妊娠期 HIV 感染

所有 HIV 阴性的孕妇在每一次妊娠时，都应尽早接受检测。建议在可能的暴露后 6 周、3 个月以及 6 个月时接受重复检测。对于已知有感染 HIV 风险而初始检测结果为阴性的孕妇，建议在孕晚期进行重复检测，这些孕妇包括在孕产妇 HIV 感染年发病率超过 1/1000 的医疗机构接受卫生保健的孕妇、入狱的孕妇、所居住司法管辖区 HIV 发病率升高的孕妇、或者居住在需要进行妊娠晚期检测地区的孕妇。[6]The Panel on Treatment of Pregnant Women with HIV Infection and Prevention of Perinatal Transmission, US Department of Health and Human Services. Recommendations for the use of antiretroviral drugs in pregnant women with HIV infection and interventions to reduce perinatal HIV transmission in the United States. December 2018 [internet publication].https://aidsinfo.nih.gov/guidelines/html/3/perinatal/0

初始检测应为第四代抗原/抗体组合 ELISA，以检测 HIV-1 和 HIV-2 抗体以及 HIV-1 p24 抗原。该试验用于筛查确定的 HIV-1 或 HIV-2 感染以及急性 HIV-1 感染。[6]The Panel on Treatment of Pregnant Women with HIV Infection and Prevention of Perinatal Transmission, US Department of Health and Human Services. Recommendations for the use of antiretroviral drugs in pregnant women with HIV infection and interventions to reduce perinatal HIV transmission in the United States. December 2018 [internet publication].https://aidsinfo.nih.gov/guidelines/html/3/perinatal/0[66]Centers for Disease Control and Prevention (CDC); Association of Public Health Laboratories. Laboratory testing for the diagnosis of HIV infection: updated recommendations. June 2014 [internet publication].http://stacks.cdc.gov/view/cdc/23447

对初始免疫检测无反应的样本无需进一步检测。

阳性

如果抗原/抗体联合免疫检测结果呈有反应型，则应当对该样本进行可鉴别 HIV-1 抗体与 HIV-2 抗体的抗体免疫测定。首选 ELISA，如果无法应用 ELISA，也可以使用免疫印迹法或间接免疫荧光法。[66]Centers for Disease Control and Prevention (CDC); Association of Public Health Laboratories. Laboratory testing for the diagnosis of HIV infection: updated recommendations. June 2014 [internet publication].http://stacks.cdc.gov/view/cdc/23447

HIV-1 抗体阳性；或 HIV-2 抗体阳性；或 HIV 抗体阳性，但未分型。

暴露于 HIV 的婴儿应接受 HIV 感染检测。建议对所有围产期HIV暴露的婴儿在第 14 至 21 天、第 1 至 2 个月，以及第 4 至 6 个月进行检测。对于具备传播高风险的婴儿，应考虑出生时（以及停止抗逆转录病毒预防后 2 至 4 周）进行检测。若为阳性结果，应采集第二样本进行复测来尽快确证。[6]The Panel on Treatment of Pregnant Women with HIV Infection and Prevention of Perinatal Transmission, US Department of Health and Human Services. Recommendations for the use of antiretroviral drugs in pregnant women with HIV infection and interventions to reduce perinatal HIV transmission in the United States. December 2018 [internet publication].https://aidsinfo.nih.gov/guidelines/html/3/perinatal/0

对于未经母乳喂养且 2 次或 2 次以上检测呈阴性的婴儿，可以排除 HIV 感染（≥ 1 月龄时进行 1 次检测，然后≥ 4 月龄时进行 1 次检测；或者 ≥ 6 月龄时对独立的样本进行 2 次检测）。[6]The Panel on Treatment of Pregnant Women with HIV Infection and Prevention of Perinatal Transmission, US Department of Health and Human Services. Recommendations for the use of antiretroviral drugs in pregnant women with HIV infection and interventions to reduce perinatal HIV transmission in the United States. December 2018 [internet publication].https://aidsinfo.nih.gov/guidelines/html/3/perinatal/0

HIV DNA PCR 检测外周血单核细胞内的 HIV 病毒 DNA。DNA PCR 在出生时的特异度为 99.8%，在 1 月龄、3 月龄和 6 月龄时为 100%。PCR 的敏感度在出生时仅为 55%，但在 2-4 周龄时增加至超过 90%，而在 3 月龄和 6 月龄时达到 100%。[71]Havens PL, Mofenson LM; American Academy of Pediatrics Committee on Pediatric AIDS. Evaluation and management of the infant exposed to HIV-1 in the United States. Pediatrics. 2009 Jan;123(1):175-87.http://pediatrics.aappublications.org/content/123/1/175.longhttp://www.ncbi.nlm.nih.gov/pubmed/19117880?tool=bestpractice.com[72]American Academy of Pediatrics Committee on Pediatric AIDS. HIV testing and prophylaxis to prevent mother-to-child transmission in the United States. Pediatrics. 2008 Nov;122(5):1127-34.http://pediatrics.aappublications.org/content/122/5/1127.longhttp://www.ncbi.nlm.nih.gov/pubmed/18977995?tool=bestpractice.com[73]Burgard M, Blanche S, Jasseron C, et al. Performance of HIV-1 DNA or HIV-1 RNA tests for early diagnosis of perinatal HIV-1 infection during anti-retroviral prophylaxis. J Pediatr. 2012 Jan;160(1):60-6.e1.http://www.jpeds.com/article/S0022-3476%2811%2900681-0/fulltexthttp://www.ncbi.nlm.nih.gov/pubmed/21868029?tool=bestpractice.com[74]Lilian RR, Kalk E, Bhowan K, et al. Early diagnosis of in utero and intrapartum HIV infection in infants prior to 6 weeks of age. J Clin Microbiol. 2012 Jul;50(7):2373-7.http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3405609/http://www.ncbi.nlm.nih.gov/pubmed/22518871?tool=bestpractice.com

HIV RNA PCR 用于检测血浆中的胞外病毒 RNA。大于 5000 拷贝时，特异性与 DNA PCR 相当；然而，该检测在病毒载量小于 5000 时是准确的，可进行重复检测，以确认 HIV 的诊断。敏感度在出生后为 25%-58%，在 1 月龄时提高到 89%，并在 3 月龄时提高到 90%-100%。[71]Havens PL, Mofenson LM; American Academy of Pediatrics Committee on Pediatric AIDS. Evaluation and management of the infant exposed to HIV-1 in the United States. Pediatrics. 2009 Jan;123(1):175-87.http://pediatrics.aappublications.org/content/123/1/175.longhttp://www.ncbi.nlm.nih.gov/pubmed/19117880?tool=bestpractice.com[72]American Academy of Pediatrics Committee on Pediatric AIDS. HIV testing and prophylaxis to prevent mother-to-child transmission in the United States. Pediatrics. 2008 Nov;122(5):1127-34.http://pediatrics.aappublications.org/content/122/5/1127.longhttp://www.ncbi.nlm.nih.gov/pubmed/18977995?tool=bestpractice.com[73]Burgard M, Blanche S, Jasseron C, et al. Performance of HIV-1 DNA or HIV-1 RNA tests for early diagnosis of perinatal HIV-1 infection during anti-retroviral prophylaxis. J Pediatr. 2012 Jan;160(1):60-6.e1.http://www.jpeds.com/article/S0022-3476%2811%2900681-0/fulltexthttp://www.ncbi.nlm.nih.gov/pubmed/21868029?tool=bestpractice.com

阳性

HIV-1 免疫印迹法可作为 HIV-1/HIV-2 抗体鉴别免疫测定的二线替代方案。[66]Centers for Disease Control and Prevention (CDC); Association of Public Health Laboratories. Laboratory testing for the diagnosis of HIV infection: updated recommendations. June 2014 [internet publication].http://stacks.cdc.gov/view/cdc/23447

如果检测结果呈阴性或不确定，则应进行 HIV-1 核酸检测。

HIV-1 抗体呈阳性

可使用 HIV-1 IFA 替代 HIV-1/HIV-2 抗体鉴别免疫测定。[66]Centers for Disease Control and Prevention (CDC); Association of Public Health Laboratories. Laboratory testing for the diagnosis of HIV infection: updated recommendations. June 2014 [internet publication].http://stacks.cdc.gov/view/cdc/23447

如果检测结果呈阴性或不确定，则应进行 HIV-1 核酸检测。

HIV-1 抗体呈阳性

如果 HIV-1/HIV-2 抗原/抗体联合免疫检测结果有反应，而 HIV-1/HIV-2 抗体鉴别免疫检测无反应或结果不确定，则应当对该样本进行 HIV-1 核酸检测。[66]Centers for Disease Control and Prevention (CDC); Association of Public Health Laboratories. Laboratory testing for the diagnosis of HIV infection: updated recommendations. June 2014 [internet publication].http://stacks.cdc.gov/view/cdc/23447

HIV-1 核酸检测有反应、HIV-1/HIV-2 抗体鉴别免疫检测无反应为急性 HIV-1 感染的实验室证据。

HIV-1 核酸检测有反应、HIV-1/HIV-2 抗体鉴别免疫检测结果不确定，提示经 HIV-1 核酸检测证实的 HIV-1 感染。

HIV-1 核酸检测阴性、HIV-1/HIV-2 抗体鉴别免疫检测结果无反应或不确定，表明初始联合免疫测定的结果为假阳性。

阳性

指示免疫状态并协助分期。

对于所有女性，应该初始就诊时进行检测。对于以下女性：接受治疗的时间<2 年的女性，CD4 计数<300 个/μL 的女性，以及依从性不一致和/或病毒载量可检测出的女性，应至少每 3-6 个月反复检测一次。对于接受治疗的时间≥2 年、病毒持续受到抑制并且 CD4 计数>300 个/μL 的女性，不需要在妊娠期行进一步监测。[6]The Panel on Treatment of Pregnant Women with HIV Infection and Prevention of Perinatal Transmission, US Department of Health and Human Services. Recommendations for the use of antiretroviral drugs in pregnant women with HIV infection and interventions to reduce perinatal HIV transmission in the United States. December 2018 [internet publication].https://aidsinfo.nih.gov/guidelines/html/3/perinatal/0

CD4 计数超过 500 个细胞/μL：患者通常无症状；CD4 计数少于 350 个细胞/μL：提示实质性免疫抑制；CD4 计数少于 200 个/μL：使患者有发生多数机会性感染的风险

对 HIV 检测呈阳性的妊娠女性进行连续病毒载量测定是标准做法。

应在初诊时进行监测，在启动或更换药物治疗后 2-4 周进行监测，在 RNA 水平无法检测出之前，每月监测一次，然后在妊娠期至少每 3 个月监测一次。应在妊娠 34-46 周时再评估一次，以指导关于分娩模式的决策。[6]The Panel on Treatment of Pregnant Women with HIV Infection and Prevention of Perinatal Transmission, US Department of Health and Human Services. Recommendations for the use of antiretroviral drugs in pregnant women with HIV infection and interventions to reduce perinatal HIV transmission in the United States. December 2018 [internet publication].https://aidsinfo.nih.gov/guidelines/html/3/perinatal/0

近期感染患者或晚期感染患者的水平可能达到数百万拷贝/mL

在抗逆转录病毒治疗开始前进行基线检查，之后加以监测。

可发现肾功能损害

在抗逆转录病毒治疗开始前进行基线检查，之后加以监测。

可能正常；基线肝功能检查异常可能提示慢性乙型肝炎、慢性丙型肝炎或酗酒

应在每次妊娠的早期筛查肺结核、病毒性肝炎和性传播感染 (sexually transmitted infection, STI)。

可能为阳性

对于开始或调整抗逆转录病毒治疗之前 HIV RNA 水平在需行耐药性检测阈值（即 500-1000 拷贝/mL）之上的所有孕妇，应进行该检查。应在获取结果前启动治疗，因为一旦获取结果，就可根据结果对治疗方案进行调整。[6]The Panel on Treatment of Pregnant Women with HIV Infection and Prevention of Perinatal Transmission, US Department of Health and Human Services. Recommendations for the use of antiretroviral drugs in pregnant women with HIV infection and interventions to reduce perinatal HIV transmission in the United States. December 2018 [internet publication].https://aidsinfo.nih.gov/guidelines/html/3/perinatal/0

有助于选择最恰当的治疗方案。

存在差异

在抗逆转录病毒治疗开始前进行基线检查，之后加以监测。

可以正常或有贫血或血小板减少症

对于正在接受抗逆转录病毒治疗的女性，一般推荐在妊娠 24-28 周时行标准葡萄糖筛查。[6]The Panel on Treatment of Pregnant Women with HIV Infection and Prevention of Perinatal Transmission, US Department of Health and Human Services. Recommendations for the use of antiretroviral drugs in pregnant women with HIV infection and interventions to reduce perinatal HIV transmission in the United States. December 2018 [internet publication].https://aidsinfo.nih.gov/guidelines/html/3/perinatal/0

存在差异

应对孕妇尽快进行超声检查以确定孕龄。同时建议在妊娠中期使用超声检查，观察胎儿解剖结构。[6]The Panel on Treatment of Pregnant Women with HIV Infection and Prevention of Perinatal Transmission, US Department of Health and Human Services. Recommendations for the use of antiretroviral drugs in pregnant women with HIV infection and interventions to reduce perinatal HIV transmission in the United States. December 2018 [internet publication].https://aidsinfo.nih.gov/guidelines/html/3/perinatal/0

确认孕龄；可能显示解剖结构异常