HIV筛查：推荐方案

译者：赵久良 博士

            中国协和医科大学 临床医学专业

            Email：hahozy@gmail.com

审阅者：江伟 博士

               北京协和医院 内科

               Email：edwardjw@163.com

U.S. Preventive Services Task Force*

               This statement summarizes the U.S. Preventive Services Task Force (USPSTF) recommendations on screening for HIV infection and the supporting scientific evidence, and updates the 1996 recommendations on this topic. The complete information on which this statement is based, including evidence tables and references, is included in the summaries of the evidence and evidence syntheses on this topic, available through the USPSTF Web site (www.preventiveservices.ahrq.gov). The recommendation is also posted on the Web site of the National Guideline Clearinghouse (www.guideline.gov).

Ann Intern Med. 2005;143:32-37.   www.annals.org

For author affiliation, see end of text.

美国预防工作组*

        本声明总结了美国预防工作组（USPSTF）关于HIV感染筛查的建议及其科学证据，并更新了1996年关于此专题的建议。依据的全部信息，包括证据表格和参考文献，均涵盖在关于此专题的证据总结和证据综合之中，可通过USPSTF网站（www.preventiveservices.ahrq.gov）获取。本推荐方案同时发布于美国国立指南库网站(www.guideline.gov)。

Ann Intern Med. 2005;143:32-37.  www.annals.org

关于著者简介，请参见文末。 

SUMMARY OF RECOMMENDATIONS

               The U.S. Preventive Services Task Force (USPSTF) strongly recommends that clinicians screen for HIV all adolescents and adults at increased risk for HIV infection (see Clinical Considerations for discussion of risk factors). This is a grade A recommendation. (See Appendix Table 1 for a description of the USPSTF classification of recommendations.) 

               The USPSTF found good evidence that both standard and U.S. Food and Drug Administration (FDA)–approved rapid screening tests accurately detect HIV infection. The USPSTF also found good evidence that appropriately timed interventions, particularly highly active antiretroviral therapy (HAART), lead to improved health outcomes for many of those screened, including reduced risk for clinical progression and reduced mortality. Since false-positive test results are rare, harms associated with HIV screening are minimal. Potential harms of true-positive test results include increased anxiety, labeling, and effects on close relationships. Most adverse events associated with HAART, including metabolic disturbances associated with an increased risk for cardiovascular events, may be ameliorated by changes in regimen or appropriate treatment. The USPSTF concluded that the benefits of screening individuals at increased risk substantially outweigh potential harms. (See Appendix Table 2 for a description of the USPSTF classification of levels of evidence.) 

推荐小结

        美国预防工作组（USPSTF）强烈推荐临床医师应该对HIV感染风险增高的所有青少年和成人进行HIV筛查（关于危险因素的探讨参见临床问题部分）。推荐级别：A。（关于USPSTF推荐分级的说明，请参见附录表1。） 

        USPSTF有良好证据显示标准HIV检测法和美国食品与药品管理局（FDA）批准的快速筛查法均能够准确检出HIV感染。同时USPSTF有良好证据显示适当的择期干预，尤其是高效抗逆转录病毒治疗（HAART），可以改善多数被筛查者的预后，包括疾病进展风险降低和死亡率降低。由于假阳性检测结果非常罕见，因此HIV筛查相关损害极为轻微。真阳性检测结果的潜在损害包括增加焦虑，歧视，以及对于亲密关系者的影响。多数与HAART有关的不良反应，包括代谢紊乱及相关心血管事件风险增加，均可以通过改变治疗方案或采取恰当治疗得到缓解。USPSTF由此推论，对于风险增高个体进行筛查的获益远大于其潜在损害。（关于USPSTF证据等级分级说明，请参见附录表2） 

               The USPSTF makes no recommendation for or against routinely screening for HIV adolescents and adults who are not at increased risk for HIV infection (see Clinical Considerations for discussion of risk factors). This is a grade C recommendation. 

               The USPSTF found fair evidence that screening adolescents and adults not known to be at increased risk for HIV can detect additional individuals with HIV, and good evidence that appropriately timed interventions, especially HAART, lead to improved health outcomes for some of these individuals. However, the yield of screening persons without risk factors would be low, and potential harms associated with screening have been noted (see earlier discussion). The USPSTF concluded that the benefit of screening adolescents and adults without risk factors for HIV is too small relative to potential harms to justify a general recommendation. 

        USPSTF对于HIV风险未增高的青少年和成人是否进行HIV常规筛查并未提出建议（关于危险因素的探讨参见临床问题部分）。推荐级别：C。 

        USPSTF有证据显示对于无明确HIV风险的青少年和成人进行筛查能够进一步检出HIV感染个体，且有良好证据显示适当的择期干预，尤其是HAART，能够改善其中某些个体的预后。然而，对于无危险因素的人群进行筛查的收益较低，且筛查相关的潜在损害显著（参见上述讨论）。USPSTF由此推论，对于无HIV感染危险因素的青少年和成人进行筛查，其获益相对于潜在损害太小，不宜作为一般建议。 

The USPSTF recommends that clinicians screen all pregnant women for HIV. This is a grade A recommendation. 

               The USPSTF found good evidence that both standard and FDA-approved rapid screening tests accurately detect HIV infection in pregnant women and fair evidence that introduction of universal prenatal counseling and voluntary testing increases the proportion of HIV-infected women who receive a diagnosis and are treated before delivery. There is good evidence that recommended regimens of HAART are acceptable to pregnant women and lead to significantly reduced rates of mother-to-child transmission. Early detection of maternal HIV infection also allows for discussion of elective cesarean section and avoidance of breastfeeding, both of which are associated with lower HIV transmission rates. There is no evidence of an increase in fetal anomalies or other fetal harm associated with currently recommended antiretroviral regimens (with the exception of efavirenz; see following discussion). Serious or fatal maternal events are rare using currently recommended combination therapies. The USPSTF concluded that the benefits of screening all pregnant women substantially outweigh potential harms.

        USPSTF建议临床医师应该对所有孕妇进行HIV筛查。推荐级别：A。 

        USPSTF有良好证据显示，对于妊娠妇女，标准HIV筛查法和FDA批准的快速筛查法能够准确检出HIV感染者，有一般证据显示常规产前咨询的和自愿检测的开展增加了HIV感染孕妇中在分娩前明确诊断并接受治疗的比例。有良好证据显示推荐的HAART方案易于孕妇接受，可显著降低母婴传播的发生率。母体HIV感染的早期发现还能有助于讨论择期剖宫产，并避免母乳喂养，二者均能够降低HIV传播的发生率。没有证据显示目前推荐的抗逆转录病毒治疗（依法韦仑除外；参见下文讨论）会增加胎儿畸形或者其他胎儿损害证据。目前推荐的联合疗法发生严重或者致命的母体不良事件罕见。USPSTF由此推论，对于所有妊娠妇女进行HIV筛查的益处远远大于其潜在危害。 

BACKGROUND

               In 1996, the USPSTF recommended routine counseling and screening for all persons at increased risk for HIV infection (a grade A recommendation) and routine counseling and screening for high-risk pregnant women, as well as those residing in communities where the prevalence of seropositive newborns is increased (a grade A recommendation) (1). At that time, the USPSTF found insufficient evidence to recommend for or against routine HIV screening for persons without identified risk factors (a grade C recommendation) and insufficient evidence to recommend for or against universal prenatal screening in low-prevalence communities (a grade C recommendation). Testing infants born to high-risk mothers was recommended when the antibody status of the mother is unknown (a grade B recommendation). Since then, the USPSTF approach to making recommendations has changed (2) and significant new evidence on screening for and treating HIV infection has been published in the medical literature. Therefore, this recommendation statement has been updated and revised on the basis of a new review of the literature, using the current USPSTF methodology. 

背  景

        1996年，USPSTF推荐对于所有HIV感染风险增高的人群开展常规咨询和筛查（推荐级别：A），对于高危妊娠妇女以及在血清阳性新生儿患病率较高的社区居住的妊娠妇女开展常规咨询和筛查（推荐级别：A）（1）。当时USPSTF未获得充分证据来推荐或反对对于无确定危险因素的个体开展常规HIV筛查（推荐级别：C），也未获得充分证据来推荐或反对在低发病率社区中开展常规产前筛查（推荐级别：C）。当HIV高危母亲的抗体状态未知时，推荐对新生儿进行HIV检测（推荐级别：B）。此后，USPSTF制定建议的策略已经改变（2），并且在医学文献中已经发表了大量关于HIV感染筛查和治疗的新证据。因此，这里采用最新USPSTF方法学，根据文献的最新综述，对本推荐方案进行更新和修订。 

CLINICAL CONSIDERATIONS

               A person is considered at increased risk for HIV infection (and thus should be offered HIV testing) if he or she reports 1 or more individual risk factors or receives health care in a high-prevalence or high-risk clinical setting. Individual risk for HIV infection is assessed through a careful patient history. Those at increased risk (as determined by prevalence rates) include men who have had sex with men after 1975; men and women having unprotected sex with multiple partners; past or present injection drug users; men and women who exchange sex for money or drugs or have sex partners who do; individuals whose past or present sex partners were HIV-infected, bisexual, or injection drug users; persons being treated for sexually transmitted diseases (STDs); and persons with a history of blood transfusion between 1978 and 1985. Persons who request an HIV test despite reporting no individual risk factors may also be considered at increased risk, since this group is likely to include individuals not willing to disclose high-risk behaviors. 

临床的考虑

        如果一名患者报告一个或多个独立危险因素，或者在HIV高发病率区或者高风险临床机构接受卫生服务，则被认为HIV感染风险增高（因此必须进行HIV检测）。通过对患者仔细询问病史评估HIV感染的个体风险。风险增高的患者（根据患病率判断）包括：1975年后曾与男性发生性行为的男性；与多个性伴侣有过无保护性行为的男性和女性；既往或目前正在静脉吸毒者；以性行为谋生或换取毒品的男性和女性，以及其性伴侣；既往或者目前的性伴侣为HIV感染者、双性恋或者静脉吸毒者的个体；正在接受性传播疾病（STD）治疗的个体；1978至1985年间有输血史的个体。要求行HIV检验但未报告高危因素的个体也将视为风险增高，因为该组群体中很可能包括不愿意公开高危行为的个体。 

               There is good evidence of increased yield from routine HIV screening of persons who report no individual risk factors but are seen in high-risk or high-prevalence clinical settings. High-risk settings include STD clinics, correctional facilities, homeless shelters, tuberculosis clinics, clinics serving men who have sex with men, and adolescent health clinics with a high prevalence of STDs. High-prevalence settings are defined by the Centers for Disease Control and Prevention (CDC) as those known to have a 1% or greater prevalence of infection among the patient population being served. Where possible, clinicians should consider the prevalence of HIV infection or the risk characteristics of the population they serve in determining an appropriate screening strategy. Data are currently lacking to guide clinical decisions about the optimal frequency of HIV screening. 

        有证据显示在无危险因素但就诊于高HIV患病率的临床机构的个体中进行常规HIV筛查，检出率增加。其中高危机构包括STD诊所、监狱、收容所、结核诊所、男性同性恋诊室和STD高发的青少年健康诊所。根据美国疾病控制和预防中心（CDC）定义，HIV高患病率机构是指所服务人群中HIV感染患病率大于或等于1%的机构。在可能条件下，临床医师应该考虑其所服务的群体中HIV感染的患病率或该群体的风险，以决定恰当的筛查策略。目前缺乏关于HIV最佳筛查频率的数据用以指导临床决策。 

               Current evidence supports the benefit of identifying and treating asymptomatic individuals in immunologically advanced stages of HIV disease (CD4 cell counts <200 cells/mm³ [<0.200×10⁹ cells/L]) with HAART. Appropriate prophylaxis and immunization against certain opportunistic infections have also been shown to be effective interventions for these individuals. Use of HAART can be considered for asymptomatic individuals who are in an earlier stage of disease but are at high risk for disease progression (CD4 cell count <350 cells/mm³ [< 0.350×10⁹ cells/L] or viral load >100 000 copies/mL), although definitive evidence of a significant benefit of starting HAART at these counts is currently lacking. 

        目前证据提示检出无临床症状的HIV晚期（CD4细胞计数<200个/mm³ [<0.200×10⁹/L]）个体并给予HAART方案能够使其获益。已经显示对于这些患者而言，针对某些机会性感染采取适当预防治疗和免疫接种是有效的干预措施。对于处于疾病早期但具有较高疾病进展风险的无症状个体（CD4细胞计数<350/mm³[<0.350×10⁹/L]或病毒负荷>100 000 copy/mL），尽管目前尚缺乏该计数水平下开始HAART方案能够显著获益的明确证据，但仍可考虑应用HAART方案。 

               The standard test for diagnosing HIV infection, the repeatedly reactive enzyme immunoassay followed by confirmatory Western blot or immunofluorescent assay, is highly accurate (sensitivity and specificity, ≥99%). Rapid HIV antibody testing is also highly accurate; can be performed in 10 to 30 minutes; and, when offered at the point of care, is useful for screening high-risk patients who do not receive regular medical care (for example, those seen in emergency departments), as well as women with unknown HIV status who present in active labor. 

        诊断HIV感染的标准检测法，即反复酶免疫分析阳性并经Western印迹法或者免疫荧光测定证实，具有高度准确性（敏感性和特异性均≥99%）。快速HIV抗体检测也具有较高准确性，并且可在10-30分钟内完成，在临床应用中，对于未接受常规医疗服务的高危患者（例如，急诊就诊患者）以及处于分娩状态且HIV感染状态未知的妊娠妇女的筛查很有帮助。 

               Early identification of maternal HIV seropositivity allows early antiretroviral treatment to prevent mother-to-child transmission, allows providers to avoid obstetric practices that may increase the risk for transmission, and allows an opportunity to counsel the mother against breastfeeding (also known to increase the risk for transmission). There is evidence that the adoption of “opt-out” strategies to screen pregnant women (who are informed that an HIV test will be conducted as a standard part of prenatal care unless they decline it) has resulted in higher testing rates. However, ethical and legal concerns of not obtaining specific informed consent for an HIV test using the “opt-out” strategy have been raised. While dramatic reductions in HIV transmission to neonates have been noted as a result of early prenatal detection and treatment, the extent to which detection of HIV infection and intervention during pregnancy may improve long-term maternal outcomes is unclear. 

        早期检出母体血清HIV阳性能够进行早期抗逆转录病毒治疗，以预防母婴传播，同时医师可以避免进行可能增加传播风险的产科操作，同时教育母亲避免母乳喂养（已知这也可能增加传播风险）。有证据显示采用“知情同意”策略对妊娠妇女进行筛查（告知患者HIV检测是产前检查标准程序的一部分，除非其拒绝检查）可提高检测率。但是有人提出采用这种策略进行HIV检测而未获得特定知情同意存在伦理学和法律疑问。已经发现早期产前检测和治疗能够显著降低新生儿HIV感染率，但孕期HIV感染的检测和干预在何种程度上改善母亲长期结局目前尚不明确。 

DISCUSSION

               Of the estimated 850 000 to 950 000 persons in the United States infected with HIV-1, 25% are thought to be unaware of their status (3, 4). If untreated, almost all infected individuals will eventually develop AIDS, defined by opportunistic infection or severe immune dysfunction. Despite significant recent advances in treatment, AIDS is the seventh leading cause of death in persons age 15 to 24 years and the fifth leading cause of death in persons age 25 to 44 years in the United States (5). 

讨  论

        在美国，估计有850 000-950 000人感染HIV-1病毒，其中估计约25%患者并不知情（3，4）。如果未接受治疗，几乎所有感染个体最终将发展为AIDS，即发生机会性感染或者重度免疫功能缺陷。尽管目前治疗手段有显著进展，但是在美国，AIDS仍然是15-24岁人群的第七位致死原因，是25-44岁人群中第五位致死原因（5）。 

               Incidence rates of HIV (an estimated 40 000 new infections annually) have remained steady in the United States over the past decade (6). This figure includes infection through mother-to-child (vertical) transmission, with approximately 300 infants infected each year. Women are the fastest-growing group of persons with new HIV diagnoses, and an estimated 6000 to 7000 HIV-positive women give birth each year in the United States (7, 8). Effective interventions are available to reduce rates of vertical transmission for women diagnosed with HIV infection. However, in 2000, 40% of infected infants were born to mothers not known to have HIV infection before delivery (9). 

        在过去几十年中，美国HIV感染的发病率（估计每年新感染40 000人）保持稳定状态（6）。这一数字包括通过母婴（垂直）传播者，每年大约有300名新生儿感染。女性是新发HIV的人群中增长速度最快的群体，估计美国每年有6000-7000名HIV阳性的妇女分娩（7，8）。对于已诊断HIV感染的妇女，可采取有效干预措施降低垂直传播发生率。然而，2000年，有40%的感染新生儿其母亲在分娩前并未知晓已感染HIV（9）。 

               To update its 1996 recommendations on HIV screening, the USPSTF examined the evidence from 1983 through June 2004 on the benefits and harms of screening and of currently available interventions for HIV infection in adults, adolescents, and pregnant women. Relevant studies on risk factor assessment and the accuracy and acceptability of testing were also reviewed. 

        为了更新1996年关于HIV筛查的建议，USPSTF查阅了1983年至2004年6月间关于成人、青少年和妊娠妇女中HIV筛查和现有干预措施的获益和损害的证据。同时还回顾总结了关于危险因素评估和检测方法准确性和可接受性的相关研究。 

               The USPSTF review found that standard testing for HIV infection has a sensitivity and specificity greater than 99% and that false-positive test results are rare, even in low-risk settings (10, 11). While indeterminate results may occur a little more frequently among parous and pregnant women, the diagnostic accuracy of standard HIV testing is thought to be similar for pregnant women and nonpregnant women and men (12). Alternative FDA-approved screening technologies are also highly accurate and may increase testing acceptability. Compared with standard HIV testing, the reported sensitivities of rapid tests on blood specimens range from 96% to 100%, with specificities greater than 99.9% (13–15). Reported sensitivities and specificities of oral fluid HIV tests are also high (>99%), although the diagnostic accuracy of urine tests appears lower than that of standard testing (16, 17). One good-quality study of the only FDA-approved home collection kit, which uses finger stick blood spot samples, found it to be highly accurate compared with standard testing (18).

        USPSTF回顾发现HIV标准检测法的敏感性和特异性均大于99%，假阳性检查结果罕见，即使在低危机构中亦是如此（10，11）。尽管经产妇和妊娠妇女中出现不确定结果的频率略高，但仍认为标准HIV检测法对于妊娠妇女、非妊娠妇女和男性的诊断准确性相近（12）。其他经FDA批准的筛查技术也具有高度准确性，并可能提高可接受性。与标准HIV检测法相比，血标本快速检测法的敏感性范围为96%-100%，特异性超过99.9%（13-15）。口腔液体HIV检测法的敏感性和特异性同样很高（>99%），而尿液检测法的诊断准确性低于标准检测法（16，17）。一项关于仅FDA批准的家用试剂盒（通过指血采样）的高质量研究结果发现，与标准检测法比较，具有高度准确性（18）。 

               A large, good-quality U.S. study found that risk factor assessment can identify individuals at substantially higher risk for HIV but still misses a significant proportion (20% to 26%) of HIV-positive clients who report no risk factors (19) (since some patients may choose not to disclose high risk behaviors and others, especially women, may be unknowingly at risk from an infected sex partner) (20). There is fair evidence to indicate that a broader strategy targeted to individuals who report risk factors, combined with routine (voluntary) testing of those being seen in high-prevalence clinical settings, would result in substantially fewer missed diagnoses (21–23). In 2 good-quality studies, HIV screening of populations with a 1% prevalence rate was found to be cost-effective (in terms of acceptable cost per quality-adjusted life-year) compared with no screening (24, 25). One study (25) found that screening populations with even lower prevalence rates is also cost-effective if one assumes secondary transmission benefits. Neither study, however, reported on the incremental cost-effectiveness of screening lower-risk versus higher-risk patients. 

        一项在美国开展的大规模研究发现，危险因素评估能够识别具有明显较高HIV感染风险的个体，但是仍会遗漏一定比例（20%-26%）的声称无危险因素的个体（19）（因为某些患者会选择不透露其高危行为和其他因素，尤其是女性，可能并不了解性伴侣的感染状态）（20）。有证据提示采用更广泛的策略，以报告危险因素的个体为主，结合在高患病率临床机构就诊患者中的常规（自愿）检测，将显著减少漏诊（21-23）。两项高质量的研究发现，在患病率为1%的群体中进行HIV筛查与不筛查相比，是经济的（根据获得每个质量调整生命年的成本）（24，25）。一项研究（25）发现，如果考虑再次传播的风险，那么即使人群患病率更低，筛查仍是经济的。但是这两项研究都没有报道筛查低危患者相对于高危患者的成本增加。 

               The wide adoption in 1995 to 1997 of the use of HAART regimens with 3 or more antiretroviral agents has been associated with a marked decline in morbidity and mortality of HIV-infected patients in the United States (3). Good-quality evidence has shown HAART regimens to be consistently effective in reducing clinical progression and mortality in persons with CD4 cell counts less than 200 cells/mm³ (<0.200×10⁹ cells/L) (26, 27); the percentage of patients found in studies to be candidates for HAART regimens at the time of HIV diagnosis has ranged from 12% to 43% (20, 28). In addition, 2 good-quality systematic reviews found that the use of antibiotic medication to prevent opportunistic infections (for example, Pneumocystis carinii pneumonia and disseminated Mycobacterium avium–intracellulare complex) is effective in persons with advanced disease (29, 30). Theoretically, asymptomatic patients in an earlier stage of disease at the time of diagnosis (CD4 cell counts between 200 to 350 cells/mm3 [0.200 to 0.350×10⁹ cells/L] or viral load >100 000 copies/mL) may also benefit from HAART regimens. However, there are no completed trials showing clinical benefit from treatment versus no treatment in such patients. Data from the Strategies for Management of Anti-Retroviral Therapy (SMART) trial, which focuses on this group, will not be available for a few more years. 

        1995-1997年，随着含3种或者更多种抗逆转录病毒药物的HAART方案的广泛应用，美国HIV感染患者的发病率和死亡率均显著降低（3）。高质量的证据显示在CD4细胞计数小于200/mm³（<0.200×10⁹/L）的患者中，HAART方案能够持续有效地减少疾病进展并降低死亡率（26，27）；研究中诊断HIV时适于应用HAART方案的患者百分比约为12%至43%（20，28）。除此之外，两项高质量系统回顾发现晚期疾病患者使用抗生素类药物可有效预防机会性感染（例如卡氏肺孢子虫肺炎和播散性鸟-分枝杆菌胞内复合体）（29，30）。理论上，诊断时处于疾病早期的无症状患者（CD4细胞计数200-350/mm³[0.200-0.350×10⁹ /L]）应用HARRT方案也可能获益。然而，目前没有完整的临床试验显示对于该类患者给予治疗相对于不治疗是否有临床获益。抗逆转录病毒疗法治疗策略（SMART）临床试验主要针对该类人群，其数据将在数年后公布。 

               The standard of care in the United States for preventing vertical HIV transmission in seropositive pregnant women has evolved from monotherapy (zidovudine) to combination antiretroviral regimens, including HAART regimens, starting at 14 to 34 weeks’ gestation through labor and augmented with 6 weeks of neonatal prophylaxis with zidovudine (31). Avoidance of breastfeeding is recommended for seropositive women since observational studies have shown that breastfeeding increases transmission rates even when adjusted for other factors, including antiretroviral use. A good-quality randomized clinical trial has demonstrated that elective cesarean section also reduces vertical transmission, compared with other modes of delivery, by minimizing contact between the fetus and infected maternal body fluids (32), although the benefit appears small in women with undetectable viral loads. There is fair to good evidence that the newer regimens, in combination with formula feeding and elective cesarean delivery, are associated with reductions in perinatal transmission ranging from 14% to 25% without interventions to 1% to 2% with interventions. 

        美国血清阳性妊娠妇女预防HIV垂直传播的标准治疗已经从单一治疗（齐多夫定）发展为联合抗逆转录病毒治疗，包括HAART方案，从妊娠第14-34周开始直至分娩，并增加新生儿预防性应用齐多夫定6周（31）。由于观察性研究发现即使校正其他因素，包括应用抗逆转录病毒药物在内，血清阳性妇女的母乳喂养仍然会增加传播率，因而建议血清阳性妇女避免母乳喂养。一项随机临床试验证实，择期剖宫产与其他分娩方式相比，通过尽可能减少胎儿和感染母亲体液接触的方法（32），也可以减少垂直传播，虽然对于病毒负荷低于检测水平的妇女似乎获益很小。还有证据显示新治疗方案，联合配方乳喂养和择期剖宫产，可使围产期传播发生率从未干预的14%-25%降至干预后的1%-2%。 

               Information about the consequences of false-positive HIV test results (for example, anxiety and labeling) is mostly anecdotal, although true-positive HIV test results have been shown to result in anxiety, depression, social stigmatization, changes in relationships with sexual partners, and discrimination (33). Evidence suggests that persons testing positive for HIV (especially heterosexual sero-discordant couples) are more likely than others to avoid risky sexual behavior. On the other hand, optimistic beliefs about the effectiveness of HAART regimens have been shown to be associated with increased risky behaviors in individuals known to be seropositive (34, 35). All antiretroviral drugs and drug combinations are associated with specific harm profiles, although most harms are short term or self-limited and effective alternatives can often be found (36). Metabolic disturbances (hyperlipidemia and diabetes) related to HAART regimens have been associated with an increased incidence of cardiovascular events, especially with longer exposure (37). The estimated 3-year benefits of HAART regimens appear, however, to greatly outweigh the cardiovascular complications. 

        HIV检测真阳性结果会导致焦虑、抑郁、社会耻辱感、与性伴侣的关系改变以及歧视等（33）。关于HIV检测假阳性后果（例如焦虑和歧视）的报道很少而且零散。有证据显示HIV检测阳性患者（尤其是血清结果不同的异性夫妻）与其他患者相比，更倾向于避免有风险的性行为。另一方面，已知血清阳性个体对于HAART方案有效性的过于乐观的看法反而增加高风险行为（34，35）。所有抗逆转录病毒药物和联合药物都具有相应的副作用，尽管大部分损害是短期的或者自限性的，并且往往能够找到有效替换物（36）。HAART方案相关代谢紊乱（高脂血症和糖尿病）会导致心血管事件发生率增加，尤其在长期暴露的情况下（37）。但是HAART方案的预期3年获益明显大于心血管并发症的潜在危害。 

               No significant increases in the rates of congenital anomalies, neonatal conditions, or other fetal harm have been associated with in utero exposure to FDA-approved regimens of antiretroviral drugs (38), with the exception of those including efavirenz. Efavirenz has recently been reclassified as Class D in pregnancy (positive evidence of human fetal risk). Although studies have demonstrated no ill effects of limited exposure to zidovudine monotherapy in women followed postpartum for as long as 6 years, no studies have evaluated the effects of limited exposure to combination antiretroviral drugs during pregnancy on the long-term clinical outcomes of HIV-infected women. 

        除了含依法韦仑的方案外，所有FDA批准的抗逆转录病毒药物方案（38）的宫内暴露，均不会显著增加先天畸形、新生儿疾病或者其他胎儿损害的发生率。最近依法韦仑被重新定级为妊娠D级（具有人类胎儿风险的阳性证据）。尽管试验证实接受齐多夫定单一治疗的妇女产后长达6年内无不良后果，但是目前尚没有研究评价妊娠期间使用抗逆转录病毒药物联合治疗对HIV感染妇女长期影响。 

RECOMMENDATIONS OF OTHER GROUPS

               Counseling and HIV testing of high-risk individuals (as defined in the Clinical Considerations section) are recommended by the CDC (39), the Canadian Task Force on the Periodic Health Examination (now the Canadian Task Force on Preventive Health Care) (40), and numerous professional organizations, including the American Medical Association (AMA) (41), the American Academy of Family Physicians (AAFP) (42), the American College of Obstetricians and Gynecologists (ACOG) (43), the American College of Physicians (ACP) (44), and the Infectious Diseases Society of America (IDSA) (45). Also, the American Academy of Pediatrics (AAP) (46) considers all sexually active adolescents to be a high-risk group and recommends they be counseled and offered HIV testing. In addition, the CDC recommends that routine, voluntary testing be offered to all patients seen either in health care facilities where the prevalence of HIV infection is 1% or greater or in settings serving client populations at increased behavioral or clinical HIV risk. 

其他工作小组的建议

        美国CDC（39）、加拿大定期体检工作组（现为加拿大预防卫生服务工作组）（40）和众多专业组织，包括美国医学会（AMA）（41）、美国家庭医师学会（AAFP）（42）、美国妇产科医师学会（ACOG）（43）、美国医师协会（ACP）（44）和美国传染病学会（IDSA）（45）等均推荐对高危个体（定义见临床问题章节）提供咨询服务和HIV检测。同时，美国儿科学会（AAP）（46）认为所有性行为活跃的青少年均为高危人群，推荐对该人群提供咨询服务和HIV检测。除此之外，美国CDC建议向所有就诊于HIV感染患病率达到或高于1%的医疗卫生机构或者所服务人群具有较高行为或临床HIV风险的机构的患者提供常规、自愿HIV检测。 

               The CDC, AMA, AAFP, ACOG, IDSA, AAP (47), and the American College of Nurse-Midwives (48) recommend that all pregnant women be routinely counseled and encouraged to have HIV testing. The ACOG, AAP, and the CDC go further in recommending that HIV testing be part of a routine battery of prenatal blood tests unless declined (that is, an “opt-out” approach). The CDC and ACOG also recommend retesting in the third trimester women who are known to be at high risk for HIV, as well as rapid HIV testing in labor for women with undocumented HIV status. 

        美国CDC、AMA、AAFP、ACOG、IDSA、AAP（47）以及美国护士助产士学会（48）均推荐所有妊娠妇女接受常规咨询，并鼓励其进行HIV检测。ACOG、AAP和CDC进一步建议HIV检测应当成为产前血液检验的常规项目，除非患者表示拒绝（即“知情同意”策略）。CDC和ACOG还推荐已知具有HIV高风险的妇女在妊娠晚期应再次进行HIV检测，同时对于HIV状态未知的妇女在临产前应进行快速HIV检测。 

APPENDIX

               Members of the U.S. Preventive Services Task Force are Alfred O. Berg, MD, MPH, Chair (University of Washington, Seattle, Washington); Janet D. Allan, PhD, RN, CS, Vice-Chair (University of Maryland, Baltimore, Baltimore, Maryland); Ned Calonge, MD, MPH (Colorado Department of Public Health and Environment, Denver, Colorado); Paul S. Frame, MD (Tri-County Family Medicine, Cohocton, and University of Rochester, Rochester, New York); Joxel Garcia, MD, MBA (Pan American Health Organization, Washington, DC); Leon Gordis, MD, MPH, DrPH (Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland); Russell Harris, MD, MPH (University of North Carolina School of Medicine, Chapel Hill, North Carolina); Mark S. Johnson, MD, MPH (University of Medicine and Dentistry of New Jersey–New Jersey Medical School, Newark, New Jersey); Jonathan D. Klein, MD, MPH (University of Rochester School of Medicine, Rochester, New York); Carol Loveland-Cherry, PhD, RN (University of Michigan School of Nursing, Ann Arbor, Michigan); Virginia A. Moyer, MD, MPH (University of Texas Health Science Center, Houston, Texas); Judith K. Ockene, PhD (University of Massachusetts Medical School, Worcester, Massachusetts); C. Tracy Orleans, PhD (The Robert Wood Johnson Foundation, Princeton, New Jersey); Albert L. Siu, MD, MSPH (Mount Sinai Medical Center, New York, New York); Steven M. Teutsch, MD, MPH (Merck & Co., Inc., West Point, Pennsylvania); and Carolyn Westhoff, MD, MSc (Columbia University, New York, New York). 

               This list includes members of the Task Force at the time these recommendations were finalized. For a list of current Task Force members, go to www.ahrq.gov/clinic/uspstfab.htm. 

               From the U.S. Preventive Services Task Force, Agency for Healthcare Research and Quality, Rockville, Maryland. 

Disclaimer: Recommendations made by the USPSTF are independent of the U.S. government. They should not be construed as an official position of the Agency for Healthcare Research and Quality or the U.S. Department of Health and Human Services. 

Requests for Single Reprints: Reprints are available from the USPSTF Web site (www.preventiveservices.ahrq.gov) and in print through the Agency for Healthcare Research and Quality Publications Clearinghouse (800-358-9295).

Appendix Table 1. U.S. Preventive Services Task Force Recommendations and Ratings* 

* The U.S. Preventive Services Task Force (USPSTF) grades its recommendations according to one of five classifications (A, B, C, D, I) reflecting the strength of evidence and magnitude of net benefit (benefits minus harms).

 附录表1. USPSTF推荐等级划分*

*美国特别预防特别工作组（USPSTF）将建议分为5个等级（A，B，C，D，I），用以反映证据强度和实际获益程度（获益减去损害）。

Appendix Table 2. U.S. Preventive Services Task Force Grades for Strength of Overall Evidence*

* The U.S. Preventive Services Task Force (USPSTF) grades the quality of the overall evidence for a service on a three-point scale (good, fair, poor).

 附录表2：美国预防工作组整体证据强度分级*

*美国预防工作组（USPSTF）将整体证据质量分级为三等（良好，一般，较差）。

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