Routine antenatal HIV testing
Routine antenatal HIV testing
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常规产前艾滋病毒检测
DOI：
10.1136/bmj.319.7216.1069
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发表时间：
1999
期刊：
影响因子：
--
通讯作者：
V. Harindra
中科院分区：
文献类型：
--
作者：
E. Foley;V. Harindra
编辑-Postma等人和Simpson等人最近的论文强调了在产前诊所建立HIV感染检测政策的困难问题。
Postma等人的论文研究了英国孕妇普遍自愿检测的成本效益，即NHS的医疗保健成本。虽然英国没有界定每增加一个生命年的成本可以接受的分界点，但美国建议的分界点约为50 000美元。他们的结论是，在高流行率的地区，如伦敦，普遍的，自愿的孕妇产前筛查是成本效益高的;然而，在低流行率的地区，筛查可能不是合理的成本效益。
在产前诊所进行的艾滋病毒感染筛查符合Wilson和Junger作为良好检测的大部分标准。3艾滋病毒感染可以是无症状的;检测简单、相对无痛、敏感和特异;有有效的治疗方法可以大大降低胎儿感染的风险。然而，大多数产前诊所没有进行普遍检测。这与大多数产前诊所普遍采用的唐氏综合征筛查的特殊方式形成了鲜明对比，但目前可用的单个测试中没有一个符合Wilson和Junger的许多标准。对胎儿风险低的测试不是很敏感或特异。尽管这些检测的记录未经证实，但它们是可用的，有时病人承担检测费用。
艾滋病毒检测存在耻辱感;选择加入的政策只会加强这种耻辱感，因为它只检测那些明显属于高风险群体的人。在低流行率地区，没有大量“高危”妇女，艾滋病毒感染者可能更难通过筛查问卷发现，因为她们与其他人口混在一起。在朴茨茅斯，我们三分之一的艾滋病毒阳性患者不属于任何公认的高风险群体。Simpson等人的论文表明，对于一个有效的筛查计划，选择退出检测政策是产前筛查中唯一有效的模式;检测的使用率增加到88%，而选择加入政策的使用率为35%。这项政策不仅适用于艾滋病毒检测流行率高的地区，而且适用于艾滋病毒感染流行率低的地区，以便不错过减少新生儿感染和治疗无症状母亲的机会。
Editor—The recent papers by Postma et al and Simpson et al highlight the difficult issues in establishing a policy to test for HIV infection in antenatal clinics.1,2
Postma et al’s paper examines the cost effectiveness of universal, voluntary testing of pregnant women in England in terms of healthcare costs to the NHS. Although no cut off point at which the cost for each life year gained becomes acceptable has been defined for England, a cut off point of around $50 000 is suggested in the United States. They conclude that in areas of high prevalence, such as London, universal, voluntary antenatal screening of pregnant women is cost effective; how- ever, in areas of low prevalence, screening may not be justified in terms of cost effectiveness.
Screening for HIV infection in antenatal clinics fulfils most of Wilson and Junger’s criteria as a good test.3 HIV infection can be asymptomatic; the tests are simple, relatively pain free, sensitive and specific; and there is effective treatment that can substantially reduce the risk of infection in the fetus. Yet universal testing is not performed in most antenatal clinics. This contrasts with the ad hoc way in which universal screening for Down’s syndrome has been introduced in most antenatal clinics—yet none of the individual tests currently available fulfil many of Wilson and Junger’s criteria. Tests which are of low risk to the fetus are not very sensitive or specific. In spite of their unproved record, tests are available, sometimes with the patient bearing the cost of testing.
There is stigma surrounding HIV testing; an opt-in policy serves only to reinforce this by testing only those in obvious high risk groups. In low prevalence areas, where there are not large numbers of “high risk” women, those with HIV infection may be even harder to detect from a screening questionnaire as they mingle with the rest of the population. In Portsmouth a third of our HIV positive patients do not fall into any recognised high risk group. Simpson et al’s paper shows that for an effective screening programme to be instigated, an opt-out policy of testing is the only model which is effective in antenatal screening; the uptake of the test increased to 88% compared with a 35% uptake with an opt-in policy. This policy should be adopted not only for areas of high prevalence of HIV testing but also for areas where the prevalence of HIV infection is low, so that the opportunity to reduce infection in the neonate and treat the asymptomatic mother is not missed.