: with 95% of people diagnosed,

99% on treatment, and 98% virally suppressed. Although the epidemic is mainly concentrated among men

 

who have sex with men (MSM), in recent years the proportion of new diagnoses among heterosexual

people has surpassed that in MSM. Moreover, while HIV testing has returned to pre-COVID-19 levels

among MSM, testing among other groups has not. Reaching the 5% of people living with HIV who remain

undiagnosed is crucial to stopping HIV transmission and ending AIDS and HIV related deaths by 2030. In

2021, the UK Government’s Zero HIV action plan recommended switching to an opt-out HIV testing service

in key areas with the highest HIV prevalence and allocated £20 million for opt-out testing over 3 years. In

April, 2022, accident and emergency departments in the UK cities of Blackpool, Brighton, London, and

Manchester initiated opt-out HIV testing. The results of the first 9 months’ roll-out of the programme were

reported at the British HIV Association (BHIVA) Spring meeting in April.

33 accident and emergency departments participated in the programme, which includes not only testing

for HIV but also for hepatitis B virus and hepatitis C virus. People with positive diagnoses are contacted by

the relevant department within the hospitals to link them to care. In the first 9 months of the programme,

57% of emergency department attendances with blood tests tested for HIV, 18% for hepatitis B virus, and

24% for hepatitis C virus (fewer sites were implementing hepatitis screening). Of the HIV positive tests, 282

were new diagnoses (7·7% of 3664 positive results), 144 (3·9%) were people who were lost to care, and

3238 (88·4%) were previously diagnosed people who were engaged in care. 220 (78%) of new diagnoses

were successfully linked to care, and 54 (38%) who had been lost to care were reengaged. The number

needed to test was 1.562 for one new diagnosis or person lost to care. Estimates based on the current rate

of testing suggest 900000 HIV tests would be done by the end of the first 12 months of the programme,

and contrasts sharply with the 114000 tests done in emergency departments in England in 2019 before the

programme.

These first set of results clearly show that the opt-out strategy is working , identifying new cases and

people lost to care. However, the numbers also show that not all people are being tested, which may be a

result of people opting out or overworked emergency department staff not ordering the test. Surveys of

emergency department staff at two opt-out sites suggest interventions are needed to help staff with the

screening discussion with patients, in particular with women, older people, and Black people, all of whom

were less likely to get screening. Also, the numbers presented suggest more needs to be done for linking

people to care, particularly re-engagement.

In England, 46% of all new diagnoses are late diagnoses (CD4 count < 350 cells per µL within 91 days of

diagnosis), and people diagnosed late are 13 times more likely to die within a year of their diagnosis, so the

need to identify those people earlier is imperative. Opt-out testing in the UK is particularly effective at

identifying those disproportionately affected by a late diagnosis, including women, older people, and those

from Black African communities, all groups who are less likely to access sexual health services. Also, the

long-term cost savings to the NHS of an opt-out strategy are not insignificant. The first 100 days of opt-out

testing cost £2 million to the NHS but with an estimated minimum saving of £6–8 million in care costs.

In a previous Editorial, we questioned the selective implementation of the opt-out programme just to

areas of very high prevalence. Initial results show that the opt-out programme is not just a good public

health strategy but it is also cost-effective. An opt-out approach helps to destigmatise and normalise HIV

testing and to address inequalities in access to HIV care. Opt-out can find cases among people who would

not consider themselves at risk of acquiring HIV, many of whom would never seek sexual health services.

Also, the potential exists to get people already aware of their status who have disengaged from care back

into the care system. Early detection of HIV early results in significant cost savings since the costs for care

of people who present late with HIV are considerably higher. Having come so far in the fight against HIV,

for the UK to go the last mile in an equitable way that leaves no-one behind, opt-out HIV testing should be

expanded now to other areas in the next tier of HIV prevalence, and perhaps to all emergency

departments. ■ The Lancet HIV