不同告知时间的HIV感染者危险性行为及影响因素研究
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摘要
危险性行为是指在所有同性或异性性生活过程中能够引起双方血液及体液交换的性行为。性传播已成为目前导致中国艾滋病病毒(HIV)流行的主要途径。HIV感染者的危险性行为除可能造成HIV二代传播外,也可能使本人感染性传播疾病和机会性感染病原体,或重复感染不同型别毒株或耐药毒株,影响抗病毒治疗效果。
到2007年10月底,全国累计报告HIV感染者和艾滋病病人223,501例,行为调查结果亦证明该人群危险性行为发生仍然存在。随着监测、流行病学调查、自愿咨询检测和感染者随访管理工作力度的不断加大,越来越多的感染者将被确认并告知阳性检测结果,同时抗病毒治疗可能使他们存活时间延长,增加了传播HIV的机会。良好有效的卫生服务和行为干预措施有助于减少HIV感染者危险性行为,从而有效控制HIV传播。
本研究通过了解不同告知时间的HIV感染者危险性行为发生情况,探讨个人性伴,家庭和社会环境以及医疗卫生服务因素对HIV感染者危险性行为的影响,建立基于健康行为理论的HIV感染者危险性行为路径模型,为疫情估计提供基础数据,为改进HIV感染者医疗卫生服务措施提供依据。
方法
本研究采用定量调查和定性调查相结合的方式,于2008年7月至12月对云南省德宏傣族景颇族自治州潞西市,盈江县,广西壮族自治区柳州市鹿寨县和贺州市八步区1120名HIV感染者通过面对面访谈进行了问卷调查,调查对象年龄18至49岁,于2006年1月至2008年12月HIV抗体确认阳性并被告知结果。同时对38名HIV感染者和20名工作人员分别进行了个人和小组访谈。
定量调查研究设计包括组间比较和组内比较,对于调查对象中的HIV感染者夫妇,随机选择其中一方作为研究对象。组间比较首先对974名新告知组和已告知组调查对象过去6个月危险性行为进行比较分析,探讨告知前后两组危险性行为的差异,以及个人、性伴和性行为因素的影响；其次对836名已告知组调查对象过去6个月危险性行为进行比较分析,探讨已告知不同时间组危险性行为的差异,以及个人、性伴和性行为、家庭和社会支持以及医疗卫生服务的影响,并建立基于健康行为理论的HIV感染者危险性行为预测模型。组内比较即对177名2008年1月至6月告知组告知前后危险性行为进行比较分析,探讨同一组调查对象告知前后危险性行为的差异,以及个人、性伴和性行为、家庭和社会支持以及医疗卫生服务等对告知后危险性行为的影响。
HIV感染者个人访谈内容包括接受医疗卫生服务情况,阳性结果通知和安全套使用行为等；工作人员小组访谈内容包括安全套推广工作现状、存在问题和建议以及工作人员需求等。
结果
974名调查对象中,新告知组138人(14.2%)；已告知组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%),盈江县330人(50.6%),广西322人,占33.1%,其中鹿寨县164人(50.9%),八步区158人(49.1%)；男性553人,占56.8%,女性421人,占43.2%；年龄最小18岁,最大49岁,平均年龄为32.5±7.2岁,年龄中位数为32岁。
974名调查对象中,704人过去6个月曾发生过性行为,占72.3%,其中仅与固定性伴发生性行为者623人,占88.5%,仅与非固定性伴发生性行为者50人,占7.1%,与固定和非固定性伴均发生过性行为者31人,占4.4%。
1.不同告知时间的HIV感染者危险性行为
组间比较结果显示,974名调查对象中,已告知组70.5%(549/836)过去6个月发生性行为,显著低于新告知组(83.3%)；发生性行为者中,已告知组坚持正确使用安全套(第三阶段)者所占比例(55.7%)高于新告知组(7.0%),而无安全套使用意向者(第一阶段)所占比例(9.3%)低于新告知组(18.3%),已告知组最近一次与固定和非固定性伴发生性行为时使用安全套的比例分别为72.7%和66.7%,而新告知组上述比例分别为16.2%和22.2%。
组内比较结果显示,177名调查对象中,未发生性行为者由告知前的27.7%上升到告知后的30.5%,安全套使用行为处于第三阶段者由13.6%上升到36.2%,而安全套使用行为处于第二阶段和第一阶段者分别由48.6%和10.2%下降至26.6%和6.8%,告知前后行为分布的状况有显著差异,且存在一致性。
已告知各组调查对象发生性行为的比例无明显差异,但是与2006年告知组相比,2007年1月至6月告知组无使用安全套意向(第一阶段)的概率较低,提示安全套使用意识和行为在被告知阳性结果后不同时间段有所不同。
2.影响因素
2.1个人基本情况
本研究发现,云南调查对象报告危险性行为发生率高于广西。省份为广西者感知的艾滋病易感性水平较高,其差异可能与调查偏倚以及环境因素有关；女性安全套使用自我效能低于男性,因此也更容易发生危险性行为；年龄较大组发生性行为的概率较低,但与安全套使用行为阶段无显著关联；与伴侣共同生活者(已婚/同居者)发生性行为概率以及坚持使用安全套的比例均较高；已告知各组调查对象中,小学文化程度者安全套使用行为处于第二阶段者的概率低于高中以上组；家庭人均月收入高者发生性行为比例较高,且更可能坚持使用安全套。组内比较结果显示,注射毒品传播和性传播者告知后不安全行为发生概率无显著差异,而其他途径传播者发生不安全行为的风险高于与注射毒品传播者,由于样本量较小,判断传播途径和不安全性行为之间的关联应谨慎。此外,本研究未发现吸毒和饮酒与危险性行为有显著关联。
调查对象感知的艾滋病严重性、易感性、安全套使用益处和障碍以及自我效能和社会规范等可能直接或通过其他认知态度因素间接影响安全套使用行为阶段,安全套使用障碍对于安全套使用行为阶段影响最为明显,其次是艾滋病易感性、自我效能和社会规范,而艾滋病严重性和安全使用益处对安全套使用行为阶段的影响较小,且为间接效应。艾滋病病人感知的易感性、安全套使用益处和社会规范水平均高于无症状感染者,艾滋病知识知晓者感知的艾滋病严重性、易感性和社会规范水平较高,因而上述两组坚持使用安全套的概率较高；负面情绪水平高者,感知的艾滋病严重性和安全套使用障碍水平较高,而感知的艾滋病易感性水平较低,容易发生不安全性行为。
2.2性伴和性行为
本研究发现,HIV感染者之间发生危险性行为的概率高于阴性性伴,而与阳性性伴和感染状况不明性伴发生危险性行为的差别无统计学意义。HIV感染者与固定性伴发生危险性行为的概率较低,尤其是保持性关系较长者。有非固定性伴者安全套使用行为处于第一阶段的概率较高,且同时有固定和非固定性伴者发生危险性行为的概率高于仅有非固定性伴者。定性访谈结果亦提示某些有固定性伴的HIV感染者因为不愿意使用安全套而与其他性伴发生性行为。本研究发现多数HIV感染者固定性伴知晓感染状况,而非固定性伴知晓率较低,但本研究未证明性伴知晓情况与危险性行为发生存在关联。HIV感染者安全套使用行为与性伴类型无关。性行为频率较低者,坚持使用安全套比例较高。
2.3家庭和社会支持
由于担忧被歧视,HIV感染者通常不愿意暴露本人感染状况,但愿意将结果告知关系密切者。已告知组调查对象中,78.7%亲人知晓感染状况,27.2%其他人知晓感染状况,72.7%获得支持,23.1%感到歧视。研究结果显示,未获得支持者无安全套使用意向的概率较高,感到歧视则增加了不坚持使用安全套的风险。此外,参与感染者小组活动者无安全套使用意向者比例较低,获得物质经济支持者发生性行为的比例略高,但对安全套使用行为阶段的影响不显著。
2.4医疗卫生服务
本研究结果显示,获得良好检测和告知服务者坚持使用安全套概率较高。良好检测和告知服务包括获得知情同意,由医生或者防疫人员单独告知本人结果以及检测前后获得充分信息等。
定性访谈结果显示,免费安全套在质量、性能、款式和包装等方面存在的问题可能影响其可接受性,部分HIV感染者由于担心身份泄露不愿意接受免费安全套。已告知组调查对象中,65.3%均获得了免费安全套,获得安全套者性行为发生概率较高,但危险性行为发生概率较低。这可能由于免费安全套发放改善了安全套可及性,也可能与样本选择偏倚或社会期望偏倚有关。
本研究结果表明,获得面对面信息交流者安全套使用行为处于第二阶段的概率高于第三阶段,而行为处于第一阶段的比例较低,提示面对面信息交流者有助于提高安全套使用意向,但促进坚持使用安全套的作用有限；获得公众艾滋病信息者和参加艾滋病预防宣传教育活动者发生危险性行为的可能性较高,可能与选择偏倚有关；是否获得安全套使用信息与过去6个月安全套使用行为阶段无关,但获得安全套使用信息者发生性行为比例较高,可能与发生性行为者更关注安全套使用信息有关。
已告知各组调查对象中,58.9%(492/836)接受抗病毒治疗。接受抗病毒治疗者安全套使用行为处于第三阶段的概率较高,而行为处于第一阶段的概率较低。多因素分析结果显示,接受抗病毒治疗与安全套使用行为阶段的关联未达显著性水平。
结论
在被告知阳性检测结果后,HIV感染者危险性行为较之前有所下降。HIV感染者的危险性行为与个人,性伴、家庭和社会支持以及医疗卫生服务等多种因素有关。建议进一步加强HIV检测咨询、告知和随访管理工作,改善卫生服务质量；根据干预对象特点和行为特征采取有针对的干预措施,干预过程中应重视认知态度的变化；以社区和家庭为单位开展有针对性的预防宣传工作,以减少歧视,促进针对HHIV感染者的社会支持。
Background and objectives
Sexual risk behavior refers to all those behaviors that result in exchange of body fluids between sex partners when having sex. Sexual transmission has become the most common HIV transmission route in China. Besides the secondary transmission of HIV, sexual risk behaviors also make people living with HIV/AIDS (PLHA) infected with other pathogens that causes STDs and opportunistic infections or reinfected with HIV of other subtypes or drug resistance strains, which may decrease the effectiveness of antiretroviral therapy.
By the end of October2007, the cumulative number of reported HIV positive cases in China was223,501. Data from behavioral investigations showed that sexual risk behaviors still commonly existed among those reported. With the strengthened implementation of HIV surveillance, epidemiological investigations and HIV voluntary counseling and testing, more HIV/AIDS cases will be detected, and use of antiretroviral therapy may prolong their life, which increase the probability of HIV transmission. Valid health care service and intervention strategies may reduce sexual risk behaviors among PLHA to prevent the spread of HIV.
This study investigated the sexual risk behaviors and related factors of PLHA over different time period after being notified as HIV sero-positive to explore the impact of factors at individual, family and community level as well as health care services on the sexual risk behaviors and to construct the health behavior theory based model of sexual risk behavior through path analysis so as to provide data for HIV/AIDS estimation and projection as well as evidence for improve the health care services on PLHA.
Methods
Both quantitative and qualitative investigations were used in this study. During July to December2008, a face to face questionnaire survey on1120 PLHA aged18to49years old who were detected and notified as HIV sero-positive from2006to2008was conducted in Luxi city and Yingjiang County of Dehong Zhou, Yunnan province and Luzhai county of Liuzhou city and Babu district of Hezhou city, Guangxi province. Also in-depth interview and group interview were conducted respectively on38PHLA and20staffs at primary level.
Between-group and within group comparison were used for quantitative survey. Only one of HIV infection couples was randomly involved in data analysis. Firstly, Sexual risk behaviors of974PHLA during the past6months were compared between those who were newly notified and those who had been notified as sero-positive at least6months to explore the difference of sexual risk behaviors between the2groups as well as the impact of individual, sex partner and frequency of sexual behavior.
Secondly, sexual risk behaviors during the past6months of836PLHA who had been notified as sero-positive at least6months ago were analyzed to explore the difference of sexual risk behaviors among those over different time period after being notified and correlates of individual, sex partner, family and community and health care services as well. Also, a health behavior theory based model for sexual risk behavior of PLHA was constructed.
Thirdly, sexual risk behavior of177PLHA during6months before and after being notified as sero-positive was compared to explore the difference of sexual risk behaviors within group. Moreover, correlates of individual, sex partner, family and community and health care services were also determined.
In-depth interview targeted at PLHA aimed to learn about the status of health care services, HIV sero-positive disclosure and condom using behavior. Group interview on staffs include status of condom promotion, problems and suggestions as well as the needs of staffs.
Results
Of974participants,138(14.2%) were newly notified and836(85.8%) had been notified at least6months ago of whom174(20.8%) were notified during January to June2008,234(28.0%) during July to December2007,242(28.9%) during January to June2007and186人(22.2%) were notified in2006. Of974participants,652(66.9%) were from Yunnan with322(49.4%) from Luxi and 330(50.6%) from Yingjiang,322(33.1%) were from Guangxi with164(50.9%) from Luzhai and158(49.1%) form Babu;553(56.8%) were male and421(43.2%) were female. The age ranged18to49years old with mean of32.5+7.2and medium of32years old.
Of974participants,704(72.3%) had had sex behavior during the past months with623(88.5%) having regular sex partner,50(7.1%) having casual sex partner and31(4.4%) having both。
1. Sexual behavior over different time period after being notified as seropositive.
Data from between group comparison showed that70.5%of those who had been notified had had sex behavior during the past6months, which was significantly less than that (83.3%) of those who were newly notified. And among those who had had sex, the proportion of consistent condom use was higher and the proportion of precontemplation stage of condom use was lower by those who had been notified than who were newly notified. Of those who had been notified, the proportion of condom use with regular and casual partner when having sex last time were72.7%and66.7%and of those who were newly notified, the proportion were16.2%and22.2%respectively.
Within group comparison showed that during6months before and after being notified, the proportion of those who had not had sex behavior was27.7%and30.5%and the proportion of those who had use condom consistently was13.6%and36.2%, while the proportion of those at the second and precontemplation stage of condom use decreased from48.6%and10.2%to26.6%and6.8%. Both difference and agreement of distribution of sexual risk behavior before and after being notified had achieved statistical significance.
Among the groups over different time period after being notified, the difference of proportion of those who had had sex behavior had not achieved significant. However, the proportion of precontemplation stage of condom use reported by participants notified during January to June,2007was lower than by those notified in2006, which implied that there was some difference on sexual risk behavior over different time period after being notified.
2. Associated factors
2.1personal characteristics
It is found that sexual risk behavior reported by participants from Yunnan province was higher than those from Guangxi who had higher level of perceived HIV susceptibility. The difference of2provinces may be related to environmental factors or information bias. Condom use self efficacy was lower among females, so was the condom using behavior. The older age group reported lower proportion of sexual behavior. But age was not significantly related to condom using behavior. Those who had lived together with their sex partner(married of cohabitated) reported higher proportion of sexual behavior and condom use as well.
Among those who had been notified, PLHA with education background of primary school reported more second stage of condom use than those with education of high school. The probability of have sex and consistent condom use were higher among those with larger income. The between group comparison showed that there was no significant difference on sexual risk behavior between those who were infected through injection drug use and through sexual risk behavior, but sexual risk behavior was higher among those transmitted trough other routes than through injection drug use. However, in consideration of small sample size of PLHA transmitted through other routes, it still need further evidence to determine the relationship between transmission route and sexual risk behavior. In addition, no statistically significant relation was found between drug of alcohol use and sexual risk behavior.
Perceived HIV/AIDS severity, susceptibility, benefit and barrier of condom use, self efficacy and social norms may influence the stages of condom use directly or indirectly through other personal beliefs. The effect of perceived barriers was most significant, followed by HIV susceptibility, self efficacy and social norms. Perceived HIV severity and benefit only had little indirect effect on condom use. Level of perceived HIV susceptibility and benefit of condom use and social norms of AIDS patients was higher than asymptomatic HIV infections and perceived HIV severity, susceptibility and social norms was higher among those who was aware of HIV/AIDS knowledge, so the2groups said above inclined to use condom consistently. Besides, perceived HIV severity and barriers of condom use were higher and HIV susceptibility lower among those who had high level of negative emotion and sexual risk behavior as well.
2.2sex partner and sexual behavior
It is found that PLHA reported higher proportion of sexual risk behavior with HIV seropositives than with seronegatives. But no statistically significant difference of sexual risk behaviors was found between PLHA with seropositive partner and with partner of unknown serostatus. The probability of sexual risk behavior was lower between PLHA and their regular sex partner, especially those with longer relationship. PLHA who had casual sex partners inclined to report precontemplation stage of condom use. Also, those who had both types of sex partner reported more risk behavior than those who had only casual sex partners. Indepth interview showed that some PLHA who had regular sex partner seek to have unsafe sex with casual sex partners because of unwilling to use condom. Regular sex partners of most PLHA learn about their seropositive status but casual sex partners of most PLHA not. However, sex partner notification was not found be to significantly related to sexual risk behavior. Also, Sexual risk behavior was not related to types of sex partners. In addition, the proportion of consistent condom use was higher for those with less frequent sexual episode.
2.3Family and social supports
Concerned about social discrimination, PLHA were not willing to disclosure seropositive status to others except those with whom they had intimate relationship. Seropositive status of78.7%of those who had been notified was learned by relatives and27.2%by others. And72.7%gained support and23.1%experienced discrimination. It is found that PLHA who had not gained supports reported higher proportion of precontemplation stage of sexual risk behaviors and experience of discrimination increased the risk of inconsistent condom use. In addition, PLHA who participated the group activities of PLHA reported lower proportion of precontemplation stage of condom use behavior and social economic support raised the proportion of have sex, but was not significantly associated with condom use.
2.4Health care services
It is indicated that PLHA who got standardized HIV counseling and testing service reported higher proportion of consistent condom use. In this study, standardized HIV counseling and testing service was defined as informed consent and sufficient information provided before HIV testing and being notified by health care workers face to face privately and sufficient information provided after HIV tesing.
The result of the interview showed that there were some problems with condom provided for free on the quality, function, style and casing as well, which decreased the acceptability. Besides, taking thought of social discrimination, some PLHA refused to accept free condom. Of those who had been notified as sero-positive,65.3%accepted free condom during the past6months. Moreover, PLHA who had accepted free condom reported higher proportion of having sex but lower proportion of sexual risk behaviors, which may because of the enhanced accessibility of condom through providing condom for free or the bias of selection and social desire.
Data from this study showed that PLHA who got face to face communication service reported higher proportion of the second stage of condom using behavior and lower proportion of precomtemplation stage, which indicated that face to face communication help raise the intention of condom use but not use of condom consistently. The probability of sexual risk behavior was higher for those who acquired HIV related information through mass media and who participated HIV/AIDS awareness campaign, which may be the result of selection bias. Getting condom use information was not relate to the stage of condom use but with having sex behavior, which is related to more attention on condom use information for those who had had sex behavior.
Among those who had been notified,58.9%(492/836) had accepted antiretroviral therapy (ART). The probability of maintenance stage of condom using behavior among those who had accepted ART was higher and the probability of precontemplation stage was lower. But data form multivariate analysis showed that relation between ART and sexual risk behavior had not achieved significance.
Conclusions
After being notified as sero-positive, PLHA decreased their sexual risk behavior. Sexual risk behavior was determined comprehensively by factors at individual, sex partner, family and community level as well as health care services. It is suggested that HIV counseling and testing, notification of testing results and following up of PLHA be strengthened and improved; Intervention strategy should be tailor to different characteristics of PLHA and their stage of sexual risk behaviors and personal beliefs should be focused on; Family and community based awareness campaign should be carried out to reduce HIV related discrimination and promote social support for PLHA.
到2007年10月底,全国累计报告HIV感染者和艾滋病病人223,501例,行为调查结果亦证明该人群危险性行为发生仍然存在。随着监测、流行病学调查、自愿咨询检测和感染者随访管理工作力度的不断加大,越来越多的感染者将被确认并告知阳性检测结果,同时抗病毒治疗可能使他们存活时间延长,增加了传播HIV的机会。良好有效的卫生服务和行为干预措施有助于减少HIV感染者危险性行为,从而有效控制HIV传播。
本研究通过了解不同告知时间的HIV感染者危险性行为发生情况,探讨个人性伴,家庭和社会环境以及医疗卫生服务因素对HIV感染者危险性行为的影响,建立基于健康行为理论的HIV感染者危险性行为路径模型,为疫情估计提供基础数据,为改进HIV感染者医疗卫生服务措施提供依据。
方法
本研究采用定量调查和定性调查相结合的方式,于2008年7月至12月对云南省德宏傣族景颇族自治州潞西市,盈江县,广西壮族自治区柳州市鹿寨县和贺州市八步区1120名HIV感染者通过面对面访谈进行了问卷调查,调查对象年龄18至49岁,于2006年1月至2008年12月HIV抗体确认阳性并被告知结果。同时对38名HIV感染者和20名工作人员分别进行了个人和小组访谈。
定量调查研究设计包括组间比较和组内比较,对于调查对象中的HIV感染者夫妇,随机选择其中一方作为研究对象。组间比较首先对974名新告知组和已告知组调查对象过去6个月危险性行为进行比较分析,探讨告知前后两组危险性行为的差异,以及个人、性伴和性行为因素的影响；其次对836名已告知组调查对象过去6个月危险性行为进行比较分析,探讨已告知不同时间组危险性行为的差异,以及个人、性伴和性行为、家庭和社会支持以及医疗卫生服务的影响,并建立基于健康行为理论的HIV感染者危险性行为预测模型。组内比较即对177名2008年1月至6月告知组告知前后危险性行为进行比较分析,探讨同一组调查对象告知前后危险性行为的差异,以及个人、性伴和性行为、家庭和社会支持以及医疗卫生服务等对告知后危险性行为的影响。
HIV感染者个人访谈内容包括接受医疗卫生服务情况,阳性结果通知和安全套使用行为等；工作人员小组访谈内容包括安全套推广工作现状、存在问题和建议以及工作人员需求等。
结果
974名调查对象中,新告知组138人(14.2%)；已告知组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%),盈江县330人(50.6%),广西322人,占33.1%,其中鹿寨县164人(50.9%),八步区158人(49.1%)；男性553人,占56.8%,女性421人,占43.2%；年龄最小18岁,最大49岁,平均年龄为32.5±7.2岁,年龄中位数为32岁。
974名调查对象中,704人过去6个月曾发生过性行为,占72.3%,其中仅与固定性伴发生性行为者623人,占88.5%,仅与非固定性伴发生性行为者50人,占7.1%,与固定和非固定性伴均发生过性行为者31人,占4.4%。
1.不同告知时间的HIV感染者危险性行为
组间比较结果显示,974名调查对象中,已告知组70.5%(549/836)过去6个月发生性行为,显著低于新告知组(83.3%)；发生性行为者中,已告知组坚持正确使用安全套(第三阶段)者所占比例(55.7%)高于新告知组(7.0%),而无安全套使用意向者(第一阶段)所占比例(9.3%)低于新告知组(18.3%),已告知组最近一次与固定和非固定性伴发生性行为时使用安全套的比例分别为72.7%和66.7%,而新告知组上述比例分别为16.2%和22.2%。
组内比较结果显示,177名调查对象中,未发生性行为者由告知前的27.7%上升到告知后的30.5%,安全套使用行为处于第三阶段者由13.6%上升到36.2%,而安全套使用行为处于第二阶段和第一阶段者分别由48.6%和10.2%下降至26.6%和6.8%,告知前后行为分布的状况有显著差异,且存在一致性。
已告知各组调查对象发生性行为的比例无明显差异,但是与2006年告知组相比,2007年1月至6月告知组无使用安全套意向(第一阶段)的概率较低,提示安全套使用意识和行为在被告知阳性结果后不同时间段有所不同。
2.影响因素
2.1个人基本情况
本研究发现,云南调查对象报告危险性行为发生率高于广西。省份为广西者感知的艾滋病易感性水平较高,其差异可能与调查偏倚以及环境因素有关；女性安全套使用自我效能低于男性,因此也更容易发生危险性行为；年龄较大组发生性行为的概率较低,但与安全套使用行为阶段无显著关联；与伴侣共同生活者(已婚/同居者)发生性行为概率以及坚持使用安全套的比例均较高；已告知各组调查对象中,小学文化程度者安全套使用行为处于第二阶段者的概率低于高中以上组；家庭人均月收入高者发生性行为比例较高,且更可能坚持使用安全套。组内比较结果显示,注射毒品传播和性传播者告知后不安全行为发生概率无显著差异,而其他途径传播者发生不安全行为的风险高于与注射毒品传播者,由于样本量较小,判断传播途径和不安全性行为之间的关联应谨慎。此外,本研究未发现吸毒和饮酒与危险性行为有显著关联。
调查对象感知的艾滋病严重性、易感性、安全套使用益处和障碍以及自我效能和社会规范等可能直接或通过其他认知态度因素间接影响安全套使用行为阶段,安全套使用障碍对于安全套使用行为阶段影响最为明显,其次是艾滋病易感性、自我效能和社会规范,而艾滋病严重性和安全使用益处对安全套使用行为阶段的影响较小,且为间接效应。艾滋病病人感知的易感性、安全套使用益处和社会规范水平均高于无症状感染者,艾滋病知识知晓者感知的艾滋病严重性、易感性和社会规范水平较高,因而上述两组坚持使用安全套的概率较高；负面情绪水平高者,感知的艾滋病严重性和安全套使用障碍水平较高,而感知的艾滋病易感性水平较低,容易发生不安全性行为。
2.2性伴和性行为
本研究发现,HIV感染者之间发生危险性行为的概率高于阴性性伴,而与阳性性伴和感染状况不明性伴发生危险性行为的差别无统计学意义。HIV感染者与固定性伴发生危险性行为的概率较低,尤其是保持性关系较长者。有非固定性伴者安全套使用行为处于第一阶段的概率较高,且同时有固定和非固定性伴者发生危险性行为的概率高于仅有非固定性伴者。定性访谈结果亦提示某些有固定性伴的HIV感染者因为不愿意使用安全套而与其他性伴发生性行为。本研究发现多数HIV感染者固定性伴知晓感染状况,而非固定性伴知晓率较低,但本研究未证明性伴知晓情况与危险性行为发生存在关联。HIV感染者安全套使用行为与性伴类型无关。性行为频率较低者,坚持使用安全套比例较高。
2.3家庭和社会支持
由于担忧被歧视,HIV感染者通常不愿意暴露本人感染状况,但愿意将结果告知关系密切者。已告知组调查对象中,78.7%亲人知晓感染状况,27.2%其他人知晓感染状况,72.7%获得支持,23.1%感到歧视。研究结果显示,未获得支持者无安全套使用意向的概率较高,感到歧视则增加了不坚持使用安全套的风险。此外,参与感染者小组活动者无安全套使用意向者比例较低,获得物质经济支持者发生性行为的比例略高,但对安全套使用行为阶段的影响不显著。
2.4医疗卫生服务
本研究结果显示,获得良好检测和告知服务者坚持使用安全套概率较高。良好检测和告知服务包括获得知情同意,由医生或者防疫人员单独告知本人结果以及检测前后获得充分信息等。
定性访谈结果显示,免费安全套在质量、性能、款式和包装等方面存在的问题可能影响其可接受性,部分HIV感染者由于担心身份泄露不愿意接受免费安全套。已告知组调查对象中,65.3%均获得了免费安全套,获得安全套者性行为发生概率较高,但危险性行为发生概率较低。这可能由于免费安全套发放改善了安全套可及性,也可能与样本选择偏倚或社会期望偏倚有关。
本研究结果表明,获得面对面信息交流者安全套使用行为处于第二阶段的概率高于第三阶段,而行为处于第一阶段的比例较低,提示面对面信息交流者有助于提高安全套使用意向,但促进坚持使用安全套的作用有限；获得公众艾滋病信息者和参加艾滋病预防宣传教育活动者发生危险性行为的可能性较高,可能与选择偏倚有关；是否获得安全套使用信息与过去6个月安全套使用行为阶段无关,但获得安全套使用信息者发生性行为比例较高,可能与发生性行为者更关注安全套使用信息有关。
已告知各组调查对象中,58.9%(492/836)接受抗病毒治疗。接受抗病毒治疗者安全套使用行为处于第三阶段的概率较高,而行为处于第一阶段的概率较低。多因素分析结果显示,接受抗病毒治疗与安全套使用行为阶段的关联未达显著性水平。
结论
在被告知阳性检测结果后,HIV感染者危险性行为较之前有所下降。HIV感染者的危险性行为与个人,性伴、家庭和社会支持以及医疗卫生服务等多种因素有关。建议进一步加强HIV检测咨询、告知和随访管理工作,改善卫生服务质量；根据干预对象特点和行为特征采取有针对的干预措施,干预过程中应重视认知态度的变化；以社区和家庭为单位开展有针对性的预防宣传工作,以减少歧视,促进针对HHIV感染者的社会支持。
Background and objectives
Sexual risk behavior refers to all those behaviors that result in exchange of body fluids between sex partners when having sex. Sexual transmission has become the most common HIV transmission route in China. Besides the secondary transmission of HIV, sexual risk behaviors also make people living with HIV/AIDS (PLHA) infected with other pathogens that causes STDs and opportunistic infections or reinfected with HIV of other subtypes or drug resistance strains, which may decrease the effectiveness of antiretroviral therapy.
By the end of October2007, the cumulative number of reported HIV positive cases in China was223,501. Data from behavioral investigations showed that sexual risk behaviors still commonly existed among those reported. With the strengthened implementation of HIV surveillance, epidemiological investigations and HIV voluntary counseling and testing, more HIV/AIDS cases will be detected, and use of antiretroviral therapy may prolong their life, which increase the probability of HIV transmission. Valid health care service and intervention strategies may reduce sexual risk behaviors among PLHA to prevent the spread of HIV.
This study investigated the sexual risk behaviors and related factors of PLHA over different time period after being notified as HIV sero-positive to explore the impact of factors at individual, family and community level as well as health care services on the sexual risk behaviors and to construct the health behavior theory based model of sexual risk behavior through path analysis so as to provide data for HIV/AIDS estimation and projection as well as evidence for improve the health care services on PLHA.
Methods
Both quantitative and qualitative investigations were used in this study. During July to December2008, a face to face questionnaire survey on1120 PLHA aged18to49years old who were detected and notified as HIV sero-positive from2006to2008was conducted in Luxi city and Yingjiang County of Dehong Zhou, Yunnan province and Luzhai county of Liuzhou city and Babu district of Hezhou city, Guangxi province. Also in-depth interview and group interview were conducted respectively on38PHLA and20staffs at primary level.
Between-group and within group comparison were used for quantitative survey. Only one of HIV infection couples was randomly involved in data analysis. Firstly, Sexual risk behaviors of974PHLA during the past6months were compared between those who were newly notified and those who had been notified as sero-positive at least6months to explore the difference of sexual risk behaviors between the2groups as well as the impact of individual, sex partner and frequency of sexual behavior.
Secondly, sexual risk behaviors during the past6months of836PLHA who had been notified as sero-positive at least6months ago were analyzed to explore the difference of sexual risk behaviors among those over different time period after being notified and correlates of individual, sex partner, family and community and health care services as well. Also, a health behavior theory based model for sexual risk behavior of PLHA was constructed.
Thirdly, sexual risk behavior of177PLHA during6months before and after being notified as sero-positive was compared to explore the difference of sexual risk behaviors within group. Moreover, correlates of individual, sex partner, family and community and health care services were also determined.
In-depth interview targeted at PLHA aimed to learn about the status of health care services, HIV sero-positive disclosure and condom using behavior. Group interview on staffs include status of condom promotion, problems and suggestions as well as the needs of staffs.
Results
Of974participants,138(14.2%) were newly notified and836(85.8%) had been notified at least6months ago of whom174(20.8%) were notified during January to June2008,234(28.0%) during July to December2007,242(28.9%) during January to June2007and186人(22.2%) were notified in2006. Of974participants,652(66.9%) were from Yunnan with322(49.4%) from Luxi and 330(50.6%) from Yingjiang,322(33.1%) were from Guangxi with164(50.9%) from Luzhai and158(49.1%) form Babu;553(56.8%) were male and421(43.2%) were female. The age ranged18to49years old with mean of32.5+7.2and medium of32years old.
Of974participants,704(72.3%) had had sex behavior during the past months with623(88.5%) having regular sex partner,50(7.1%) having casual sex partner and31(4.4%) having both。
1. Sexual behavior over different time period after being notified as seropositive.
Data from between group comparison showed that70.5%of those who had been notified had had sex behavior during the past6months, which was significantly less than that (83.3%) of those who were newly notified. And among those who had had sex, the proportion of consistent condom use was higher and the proportion of precontemplation stage of condom use was lower by those who had been notified than who were newly notified. Of those who had been notified, the proportion of condom use with regular and casual partner when having sex last time were72.7%and66.7%and of those who were newly notified, the proportion were16.2%and22.2%respectively.
Within group comparison showed that during6months before and after being notified, the proportion of those who had not had sex behavior was27.7%and30.5%and the proportion of those who had use condom consistently was13.6%and36.2%, while the proportion of those at the second and precontemplation stage of condom use decreased from48.6%and10.2%to26.6%and6.8%. Both difference and agreement of distribution of sexual risk behavior before and after being notified had achieved statistical significance.
Among the groups over different time period after being notified, the difference of proportion of those who had had sex behavior had not achieved significant. However, the proportion of precontemplation stage of condom use reported by participants notified during January to June,2007was lower than by those notified in2006, which implied that there was some difference on sexual risk behavior over different time period after being notified.
2. Associated factors
2.1personal characteristics
It is found that sexual risk behavior reported by participants from Yunnan province was higher than those from Guangxi who had higher level of perceived HIV susceptibility. The difference of2provinces may be related to environmental factors or information bias. Condom use self efficacy was lower among females, so was the condom using behavior. The older age group reported lower proportion of sexual behavior. But age was not significantly related to condom using behavior. Those who had lived together with their sex partner(married of cohabitated) reported higher proportion of sexual behavior and condom use as well.
Among those who had been notified, PLHA with education background of primary school reported more second stage of condom use than those with education of high school. The probability of have sex and consistent condom use were higher among those with larger income. The between group comparison showed that there was no significant difference on sexual risk behavior between those who were infected through injection drug use and through sexual risk behavior, but sexual risk behavior was higher among those transmitted trough other routes than through injection drug use. However, in consideration of small sample size of PLHA transmitted through other routes, it still need further evidence to determine the relationship between transmission route and sexual risk behavior. In addition, no statistically significant relation was found between drug of alcohol use and sexual risk behavior.
Perceived HIV/AIDS severity, susceptibility, benefit and barrier of condom use, self efficacy and social norms may influence the stages of condom use directly or indirectly through other personal beliefs. The effect of perceived barriers was most significant, followed by HIV susceptibility, self efficacy and social norms. Perceived HIV severity and benefit only had little indirect effect on condom use. Level of perceived HIV susceptibility and benefit of condom use and social norms of AIDS patients was higher than asymptomatic HIV infections and perceived HIV severity, susceptibility and social norms was higher among those who was aware of HIV/AIDS knowledge, so the2groups said above inclined to use condom consistently. Besides, perceived HIV severity and barriers of condom use were higher and HIV susceptibility lower among those who had high level of negative emotion and sexual risk behavior as well.
2.2sex partner and sexual behavior
It is found that PLHA reported higher proportion of sexual risk behavior with HIV seropositives than with seronegatives. But no statistically significant difference of sexual risk behaviors was found between PLHA with seropositive partner and with partner of unknown serostatus. The probability of sexual risk behavior was lower between PLHA and their regular sex partner, especially those with longer relationship. PLHA who had casual sex partners inclined to report precontemplation stage of condom use. Also, those who had both types of sex partner reported more risk behavior than those who had only casual sex partners. Indepth interview showed that some PLHA who had regular sex partner seek to have unsafe sex with casual sex partners because of unwilling to use condom. Regular sex partners of most PLHA learn about their seropositive status but casual sex partners of most PLHA not. However, sex partner notification was not found be to significantly related to sexual risk behavior. Also, Sexual risk behavior was not related to types of sex partners. In addition, the proportion of consistent condom use was higher for those with less frequent sexual episode.
2.3Family and social supports
Concerned about social discrimination, PLHA were not willing to disclosure seropositive status to others except those with whom they had intimate relationship. Seropositive status of78.7%of those who had been notified was learned by relatives and27.2%by others. And72.7%gained support and23.1%experienced discrimination. It is found that PLHA who had not gained supports reported higher proportion of precontemplation stage of sexual risk behaviors and experience of discrimination increased the risk of inconsistent condom use. In addition, PLHA who participated the group activities of PLHA reported lower proportion of precontemplation stage of condom use behavior and social economic support raised the proportion of have sex, but was not significantly associated with condom use.
2.4Health care services
It is indicated that PLHA who got standardized HIV counseling and testing service reported higher proportion of consistent condom use. In this study, standardized HIV counseling and testing service was defined as informed consent and sufficient information provided before HIV testing and being notified by health care workers face to face privately and sufficient information provided after HIV tesing.
The result of the interview showed that there were some problems with condom provided for free on the quality, function, style and casing as well, which decreased the acceptability. Besides, taking thought of social discrimination, some PLHA refused to accept free condom. Of those who had been notified as sero-positive,65.3%accepted free condom during the past6months. Moreover, PLHA who had accepted free condom reported higher proportion of having sex but lower proportion of sexual risk behaviors, which may because of the enhanced accessibility of condom through providing condom for free or the bias of selection and social desire.
Data from this study showed that PLHA who got face to face communication service reported higher proportion of the second stage of condom using behavior and lower proportion of precomtemplation stage, which indicated that face to face communication help raise the intention of condom use but not use of condom consistently. The probability of sexual risk behavior was higher for those who acquired HIV related information through mass media and who participated HIV/AIDS awareness campaign, which may be the result of selection bias. Getting condom use information was not relate to the stage of condom use but with having sex behavior, which is related to more attention on condom use information for those who had had sex behavior.
Among those who had been notified,58.9%(492/836) had accepted antiretroviral therapy (ART). The probability of maintenance stage of condom using behavior among those who had accepted ART was higher and the probability of precontemplation stage was lower. But data form multivariate analysis showed that relation between ART and sexual risk behavior had not achieved significance.
Conclusions
After being notified as sero-positive, PLHA decreased their sexual risk behavior. Sexual risk behavior was determined comprehensively by factors at individual, sex partner, family and community level as well as health care services. It is suggested that HIV counseling and testing, notification of testing results and following up of PLHA be strengthened and improved; Intervention strategy should be tailor to different characteristics of PLHA and their stage of sexual risk behaviors and personal beliefs should be focused on; Family and community based awareness campaign should be carried out to reduce HIV related discrimination and promote social support for PLHA.
引文
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[35]Marks G, Crepaz N. HIV-positive men's sexual practices in the context of self-disclosure of HIV status[J]. J Acquir Immune Defic Syndr,2001,27(1):79-85.
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[57]Remien RH, Halkitis PN,O'Leary A, et al. Risk Perception and sexual risk behaviors among HIV-positive men on antiretroviral therapy[J]. AIDS Behav,2005 Jun;9(2):167-176.
[58]Vanable PA, Ostrow DG, McKirnan DJ, et al. Impact of combination therapies on HIV risk perceptions and sexual risk among HIV-positive and HIV-negative gay and bisexual men[J]. Health Psychol,2000 Mar;19(2):134-145.
[59]Van d, V, Mao L, Fogarty A, et al. Undetectable viral load is associated with sexual risk taking in HIV serodiscordant gay couples in Sydney[J]. AIDS,2005 Jan 28;19(2):179-184.
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[61]Halkitis PN, Green KA, Remien RH, et al. Seroconcordant sexual partnerings of HIV-seropositive men who have sex with men[J]. AIDS,2005 Apr;19(Suppl 1):S77-S86.
[62]Muller 0, Sarangbin S, Ruxrungtham K, et al. Sexual risk behaviour reduction associated with voluntary HIV counselling and testing in HIV infected patients in Thailand[J]. AIDS Care.1995;7 (5):567-572.
[63]Gary M, Cherilyn R B, T Shelley D. Negative Affect and Unsafe Sex in HIV-Positive Men[J]. AIDS and Behavior,1998 Jun;2(2):89-99.
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[67]Godin G, Savard J, Kok G, et al. HIV seropositive gay men:understanding adoption of safe sexual practices[J]. AIDS Educ and Prev,1996 Dec; 8(6):529-545.
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