西班牙急診室進行有針對性的愛滋病毒檢測

資料來源：www.thelancet.com/hiv Vol 10 September 2023

《剌胳針 HIV》6 月號發表的一篇社論強調了英國 33 個急診科的選擇性退出 HIV 檢測策略。根據 9 個月內進行的 665 ,746 次檢測得出 282 例新診斷。據稱該策略具有成本效益，但 0·04% 的 HIV 陽性率低於公認的0·1% 成本效益臨界值。

與聯合國愛滋病規劃署的95-95-95 目標相比，西班牙的數字為87-97-97。為了減少未確診的愛滋病毒感染者數量，西班牙急診醫學學會 (SEMES) 得到了西班牙傳染病和臨床微生物學學會的認可在吉利德科學公司的支持下，開始制定一項有針對性的選擇性加入愛滋病毒檢測策略 (targeted opt-in HIV testing strategy)，該策略將在西班牙急診室實施。 該策略包括要求所有符合以下六項標準之一的急診科就診者進行HIV 檢測（這些標准在急診科常見，且與HIV 高盛行率相關）：性傳播感染、帶狀皰疹（在18 歲至65 歲的個人中）、社區獲得性肺炎（18-65 歲的個體）、單核細胞增多症、參與藥愛性行為或要求暴露後預防。

在急診科實施這些建議是 SEMES 的首要任務，該機構正在透過名為 Deja tu huella（留下你的印記）的計畫為急診科開發結構化培訓。 該計畫已在西班牙121個急診室實施，2021年至2022年期間已進行了66 ,813次愛滋病毒檢測。這些檢測導致新診斷出901例愛滋病毒，愛滋病毒檢出率為1·35%。 對我們數據的分析顯示，HIV 檢測數量增加了四倍，並且我們列出的六項標準的 HIV 檢出率大於 0·1%。 2022 年的一項經濟研究顯示，實施 SEMES 建議需要在未來 20 年內投資 2000 萬歐元，但可能會節省 44.11億歐元。

愛滋病毒檢測需要明確同意，這是在西班牙實施普遍選擇退出檢測策略的一個重要障礙。 此外，對250 個西班牙急診部門負責人進行的一項調查顯示，他們不願意實施普遍的愛滋病毒篩查策略。 SEMES (the Spanish Emergency Medicine Society) 選擇了有針對性的選擇性加入策略，與選擇恬退出策略相比，因為這可能更有效、更具成本效益，並且得到了急診室專業人員更高的贊同。急診室的愛滋病毒檢測對於提高尚不知道自己血清陽性的新愛滋病毒感染之個人的檢測率至關重要。因此，應廣泛推廣急診科的愛滋病毒檢測，並採取適合不同情況的策略。吉利德支持西班牙急診醫學協會開發 Deja tu huella。 然而，吉利德在這篇手稿的撰寫中沒有發揮任何作用；作者們沒有得到任何補償。

我們聲明不存在競爭利益。

*Juan González-Del Castillo, Òscar Miró, Manuel Vázquez Lima  infurg@gruposemes.org

西班牙急診醫學會傳染病組，馬德里 28006，西班牙 (JG-DC)； 西班牙馬德里聖卡洛斯診所醫院急診科 (JG-DC)； 西班牙巴塞羅那大學 IDIBAPS 醫院診所急診科（ÒM）； 西班牙急診醫學協會，西班牙馬德里（MVL）； 西班牙比拉加西亞德奧薩薩爾內斯醫院急診科 (MVL)

Targeted HIV testing in Spanish emergency departments

www.thelancet.com/hiv Vol 10 September 2023

An Editorial published in the June issue of The Lancet HIV highlights an opt-out HIV testing strategy in 33 emergency departments in the UK.1 282 new diagnoses were made based on 665 746 tests done over a 9 month period. It is claimed the strategy is cost-effective but the 0·04% positive rate for HIV is below the accepted 0·1% cutoff for cost-effectiveness.2

Compared with the UNAIDS 95-95-95 targets, Spain has figures of 87-97-97. To reduce the number of undiagnosed people with HIV, the Spanish Emergency Medicine Society (SEMES), endorsed by the Spanish Society of Infectious Diseases and Clinical Microbiology and with the support of Gilead Sciences, began to work on a targeted opt-in HIV testing strategy to be implemented in Spanish emergency departments. The strategy comprised requesting an HIV test for all emergency department attendees who had any of the following six criteria (which are frequently seen in the emergency department and are associated with high HIV prevalence): sexually transmitted infections, herpes zoster (in individuals aged 18–65 years), community-acquired pneumonia (in individuals aged 18–65 years), mononucleosis, chemsex participation, or request for postexposure prophylaxis.4

I m p l e m e n t a t i o n  o f  t h e s e recommendations in emergency departments is a priority for SEMES, which is developing structured training for emergency departments through a programme called Deja tu huella (Leave your mark). The programme has been implemented in 121 Spanish emergency departments, which have done 66 813 HIV tests during 2021 and 2022. The tests have resulted in 901 new diagnoses of HIV, which is a 1·35% HIV detection rate. Analyses of our data show a four times increase in the number of HIV tests done, and that the six criteria we listed have obtained rates of HIV detection greater than 0·1%. An economic study from 2022 showed that the implementation of SEMES recommendations requires an investment of €20 million over the next 20 years, but would result in potential savings of €4·411 billion.

The requirement for explicit consent for HIV testing is an important barrier to implementing a universal strategy of opt-out testing in Spain. Moreover, a survey done among the heads of 250 Spanish emergency departments showed reluctance towards implementation of a universal HIV screening strategy. SEMES selected a targeted opt-in strategy, as this could be more effective, costefficient, and have a higher approval by emergency department professionals compared with the opt-out strategy. HIV testing in emergency departments is key to increasing detection of new HIV infections in individuals who are unaware of their seropositivity. Therefore, HIV testing in emergency departments should be widely promoted, with strategies adapted to different settings. Gilead supports the Spanish Emergency Medicine Society in the development of Deja tu huella. However,Gilead did not have any role in writing of this manuscript; the authors did not receive any compensation.

We declare no competing interests.

*Juan González-Del Castillo, Òscar Miró, Manuel Vázquez Lima infurg@gruposemes.org

Infectious Diseases Group of Spanish Emergency Medicine Society, Madrid 28006, Spain (JG-DC); Emergency Department, Instituto de Investigación Sanitaria, Hospital Clínico San Carlos, Madrid, Spain (JG-DC); Emergency Department, Hospital Clínic, IDIBAPS, Universitat de Barcelona, Barcelona, Spain (ÒM); Spanish Emergency Medicine Society, Madrid, Spain (MVL); Emergency Department, Hospital do Salnes, Vilagarcía de Aousa, Spain (MVL)