【摘要】：危險(xiǎn)性行為是指在所有同性或異性性生活過程中能夠引起雙方血液及體液交換的性行為。性傳播已成為目前導(dǎo)致中國艾滋病病毒(HIV)流行的主要途徑。HIV感染者的危險(xiǎn)性行為除可能造成HIV二代傳播外,也可能使本人感染性傳播疾病和機(jī)會(huì)性感染病原體,或重復(fù)感染不同型別毒株或耐藥毒株,影響抗病毒治療效果。 到2007年10月底,全國累計(jì)報(bào)告HIV感染者和艾滋病病人223,501例,行為調(diào)查結(jié)果亦證明該人群危險(xiǎn)性行為發(fā)生仍然存在。隨著監(jiān)測、流行病學(xué)調(diào)查、自愿咨詢檢測和感染者隨訪管理工作力度的不斷加大,越來越多的感染者將被確認(rèn)并告知陽性檢測結(jié)果,同時(shí)抗病毒治療可能使他們存活時(shí)間延長,增加了傳播HIV的機(jī)會(huì)。良好有效的衛(wèi)生服務(wù)和行為干預(yù)措施有助于減少HIV感染者危險(xiǎn)性行為,從而有效控制HIV傳播。 本研究通過了解不同告知時(shí)間的HIV感染者危險(xiǎn)性行為發(fā)生情況,探討個(gè)人性伴,家庭和社會(huì)環(huán)境以及醫(yī)療衛(wèi)生服務(wù)因素對HIV感染者危險(xiǎn)性行為的影響,建立基于健康行為理論的HIV感染者危險(xiǎn)性行為路徑模型,為疫情估計(jì)提供基礎(chǔ)數(shù)據(jù),為改進(jìn)HIV感染者醫(yī)療衛(wèi)生服務(wù)措施提供依據(jù)。 方法 本研究采用定量調(diào)查和定性調(diào)查相結(jié)合的方式,于2008年7月至12月對云南省德宏傣族景頗族自治州潞西市,盈江縣,廣西壯族自治區(qū)柳州市鹿寨縣和賀州市八步區(qū)1120名HIV感染者通過面對面訪談進(jìn)行了問卷調(diào)查,調(diào)查對象年齡18至49歲,于2006年1月至2008年12月HIV抗體確認(rèn)陽性并被告知結(jié)果。同時(shí)對38名HIV感染者和20名工作人員分別進(jìn)行了個(gè)人和小組訪談。 定量調(diào)查研究設(shè)計(jì)包括組間比較和組內(nèi)比較,對于調(diào)查對象中的HIV感染者夫婦,隨機(jī)選擇其中一方作為研究對象。組間比較首先對974名新告知組和已告知組調(diào)查對象過去6個(gè)月危險(xiǎn)性行為進(jìn)行比較分析,探討告知前后兩組危險(xiǎn)性行為的差異,以及個(gè)人、性伴和性行為因素的影響；其次對836名已告知組調(diào)查對象過去6個(gè)月危險(xiǎn)性行為進(jìn)行比較分析,探討已告知不同時(shí)間組危險(xiǎn)性行為的差異,以及個(gè)人、性伴和性行為、家庭和社會(huì)支持以及醫(yī)療衛(wèi)生服務(wù)的影響,并建立基于健康行為理論的HIV感染者危險(xiǎn)性行為預(yù)測模型。組內(nèi)比較即對177名2008年1月至6月告知組告知前后危險(xiǎn)性行為進(jìn)行比較分析,探討同一組調(diào)查對象告知前后危險(xiǎn)性行為的差異,以及個(gè)人、性伴和性行為、家庭和社會(huì)支持以及醫(yī)療衛(wèi)生服務(wù)等對告知后危險(xiǎn)性行為的影響。 HIV感染者個(gè)人訪談內(nèi)容包括接受醫(yī)療衛(wèi)生服務(wù)情況,陽性結(jié)果通知和安全套使用行為等；工作人員小組訪談內(nèi)容包括安全套推廣工作現(xiàn)狀、存在問題和建議以及工作人員需求等。 結(jié)果 974名調(diào)查對象中,新告知組138人(14.2%)；已告知組836人(85.8%),其中2008年1月至6月告知者174人(20.8%),2007年7月至12月告知者234人(28.0%),2007年1月至6月告知者242人(28.9%),2006年告知者186人(22.2%)；云南652人,占66.9%,其中潞西市322人(49.4%),盈江縣330人(50.6%),廣西322人,占33.1%,其中鹿寨縣164人(50.9%),八步區(qū)158人(49.1%)；男性553人,占56.8%,女性421人,占43.2%；年齡最小18歲,最大49歲,平均年齡為32.5±7.2歲,年齡中位數(shù)為32歲。 974名調(diào)查對象中,704人過去6個(gè)月曾發(fā)生過性行為,占72.3%,其中僅與固定性伴發(fā)生性行為者623人,占88.5%,僅與非固定性伴發(fā)生性行為者50人,占7.1%,與固定和非固定性伴均發(fā)生過性行為者31人,占4.4%。 1.不同告知時(shí)間的HIV感染者危險(xiǎn)性行為 組間比較結(jié)果顯示,974名調(diào)查對象中,已告知組70.5%(549/836)過去6個(gè)月發(fā)生性行為,顯著低于新告知組(83.3%)；發(fā)生性行為者中,已告知組堅(jiān)持正確使用安全套(第三階段)者所占比例(55.7%)高于新告知組(7.0%),而無安全套使用意向者(第一階段)所占比例(9.3%)低于新告知組(18.3%),已告知組最近一次與固定和非固定性伴發(fā)生性行為時(shí)使用安全套的比例分別為72.7%和66.7%,而新告知組上述比例分別為16.2%和22.2%。 組內(nèi)比較結(jié)果顯示,177名調(diào)查對象中,未發(fā)生性行為者由告知前的27.7%上升到告知后的30.5%,安全套使用行為處于第三階段者由13.6%上升到36.2%,而安全套使用行為處于第二階段和第一階段者分別由48.6%和10.2%下降至26.6%和6.8%,告知前后行為分布的狀況有顯著差異,且存在一致性。 已告知各組調(diào)查對象發(fā)生性行為的比例無明顯差異,但是與2006年告知組相比,2007年1月至6月告知組無使用安全套意向(第一階段)的概率較低,提示安全套使用意識和行為在被告知陽性結(jié)果后不同時(shí)間段有所不同。 2.影響因素 2.1個(gè)人基本情況 本研究發(fā)現(xiàn),云南調(diào)查對象報(bào)告危險(xiǎn)性行為發(fā)生率高于廣西。省份為廣西者感知的艾滋病易感性水平較高,其差異可能與調(diào)查偏倚以及環(huán)境因素有關(guān)；女性安全套使用自我效能低于男性,因此也更容易發(fā)生危險(xiǎn)性行為；年齡較大組發(fā)生性行為的概率較低,但與安全套使用行為階段無顯著關(guān)聯(lián)；與伴侶共同生活者(已婚/同居者)發(fā)生性行為概率以及堅(jiān)持使用安全套的比例均較高；已告知各組調(diào)查對象中,小學(xué)文化程度者安全套使用行為處于第二階段者的概率低于高中以上組；家庭人均月收入高者發(fā)生性行為比例較高,且更可能堅(jiān)持使用安全套。組內(nèi)比較結(jié)果顯示,注射毒品傳播和性傳播者告知后不安全行為發(fā)生概率無顯著差異,而其他途徑傳播者發(fā)生不安全行為的風(fēng)險(xiǎn)高于與注射毒品傳播者,由于樣本量較小,判斷傳播途徑和不安全性行為之間的關(guān)聯(lián)應(yīng)謹(jǐn)慎。此外,本研究未發(fā)現(xiàn)吸毒和飲酒與危險(xiǎn)性行為有顯著關(guān)聯(lián)。 調(diào)查對象感知的艾滋病嚴(yán)重性、易感性、安全套使用益處和障礙以及自我效能和社會(huì)規(guī)范等可能直接或通過其他認(rèn)知態(tài)度因素間接影響安全套使用行為階段,安全套使用障礙對于安全套使用行為階段影響最為明顯,其次是艾滋病易感性、自我效能和社會(huì)規(guī)范,而艾滋病嚴(yán)重性和安全使用益處對安全套使用行為階段的影響較小,且為間接效應(yīng)。艾滋病病人感知的易感性、安全套使用益處和社會(huì)規(guī)范水平均高于無癥狀感染者,艾滋病知識知曉者感知的艾滋病嚴(yán)重性、易感性和社會(huì)規(guī)范水平較高,因而上述兩組堅(jiān)持使用安全套的概率較高；負(fù)面情緒水平高者,感知的艾滋病嚴(yán)重性和安全套使用障礙水平較高,而感知的艾滋病易感性水平較低,容易發(fā)生不安全性行為。 2.2性伴和性行為 本研究發(fā)現(xiàn),HIV感染者之間發(fā)生危險(xiǎn)性行為的概率高于陰性性伴,而與陽性性伴和感染狀況不明性伴發(fā)生危險(xiǎn)性行為的差別無統(tǒng)計(jì)學(xué)意義。HIV感染者與固定性伴發(fā)生危險(xiǎn)性行為的概率較低,尤其是保持性關(guān)系較長者。有非固定性伴者安全套使用行為處于第一階段的概率較高,且同時(shí)有固定和非固定性伴者發(fā)生危險(xiǎn)性行為的概率高于僅有非固定性伴者。定性訪談結(jié)果亦提示某些有固定性伴的HIV感染者因?yàn)椴辉敢馐褂冒踩锥c其他性伴發(fā)生性行為。本研究發(fā)現(xiàn)多數(shù)HIV感染者固定性伴知曉感染狀況,而非固定性伴知曉率較低,但本研究未證明性伴知曉情況與危險(xiǎn)性行為發(fā)生存在關(guān)聯(lián)。HIV感染者安全套使用行為與性伴類型無關(guān)。性行為頻率較低者,堅(jiān)持使用安全套比例較高。 2.3家庭和社會(huì)支持 由于擔(dān)憂被歧視,HIV感染者通常不愿意暴露本人感染狀況,但愿意將結(jié)果告知關(guān)系密切者。已告知組調(diào)查對象中,78.7%親人知曉感染狀況,27.2%其他人知曉感染狀況,72.7%獲得支持,23.1%感到歧視。研究結(jié)果顯示,未獲得支持者無安全套使用意向的概率較高,感到歧視則增加了不堅(jiān)持使用安全套的風(fēng)險(xiǎn)。此外,參與感染者小組活動(dòng)者無安全套使用意向者比例較低,獲得物質(zhì)經(jīng)濟(jì)支持者發(fā)生性行為的比例略高,但對安全套使用行為階段的影響不顯著。 2.4醫(yī)療衛(wèi)生服務(wù) 本研究結(jié)果顯示,獲得良好檢測和告知服務(wù)者堅(jiān)持使用安全套概率較高。良好檢測和告知服務(wù)包括獲得知情同意,由醫(yī)生或者防疫人員單獨(dú)告知本人結(jié)果以及檢測前后獲得充分信息等。 定性訪談結(jié)果顯示,免費(fèi)安全套在質(zhì)量、性能、款式和包裝等方面存在的問題可能影響其可接受性,部分HIV感染者由于擔(dān)心身份泄露不愿意接受免費(fèi)安全套。已告知組調(diào)查對象中,65.3%均獲得了免費(fèi)安全套,獲得安全套者性行為發(fā)生概率較高,但危險(xiǎn)性行為發(fā)生概率較低。這可能由于免費(fèi)安全套發(fā)放改善了安全套可及性,也可能與樣本選擇偏倚或社會(huì)期望偏倚有關(guān)。 本研究結(jié)果表明,獲得面對面信息交流者安全套使用行為處于第二階段的概率高于第三階段,而行為處于第一階段的比例較低,提示面對面信息交流者有助于提高安全套使用意向,但促進(jìn)堅(jiān)持使用安全套的作用有限；獲得公眾艾滋病信息者和參加艾滋病預(yù)防宣傳教育活動(dòng)者發(fā)生危險(xiǎn)性行為的可能性較高,可能與選擇偏倚有關(guān)；是否獲得安全套使用信息與過去6個(gè)月安全套使用行為階段無關(guān),但獲得安全套使用信息者發(fā)生性行為比例較高,可能與發(fā)生性行為者更關(guān)注安全套使用信息有關(guān)。 已告知各組調(diào)查對象中,58.9%(492/836)接受抗病毒治療。接受抗病毒治療者安全套使用行為處于第三階段的概率較高,而行為處于第一階段的概率較低。多因素分析結(jié)果顯示,接受抗病毒治療與安全套使用行為階段的關(guān)聯(lián)未達(dá)顯著性水平。 結(jié)論 在被告知陽性檢測結(jié)果后,HIV感染者危險(xiǎn)性行為較之前有所下降。HIV感染者的危險(xiǎn)性行為與個(gè)人,性伴、家庭和社會(huì)支持以及醫(yī)療衛(wèi)生服務(wù)等多種因素有關(guān)。建議進(jìn)一步加強(qiáng)HIV檢測咨詢、告知和隨訪管理工作,改善衛(wèi)生服務(wù)質(zhì)量；根據(jù)干預(yù)對象特點(diǎn)和行為特征采取有針對的干預(yù)措施,干預(yù)過程中應(yīng)重視認(rèn)知態(tài)度的變化；以社區(qū)和家庭為單位開展有針對性的預(yù)防宣傳工作,以減少歧視,促進(jìn)針對HHIV感染者的社會(huì)支持。
[Abstract]:Dangerous sexual behavior refers to the sexual behavior that can cause the exchange of blood and body fluids in all sex or heterosexual life. Sexual transmission has become the main way of causing the epidemic of HIV virus (HIV) in China. The dangerous behavior of the.HIV infected person is likely to cause the two generation of sowing and the infection of sexually transmitted diseases. Opportunistic infections, or repeated infection of different types of strains or drug-resistant strains, affect the efficacy of antiviral treatment.
By the end of October 2007, 223501 cases of HIV infected and AIDS patients were reported throughout the country. The results of the behavior survey also proved that the risk of the population still existed. With the monitoring, epidemiological investigation, voluntary counseling and testing and follow-up management of the infected people, more and more infected people will be confirmed and informed. At the same time, antiviral therapy may prolong their survival time and increase the opportunity to spread HIV. Good health services and behavioral interventions help to reduce the risk of HIV infection and thus effectively control the spread of HIV.
In this study, the risk behavior of HIV infected people at different time of notification was investigated, and the effects of personal partners, family and social environment and medical service factors on the risk behavior of HIV infected people were investigated. The risk behavior of HIV infected persons based on the health behavior theory was established as the path model to provide basic data for the estimation of the epidemic situation. To provide evidence for improving health care measures for HIV infected persons.
Method
In this study, a questionnaire survey was conducted on 1120 HIV infected people in Luxi City, Yingjiang County, Luzhai County, the Guangxi Zhuang Autonomous Region Liuzhou city and Hezhou City, Dehong, Yunnan Province, Luxi City, Yingjiang County, Liuzhou City, the Guangxi Zhuang Autonomous Region, the Guangxi Zhuang Autonomous Region, the Guangxi Zhuang Autonomous Region Province, from July 2008 to December. The respondents were aged from 18 to 49 years old. From January 2006 to December 2008, HIV antibodies were confirmed positive and informed of the results. Personal and group interviews were conducted with 38 HIV-infected persons and 20 staff members, respectively.
The quantitative investigation design includes the inter group comparison and the intra group comparison. For the HIV infected couples in the survey subjects, one of them is randomly selected as the research object. The comparison between the 974 new informing groups and the informed groups in the past 6 months is compared, and the two groups of dangerous sexual behaviors before and after the notification are discussed. The differences, as well as the effects of individuals, sexual partners and sexual behavior factors; secondly, a comparative analysis of the risk behaviors of the 836 participants in the past 6 months, and the differences in the risk behavior of different time groups, as well as the impact of individuals, sexual partners and sexual behavior, family and social support and health services, and based on the analysis of the effects of the risk behavior The risk behavior prediction model of HIV infection in the health behavior theory. The comparison of the dangerous sexual behaviors before and after the informing group of 177 to June was compared, and the differences in the risk behavior before and after the same group were discussed, as well as the individual, sexual partner and sexual behavior, family and social support and medical service. The influence on the dangerous sexual behavior after the notification.
Personal interviews with HIV infected people include medical and health services, positive results and condom use, and staff group interviews include the status of condom promotion, problems and suggestions, and staff needs.
Result
Of the 974 subjects, 138 (14.2%) were informed by the new group, and 836 (85.8%) were informed of the group from January 2008 to June (20.8%), 234 from July 2007 to December (28%), 242 (28.9%) in January 2007 to June, and 186 in 2006, and Yunnan Province, Yingjiang County 30 (50.6%), 322 in Guangxi, accounting for 33.1%, 164 (50.9%) in Luzhai county and 158 (49.1%) in the eight step area; 553 men, 56.8% and 421, accounting for 43.2%.
Of the 974 subjects, 704 had sexual behavior in the past 6 months, accounting for 72.3%, of which 623 had sex with fixed partners, accounting for 88.5%, 50 with non fixed partners, 7.1%, and 31 with both fixed and non fixed partners, accounting for 4.4%..
1. risk behavior of HIV infected people at different time of informing
The results of the group comparison showed that among the 974 subjects, 70.5% (549/836) had been informed of sexual behavior in the past 6 months, significantly lower than that of the new group (83.3%). Among the sex workers, the group had been informed that the proportion of the condom use (55.7%) was higher than the new informing group (7%), and the first order (first order). The proportion of the group (9.3%) was lower than that of the new informing group (18.3%). The proportion of the condoms was 72.7% and 66.7%, respectively, when the group was informed of the recent sexual behavior of fixed and non fixed partners, while the ratio of the new informing group was 16.2% and 22.2%., respectively.
The results of intra group comparison showed that among the 177 subjects, the non sex actors increased from 27.7% before notified to 30.5%, and the use of condom use increased from 13.6% to 36.2% from 13.6% to 36.2%, while the condom use behavior fell from 48.6% and 10.2% to 26.6% and 6.8%, respectively, to inform before and after. There are significant differences and consistency in distribution.
There was no significant difference in the proportion of the participants' sexual behavior, but compared with the 2006 informing group, the probabilities of the informing group without condom use (the first stage) from January 2007 to June were lower, suggesting that the condom use consciousness and behavior were different in different periods after the positive results of the defendant.
2. influencing factors
2.1 people's basic situation
The study found that Yunnan respondents reported a higher incidence of risk behavior than in Guangxi. The level of susceptibility to AIDS in Guangxi province was higher than that in Guangxi. The difference may be related to investigation bias and environmental factors; female condoms were less likely to use self-efficacy than men, and therefore were more likely to have dangerous sexual behavior; older groups were found to be in a larger group. The probability of sexual behavior was low, but there was no significant correlation with the behavior stage of condom use; the probability of sexual behavior and the proportion of condom use were higher in the common living (married / cohabitation). The probabilities of the second stages were lower than that of the primary school students. In the high school group, the proportion of people with high per capita monthly income was higher and more likely to insist on the use of condoms. The results showed that there was no significant difference in the probability of unsafe behavior between the drug transmission and the sexually transmitted people, while the risk of unsafe behavior in other channels was higher than that of the injection drug. In addition, there was no significant association between drug use and alcohol consumption and dangerous sexual behavior.
The perceived AIDS severity, susceptibility, condom use benefits and barriers, self efficacy and social norms may directly or indirectly affect the use of condom use behavior, and condom use barriers have the most significant impact on condom use behavior, followed by AIDS susceptibility. Sex, self-efficacy and social norms, and the impact of AIDS severity and safety on the use of condom use behavior stage less, and indirect effect. The perceived susceptibility to AIDS patients, condom use benefits and social standards are higher than asymptomatic infection, AIDS awareness awareness of AIDS severity, easy The level of perceptual and social norms is high, so the two groups are more likely to insist on condom use; those with high level of negative emotion have a higher level of perceived AIDS severity and condom use disorder, while the perceived level of AIDS susceptibility is low, and unsafe sex is easy to occur.
2.2 sexual partners and sexual behavior
The study found that the probability of risky sexual behavior among HIV infected people is higher than that of negative partners, and there is no statistically significant difference in the risk behavior between positive partners and unidentified partners. The risk of.HIV infection is lower than that of fixed partners, especially those with longer sexual relationship. The probability of full use behavior at the first stage is higher, and the risk behavior of both fixed and non fixed partners is higher than those with only non fixed partners. Qualitative interview results also suggest that some HIV infected persons with fixed partners have sex with other sex partners because they are not willing to use condoms. The number of HIV infected persons was fixed with awareness of infection, but the awareness rate of non fixed partners was low. However, this study did not prove that the use of condom use behavior of people with.HIV infection was not related to the type of sexual partners.
2.3 family and social support
Because of the fear of being discriminated, HIV infected people are usually reluctant to expose their infection status, but are willing to inform the close relationship. 78.7% of them have been told that relatives are aware of the infection, 27.2% other people know the infection, 72.7% support, and 23.1% feel discrimination. The results showed that no supporters did not use condoms. The risk of discrimination increased the risk of non use of condoms. In addition, the proportion of people who participated in the group with no condom use intention was low, and the proportion of material economic supporters to sexual behavior was slightly higher, but the effect on the use of condom behavior was not significant.
2.4 medical and health services
The results of this study show that good testing and informing operators are more likely to insist on using condoms. Good testing and notification services include informed consent, the doctor or the epidemic prevention personnel individually inform the results and obtain sufficient information before and after the test.
The results of qualitative interviews showed that the problems in the quality, performance, style and packaging of the free condoms might affect their acceptability. Some HIV infected people were not willing to accept free condoms for fear of identity leakage. In the group of respondents, 65.3% received a free condom and got the probability of condom sexual behavior. It is higher, but the probability of dangerous sexual behavior is low. This may be due to the free condom release that improves the condom accessibility, and may also be related to the selection bias of the sample or the social expectation bias.
The results of this study showed that the probability of receiving condom use behavior in the second stage was higher than the third stage, and the proportion of behavior in the first stage was low. It suggested that face-to-face information communicators help to improve condom use intention, but promote the limited use of condoms; obtain public AIDS. The likelihood of risky sexual behavior between the information and the persons participating in the AIDS prevention and education activities may be associated with the selection bias; whether the use of condom use information is not related to the use of condom use in the past 6 months, but the rate of sexual behavior in the use of condoms is higher and may be more likely to be associated with sexual actors. Pay attention to the use of condom information.
Among the participants, 58.9% (492/836) received antiviral therapy. The probability of being at the third stage was higher in the condom use behavior of the antiviral treatment, and the probability of the behavior at the first stage was lower. The results of multifactor analysis showed that the association between the antiviral treatment and the use of the condom use behavior was not significant.
conclusion
After being informed of the positive results, the risk behavior of HIV infected people decreased more than before, and the risk behavior of.HIV infected people was related to a variety of factors such as personal, sexual partners, family and social support, and medical service.
【學(xué)位授予單位】：北京協(xié)和醫(yī)學(xué)院
【學(xué)位級別】：博士
【學(xué)位授予年份】：2009
【分類號】：R512.91;R181.3

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