HIV/AIDS/STI社区综合干预效果评价研究
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摘要
背景世行贷款卫生九项目艾滋病性病预防控制子项目(H9-HIV/AIDS/STI)是我国第一个大规模综合性预防控制艾滋病性病项目。项目针对二十世纪八十年代末期我国异常严峻的艾滋病性病流行形势,以及防治工作面临的政策、资源、技术方法及社会文化观念等多方面的困难而设计,目的是建设艾滋病防治关键设施,在我国艾滋病流行形势较严重或流行危险因素较多的地区先行贯彻落实国家艾滋病防治规划、试点探索艾滋病防治政策与措施,进而以点带面推动全国的防治工作。项目在国家CDC以及新疆、广西、福建、山西四省(自治区)的32个地市和55个县实施。全部计划经费投入3999万美元,其中世界银行贷款占62.52%,国内配套占37.48%。项目于1999年11月份正式启动,于2008年6月30日结束,历经近9年的努力,全面覆盖项目所设计的机构与能力建设、政策倡导与社会动员、艾滋病性病监测、艾滋病性病干预、血液管理等领域。
目的评价H9-HIV/AIDS/STI项目的目标实现程度、有效性以及影响因素,总结该项目的经验及教训。
方法综合运用定性和定量研究方法。通过数据填报、数据索取、综合现场调查(定性访谈、多部门座谈、问卷调查与考核)等方法收集数据,采用描述性分析方法与比较分析方法(项目地区计划与执行情况比较、项目实施前后/趋势比较、项目县与非项目县比较),进行全面评估。
结果H9支持了四个项目省中65%的省级政策及98%的项目县防治政策的开发与执行。这些政策包括地域性防治长期规划、政治承诺、社会动员、技术支持、大众健康教育、高危/脆弱人群健康干预、AIDS患者及HIV感染者救助、血液管理、STI临床综合诊疗流程管理、HIV监测、安全套发放。截至2007年末,H9共支持30个国家级HIV/AIDS/STI技术方案及指南的开发与普及。项目实施期间,四省共建设209个HIV监测哨点,其中H9筹建了其中147个哨点。调查项目地区大众HIV/AIDS/STI问题知晓率从2002年3.1%上升到2007年17.4%,明显高于非项目地区同期从0.8%到3.8%的上升速度;项目地区地方政府官员知识、行为得分高于非项目地区,知晓率分别为83.6%,81.1%,差异有显著性;项目地区临床医生HIV/AIDS/STI相关知识态度得分高于非项目地区同水平医生得分,并且在STI诊断和治疗知识得分上差异呈显著性;项目地区公众最近一次性行为安全套使用率从2002年的19.8%上升到2007的30.1%,上升速度及使用率均高于非项目地区同期的11.4%及25.6%;项目地区女性商业性服务者淋病、衣原体感染、梅毒、尖锐湿疣、生殖器疱疹患病率低于非项目地区(分别为15.1%及25%, P<0.001)。H9项目组建发展的专家团队为非项目地区提供了大量的技术支持,自2006年,项目地区的实施经验开始逐步向全国推广;项目地区与非项目地区之间管理与技术人员的频繁交流与调动,使得项目地区获得的经验、知识和技能迅速传播至非项目地区;通过项目实施,探索了一批卓有成效的干预模式,为以后的MSM、娱乐场所暗娼、静脉注射吸毒者和青年/学生等人群干预以及性病规范化管理等提供了有益的借鉴。
结论H9-HIV/AIDS/STI作为我国第一个综合性STI/HIV社区干预项目,项目的总体目标及各领域主要目标基本实现,部分目标超过原先设计要求。项目在促进地区HIV政策研发与实施、政府领导层开发、HIV知识—行为—态度的改变、技术人员能力开发等方面发挥显著作用,同时,项目地区经济、文化、政策变迁等环境因素对项目实施效果也有极大的促进作用。H9-HIV/AIDS/STI项目终末评估分析认为良性管理和创造适宜文化背景是引入新项目的重要前提;整合的项目计划有利于推动价值观在社区成员内的共享;强有力的政策制订使计划方案更具有系统性和规范性;H9-HIV/AIDS/STI与政治承诺的交互作用是项目成功的另一个关键因素;系统、长期的人员培训及相关技能手册、指南的开发极大地提升了服务提供者STI/HIV相关知识技能,改善了服务水平;研究人员及服务机构之间的合作有利于推动地区实践与研究的结合,提高了循征决策水平;统一的资源配置机制在加强资源整合方面是非常必要的,根据HIV防控目标群体以及不同地区的流行情况进行资源的合理分配有利于避免地区资源分配的不平衡,保障项目的设计、实施与评估环节的完整性。
评估还提示现阶段HIV/STI防控尚未在所有领域完全铺开。从卫生服务公平性角度出发,在农村以及低收入地区加大监管力度是HIV防控工作的重点;在卫生服务体系层面上,整合多方力量,充分发挥计生和妇幼等服务网络的优势开展防治工作是未来HIV防控工作的可行方案;从服务体系监测能力而言,中国HIV/AIDS监测水平近年来取得了长足的进步,但在基层实践层面,统一理解、运用并逐步健全常规化监测体系的流程设计是必要的;从干预重点及迫切性考虑,需要加大对项目资金使用效率的论证,开发面向不同风险人群的AIDS政策、干预服务内容以及相应的资源配置措施。
Backgrounds The HIV/AIDS/STI prevention and control subproject of the ninth health project funded by the World Bank Loan, H9-HIV/AIDS/STI, is the first large-scaled comprehensive project in combating HIV/STI epidemics in China. It was launched in response to the souring HIV/STI epidemics in China in the late 1980s. It was designed to build key facilities for HIV/STI prevention and control, promote earlier implementation of China’s First Ten Year HIV/AIDS Control Plan in areas hardest hid by or at the highest risk for HIV/STIs and explore effective policies and measures to inform nation-wide battle against the epidemics. The project was implemented in 35 prefectures and 55 counties in Xinjiang, Guangxi, Fujian, and Shanxi province or autonomous regions and China Central CDC. The project total budget was $39.99 million including $25.00million (62.52%) from World Bank Loan and $14.99 million (37.4%) counterpart fund from Chinese governments at different levels. The project was formally initiated in November, 1999 and ended in June, 2008.
Objectives To evaluate the fulfillment of the planned project goals, effectiveness and impacts of the project implementation. To summarize the accomplished achievements and lessons learned.
Methods We employed a combination of both qualitative and quantitative methods including record/document reviews, key informant qualitative interviews, focus group meetings, structured KAP surveys, knowledge examinations, case studies. Historical comparisons among different time points and case-control study between project and non-project counties were used.
Results More than 65% policies in four provinces and 98% policies developed in project counties were supported by H9. These regional policies target long-term planning, political commitment, social mobilization, skill support, general population health education, high risk/vulnerable population intervention, aids for AIDS patients and HIV infectors, blood management, STI clinical comprehensive service management, HIV surveillance, condom spread. 209 HIV surveillant sentinels were established in four project provinces and among them, 146 were financed directly by H9. By the end of 2007, 30 national HIV/AIDS/STI technological formulations providing national guidelines were developed by H9.The rate of correct responses to HIV/AIDS/STI questions among the general public increased from 3.1% in 2002 to 17.4% in 2007 in project areas contrasted with 0.8% to 3.8% in non-project counties. Knowledge and behavior of local government officers are also better than non-project counties– the awareness rate of basic HIV knowledge in project counties is 83.6% versus 81.1% (P<0.05). Knowledge and attitude to HIV/AIDS/STIs among the clinical medical professionals in the project counties are better than those of the non-project counties with important and significant difference in STI diagnosis and treatment and clinical behavior intervention. Condom use (during the last sexual event) among the general population increased from 19.8% in 2002 to 30.1% in 2007contrasted with 11.4% to 25.6% in non project counties in the same period.The prevalence rate of Gonorrhea, Chlamydia infection, Syphilis, Verruca Acuminata and Herpes Genitals among female sexual workers in project counties was lower than that in the control counties (15.1% versus 25%, P<0.001) The expert team members developed in H9 began to provide extend technology and skill to the non-project regions. Some project regions with good intervention experiences were introduced nationally from 2006.
Conclusions The overall goals of the project and the main objectives in each component have been realized with some areas even have surpassed the original design.The experience concluded and lessons learned provides a unique opportunity to explore the long term comprehensive STI/HIV intervention in a low-middle income country setting. Project plays a very important role in policy development and implementation, leadership development, HIV knowledge-behavior-attitude change, skill development. At the same time, the local economic, culture and policy transition promote and deepened the project implementation. The evaluation suggests that good governance and a conducive culture are important prerequisites for incorporating a new project within an existing system. Integrated project planning played an important role in shared value introduction and spread. Robust policy-making helps to systematize and institutionalize the planning mechanisms. The interactive effect of project and political commitment is another key factor that contributed to the success of project. Systematic management and technology staffs training promote the providers’skill and attitude. Active collaboration between researchers and service agencies results in successful program adoption. A unified resource allocation mechanism was efficient in strengthening resource linkage in fighting AIDS.
The evaluation also suggests that the HIV/STI prevention and control does not extend to all the regions currently. Low income and rural area should be received high attention in the next stage concerning the equity of health intervention. Making full use of family planning and maternal and children health service net in HIV control is the practicable mechanism in future health service system strengthening. HIV/AIDS surveillance level was improved recently, unified understanding toward surveillance and unified flowing chart of the HIV surveillance is essential for the grass-root institution and staff. Developing the AIDS policies, intervention package and relevant resource distribution scheme targeting diversified HIV risk population will help to enhance the resource efficiency.
目的评价H9-HIV/AIDS/STI项目的目标实现程度、有效性以及影响因素,总结该项目的经验及教训。
方法综合运用定性和定量研究方法。通过数据填报、数据索取、综合现场调查(定性访谈、多部门座谈、问卷调查与考核)等方法收集数据,采用描述性分析方法与比较分析方法(项目地区计划与执行情况比较、项目实施前后/趋势比较、项目县与非项目县比较),进行全面评估。
结果H9支持了四个项目省中65%的省级政策及98%的项目县防治政策的开发与执行。这些政策包括地域性防治长期规划、政治承诺、社会动员、技术支持、大众健康教育、高危/脆弱人群健康干预、AIDS患者及HIV感染者救助、血液管理、STI临床综合诊疗流程管理、HIV监测、安全套发放。截至2007年末,H9共支持30个国家级HIV/AIDS/STI技术方案及指南的开发与普及。项目实施期间,四省共建设209个HIV监测哨点,其中H9筹建了其中147个哨点。调查项目地区大众HIV/AIDS/STI问题知晓率从2002年3.1%上升到2007年17.4%,明显高于非项目地区同期从0.8%到3.8%的上升速度;项目地区地方政府官员知识、行为得分高于非项目地区,知晓率分别为83.6%,81.1%,差异有显著性;项目地区临床医生HIV/AIDS/STI相关知识态度得分高于非项目地区同水平医生得分,并且在STI诊断和治疗知识得分上差异呈显著性;项目地区公众最近一次性行为安全套使用率从2002年的19.8%上升到2007的30.1%,上升速度及使用率均高于非项目地区同期的11.4%及25.6%;项目地区女性商业性服务者淋病、衣原体感染、梅毒、尖锐湿疣、生殖器疱疹患病率低于非项目地区(分别为15.1%及25%, P<0.001)。H9项目组建发展的专家团队为非项目地区提供了大量的技术支持,自2006年,项目地区的实施经验开始逐步向全国推广;项目地区与非项目地区之间管理与技术人员的频繁交流与调动,使得项目地区获得的经验、知识和技能迅速传播至非项目地区;通过项目实施,探索了一批卓有成效的干预模式,为以后的MSM、娱乐场所暗娼、静脉注射吸毒者和青年/学生等人群干预以及性病规范化管理等提供了有益的借鉴。
结论H9-HIV/AIDS/STI作为我国第一个综合性STI/HIV社区干预项目,项目的总体目标及各领域主要目标基本实现,部分目标超过原先设计要求。项目在促进地区HIV政策研发与实施、政府领导层开发、HIV知识—行为—态度的改变、技术人员能力开发等方面发挥显著作用,同时,项目地区经济、文化、政策变迁等环境因素对项目实施效果也有极大的促进作用。H9-HIV/AIDS/STI项目终末评估分析认为良性管理和创造适宜文化背景是引入新项目的重要前提;整合的项目计划有利于推动价值观在社区成员内的共享;强有力的政策制订使计划方案更具有系统性和规范性;H9-HIV/AIDS/STI与政治承诺的交互作用是项目成功的另一个关键因素;系统、长期的人员培训及相关技能手册、指南的开发极大地提升了服务提供者STI/HIV相关知识技能,改善了服务水平;研究人员及服务机构之间的合作有利于推动地区实践与研究的结合,提高了循征决策水平;统一的资源配置机制在加强资源整合方面是非常必要的,根据HIV防控目标群体以及不同地区的流行情况进行资源的合理分配有利于避免地区资源分配的不平衡,保障项目的设计、实施与评估环节的完整性。
评估还提示现阶段HIV/STI防控尚未在所有领域完全铺开。从卫生服务公平性角度出发,在农村以及低收入地区加大监管力度是HIV防控工作的重点;在卫生服务体系层面上,整合多方力量,充分发挥计生和妇幼等服务网络的优势开展防治工作是未来HIV防控工作的可行方案;从服务体系监测能力而言,中国HIV/AIDS监测水平近年来取得了长足的进步,但在基层实践层面,统一理解、运用并逐步健全常规化监测体系的流程设计是必要的;从干预重点及迫切性考虑,需要加大对项目资金使用效率的论证,开发面向不同风险人群的AIDS政策、干预服务内容以及相应的资源配置措施。
Backgrounds The HIV/AIDS/STI prevention and control subproject of the ninth health project funded by the World Bank Loan, H9-HIV/AIDS/STI, is the first large-scaled comprehensive project in combating HIV/STI epidemics in China. It was launched in response to the souring HIV/STI epidemics in China in the late 1980s. It was designed to build key facilities for HIV/STI prevention and control, promote earlier implementation of China’s First Ten Year HIV/AIDS Control Plan in areas hardest hid by or at the highest risk for HIV/STIs and explore effective policies and measures to inform nation-wide battle against the epidemics. The project was implemented in 35 prefectures and 55 counties in Xinjiang, Guangxi, Fujian, and Shanxi province or autonomous regions and China Central CDC. The project total budget was $39.99 million including $25.00million (62.52%) from World Bank Loan and $14.99 million (37.4%) counterpart fund from Chinese governments at different levels. The project was formally initiated in November, 1999 and ended in June, 2008.
Objectives To evaluate the fulfillment of the planned project goals, effectiveness and impacts of the project implementation. To summarize the accomplished achievements and lessons learned.
Methods We employed a combination of both qualitative and quantitative methods including record/document reviews, key informant qualitative interviews, focus group meetings, structured KAP surveys, knowledge examinations, case studies. Historical comparisons among different time points and case-control study between project and non-project counties were used.
Results More than 65% policies in four provinces and 98% policies developed in project counties were supported by H9. These regional policies target long-term planning, political commitment, social mobilization, skill support, general population health education, high risk/vulnerable population intervention, aids for AIDS patients and HIV infectors, blood management, STI clinical comprehensive service management, HIV surveillance, condom spread. 209 HIV surveillant sentinels were established in four project provinces and among them, 146 were financed directly by H9. By the end of 2007, 30 national HIV/AIDS/STI technological formulations providing national guidelines were developed by H9.The rate of correct responses to HIV/AIDS/STI questions among the general public increased from 3.1% in 2002 to 17.4% in 2007 in project areas contrasted with 0.8% to 3.8% in non-project counties. Knowledge and behavior of local government officers are also better than non-project counties– the awareness rate of basic HIV knowledge in project counties is 83.6% versus 81.1% (P<0.05). Knowledge and attitude to HIV/AIDS/STIs among the clinical medical professionals in the project counties are better than those of the non-project counties with important and significant difference in STI diagnosis and treatment and clinical behavior intervention. Condom use (during the last sexual event) among the general population increased from 19.8% in 2002 to 30.1% in 2007contrasted with 11.4% to 25.6% in non project counties in the same period.The prevalence rate of Gonorrhea, Chlamydia infection, Syphilis, Verruca Acuminata and Herpes Genitals among female sexual workers in project counties was lower than that in the control counties (15.1% versus 25%, P<0.001) The expert team members developed in H9 began to provide extend technology and skill to the non-project regions. Some project regions with good intervention experiences were introduced nationally from 2006.
Conclusions The overall goals of the project and the main objectives in each component have been realized with some areas even have surpassed the original design.The experience concluded and lessons learned provides a unique opportunity to explore the long term comprehensive STI/HIV intervention in a low-middle income country setting. Project plays a very important role in policy development and implementation, leadership development, HIV knowledge-behavior-attitude change, skill development. At the same time, the local economic, culture and policy transition promote and deepened the project implementation. The evaluation suggests that good governance and a conducive culture are important prerequisites for incorporating a new project within an existing system. Integrated project planning played an important role in shared value introduction and spread. Robust policy-making helps to systematize and institutionalize the planning mechanisms. The interactive effect of project and political commitment is another key factor that contributed to the success of project. Systematic management and technology staffs training promote the providers’skill and attitude. Active collaboration between researchers and service agencies results in successful program adoption. A unified resource allocation mechanism was efficient in strengthening resource linkage in fighting AIDS.
The evaluation also suggests that the HIV/STI prevention and control does not extend to all the regions currently. Low income and rural area should be received high attention in the next stage concerning the equity of health intervention. Making full use of family planning and maternal and children health service net in HIV control is the practicable mechanism in future health service system strengthening. HIV/AIDS surveillance level was improved recently, unified understanding toward surveillance and unified flowing chart of the HIV surveillance is essential for the grass-root institution and staff. Developing the AIDS policies, intervention package and relevant resource distribution scheme targeting diversified HIV risk population will help to enhance the resource efficiency.
引文
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