為最後階段提高 HIV 檢測水平

資料來源：http://www.thelancet.com/hiv 2022 年 5 月 9 日 / 財團法人台灣紅絲帶基金會編譯

  英國在結束愛滋病作為公共衛生威脅方面邁出了令人難以置信的步伐，成為世界上首批實現聯合國愛滋病規劃署 95-95-95 目標的國家之一。 2020 年，英格蘭愛滋病毒委員會建議，為了在 2030 年結束愛滋病/愛滋病毒相關死亡並在阻止愛滋病毒傳播方面走完最後一英里，應在整個衛生服務部門實施「選擇性退出檢測」(opt-out testing ，註 )。 2021 年 12 月，英國政府制定了零愛滋病毒行動計畫，以響應愛滋病毒委員會，其中包括承諾支持在事故和急診部門選擇性退出愛滋病毒檢測。令人欣慰的是，從 4 月 1 日起，布萊頓、倫敦和曼徹斯特的急診科現在提供選擇性退出 HIV 檢測。但是，選擇性和零散的實施就足夠了嗎？特別是對於一個已當選的政府，部分原因是承諾在全國範圍內應提供平等的機會和服務，這在政界被稱為升級。

  到 2020 年，英國估計有 106,890 名愛滋病毒感染者：其中 95% 知道自己的狀況，99% 正在接受治療，97% 有病毒抑制。 2014 年至 2019 年間，新增感染人數從 6,312 人降至 4,139 人。但進展並不相同。在英格蘭，男男性行為者的新診斷人數從 2019 年的 1,500 人減少到 2020 年的 890 人，減少了 41%，而可能透過異性性行為感染愛滋病毒的人從 1,320 人減少了 23% 至 1,010 人。 2020 年的數據可能會受到 SARS-CoV-2 大流行封鎖的影響，但從 2019 年到 2020 年，男男性行為者的 HIV 檢測僅下降了 7%，而異性戀者的檢測下降了 33%，這顯示影響更大異性戀者的診斷漏檢和減少男男性行為者之間傳播的更大影響。在這兩個群體中，非洲黑人和亞洲人也不太可能獲得檢測服務。

  在 2020 年英國的 106,890 名愛滋病毒感染者中，估計有 5,150 人不知道自己的愛滋病毒陽性狀況。此外，42% 的診斷為晚期（CD4 計數＜350 個細胞/µL）；這一比例高於 2019 年的 40% 和 2016 年的 35%。晚期診斷比例的增加部分與新診斷總數的下降有關；儘管如此，根據定義，未確診的愛滋病毒感染者很難與檢測服務建立聯繫。顯然，迫切需要解決特定人群中 HIV 診斷不足的問題，並降低導致持續傳播的晚期診斷比例。在 COVID-19 大流行期間與減少測試相關的挫折更加劇了這種需求。

  由 Terrence Higgins Trust、National AIDS Trust 和 Elton John AIDS Foundation 支持的獨立進程英格蘭 HIV 委員會提出了到 2030 年在英格蘭結束傳播和 HIV 導致的死亡的簡明建議。其中一項關鍵建議是愛滋病毒檢測應成為選擇性退出，這將有助於使愛滋病毒檢測正常化並識別未確診的病例。根據這一建議，英國政府的行動計畫撥款 2,000 萬英鎊用於提供選擇性退出測試。但僅限於流行率最高的關鍵地區。

然而，在當前推出中被忽視的其他領域的地方當局和議會代表已要求政府提供資金，以便在事故和急診部門引入選擇性退出之愛滋病毒檢測。貝德福德、伯明翰、布萊克浦、布里斯托爾、伯里、考文垂、利茲、萊斯特、米爾頓凱恩斯、諾丁漢、雷丁和特拉福德等地區的代表都表示，他們將從實施該方法中受益。鑑於預計生活在倫敦以外的未確診 HIV 感染者（3,000 人）幾乎是倫敦（1,650 人）的兩倍，因此對少數地區的關注似乎確實值得懷疑。如果 2,000 萬英鎊可以資助在英格蘭的大都市地區進行測試，那麼在全國的主要設施中引入選擇性退出測試肯定是具有成本效益的。

  鑑於英國迄今取得的成功，到 2030 年結束愛滋病和愛滋病毒相關死亡並阻止愛滋病毒在英國傳播的目標應該是可以實現的。然而，在任何探索中，最後的階段往往是最艱難的，而實現這些目標的關鍵步驟之一將是幫助生活在英國的 5,000 多名未確診的愛滋病毒感染者。短期成本應將選擇性退出測試擴展到每一個合理的健康互動中，而長期收益則太大更不容忽視。英國政府應滿足 HIV 委員會的建議，並在全國範圍內的衛生服務中提供選擇性退出檢測。 ■ 刺胳針愛滋病毒

註：選擇性退出檢測 (opt-out testing) ：選擇性退出 HIV 檢測，有時也稱為普遍篩查，定義為在通知受檢者將進行檢測並且他們可以拒絕或推遲檢測後，若受檢者無表達拒絕之意思便進行 HIV 檢測。

Levelling up HIV testing for the endgame

http://www.thelancet.com/hiv Vol 9 May 2022

  The UK has made incredible steps towards ending AIDS as a public health threat, being one of the first countries in the world to achieve UNAIDS 95-95-95 targets. In 2020, the HIV Commission for England recommended that to go the final mile in ending AIDS and HIV-related deaths and stopping HIV transmission by 2030, opt-out testing should be implemented across the health service. And in December, 2021, the UK Government set out its Zero HIV Action plan, in response to the HIV Commission, which included a commitment to supporting opt-out HIV testing in accident and emergency departments. It is welcome news that from April 1, emergency departments in Brighton, London, and Manchester are now providing opt-out HIV testing. But is the selective and patchy implementation enough? Particularly for a government elected, in part, on a promise to provide equality of opportunity and services across the nation, referred to in political circles as levelling up. 

  The UK had an estimated 106890 people living with HIV in 2020: of whom 95% knew their status, 99% were receiving treatment, and 97% had viral suppression. Between 2014 and 2019, new infections fell from 6312 to 4139. But the progress is not equal. In England, new diagnoses among men who have sex with men decreased by 41% from 1500 in 2019 to 890 in 2020 compared with a decline of 23% from 1320 to 1010 among people who probably acquired HIV through heterosexual sex. Data for 2020 are likely to be affected by SARS-CoV-2 pandemic lockdowns, but while HIV testing declined from 2019 to 2020 by only 7% in men who have sex with men, among heterosexual people testing declined 33%, suggesting a greater effect of missed testing on diagnosis among heterosexual people and a greater effect of reduced transmission among men who have sex with men. Among both groups, Black African people and Asian people are also less likely to access testing services.

  Among the 106890 people with HIV in the UK in 2020, an estimated 5150 did not know their HIV-positive status. Moreover, 42% of diagnoses are late (CD4 count＜350 cells per µL); and this proportion is up from 40% in 2019, and 35% in 2016. The increase in proportion with late diagnosis is, in part, related to a decline in the overall number of new diagnoses; nonetheless, people with undiagnosed HIV by definition struggle to connect withtesting services. An urgent need clearly exists to tackle HIV underdiagnosis among specific demographic groups and to reduce the proportion of late diagnosis, which fuels ongoing transmission. This need is intensified by the setbacks associated with decreased testing during the COVID-19 pandemic.

   The HIV Commission for England, an independent process supported by Terrence Higgins Trust, National AIDS Trust, and Elton John AIDS Foundation, made clear and concise recommendations to end transmissions and HIV-attributed deaths in England by 2030. One of the key recommendations was that HIV testing should become opt-out, which would help to normalise HIV testing and to identify undiagnosed cases. In line with this recommendation, the UK Government’s Action Plan earmarked £20 million to provide opt-out testing. But only in key areas with the highest prevalences.

  However, local authority and parliamentary representatives of other areas overlooked in the current rollout have asked for government funding to introduce opt-out testing for HIV in accident and emergency departments. Representatives of areas including Bedford, Birmingham, Blackpool, Bristol, Bury, Coventry, Leeds, Leicester, Milton Keynes, Nottingham, Reading, and Trafford have all said that they would benefit from implementing the approach. Given that nearly twice as many people with undiagnosed HIV infection are predicted to live outside of London (3000) compared with in London (1650), the focus on a few areas does seem questionable. If £20 million can fund testing in large metropolitan areas in England, surely it would be cost-effective to introduce opt-out testing in key facilities across the country.

  Given the UK’s successes so far, the goals to end AIDS and HIV-related deaths and to stop HIV transmission in England by 2030 should be achievable. However, in any quest, the final stretch is often the hardest, and one of the key steps on the path to achieving these goals will be reaching the more than 5000 people living in the UK with undiagnosed HIV. For a short-term cost to expand opt-out testing to every reasonable health interaction, the long-term gains are too great to be overlooked. The UK Government should meet the HIV Commission’s recommendation and make opt-out testing possible in health services nationwide. ■ The Lancet HIV