开远市暗娼艾滋病性病感染率变化趋势及其流行因素研究
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摘要
背景性接触传播已成为我国人类免疫缺陷病毒(HIV)感染主要传播途径,艾滋病疫情开始向普通人群蔓延,暗娼(FSWs)是HIV感染和性传播疾病(STIs)传播的重要桥梁人群。我国FSWs人群HIV/STIs感染率呈逐渐上升的趋势。我国至今尚缺乏FSWs人群HIV/STIs发病密度资料。
目的估计FSWs人群HIV/STIs发病密度并分析其危险因素；了解FSWs人群HIV/STIs感染率及变化趋势,并探讨HIV/STIs感染相关因素；了解影响FSWs人群产生吸毒行为的影响因素；和探讨FSWs人群的流动模式以及影响因素。
方法于2006年3月-2008年10月,每隔6个月在开远市FSWs人群中进行一次横断面调查,连续进行六次系列横断面调查；重复参加系列横断面调查的FSWs构成了一个FSWs开放式队列。每次横断面调查中,收集社会人口学特征、流动情况、、毒品使用情况、生殖健康和求医行为以及性行为等信息。采集调查对象的静脉血进行HIV、单纯疱疹病毒2型(HSV-2)、梅毒血清学检测,采集尿液用于尿吗啡检测,采集宫颈分泌物进行淋球菌和沙眼衣原体检测,采集阴道分泌物进行阴道毛滴虫的检测。在参加第一次调查的FSWs中招募270例研究对象参加封闭式队列研究,每个月进行一次电话随访,连续随访12个月。采用logistic回归广义估计方程(GEE)分析HIV/STIs感染相关因素。采用带时变协变量的Cox回归模型分析HIV/STIs新发感染和发生吸毒行为的危险因素。
结果(1)六次横断面调查中HIV感染率依次为10.3%(95% CI,8.2-12.7)、11.9%(95% CI,9.7-14.5)、13.1%(95% CI,10.7-15.8)、12.3%(95% CI,9.3-15.9)、11.7%(95% CI,9.2-14.6)、12.2%(95% CI,9.6-15.2)。多变量logistic回归GEE模型分析显示,HIV感染相关因素为年龄21-25岁(比值比(OR)=2.0)、年龄26-54岁(OR=2.1)、本省非本市户籍(OR=1.9)、低档性服务场所(OR=1.5)、拔牙/补牙或洗牙(OR=1.5)、静脉注射吸毒(OR=9.2)、口吸(OR=1.9)、从事性服务的时间≥5年(OR=1.6)、认为自己有感染HIV危险(OR=1.3)、过去1年出现过生殖器溃疡或增生物(OR=2.4)、HSV-2检测阳性(OR=2.2)。(2)FSWs开放式队列中HIV、HSV-2、梅毒、阴道毛滴虫、淋球菌、沙眼衣原体发病密度依次为1.2(95%CI0.62-2.20)／100人年、26.1(95%CI 20.7-32.1)／100人年、1.3(95%CI0.67-2.24)／100人年、6.3(95%CI 4.80-8.12)／100人年、5.6(95%CI4.17-7.25)／100人年、16.8(95%CI 14.1-19.7)／100人年。多因素Cox回归模型分析显示,HIV新发感染的危险因素为经口吸毒(风险比(HR)=5.5,95%CI1.37-22.30)、最近1周嫖客数≥7(HR=4.5,95%CI 1.34-14.85)、梅毒检测阳性(HR=4.3,95%CI 1.06-17.61)、淋球菌检测阳性(HR=4.1,95%CI 1.04-16.26)。(3)共有50例研究对象在随访过程中发生吸毒行为,吸毒行为发生率为6.7(95% CI5.04-8.79)／100人年。与吸毒行为显著相关的因素为低档性服务场所(HR=1.8,95%CI 1.04-3.15)、第一次性行为年龄≥18岁(HR=0.5,95% CI 0.27-0.81)、HIV阳性(HR=2.8，95%CI 1.24-6.13)。(4)FSWs封闭式队列中,117(43.3%)例研究对象流动到其它城市从事性服务工作。流动性发生率为5.1(95% CI 4.27-6.12)/100人月。与FSWs流动性显著相关的因素为低档性服务场所(HR=0.6,95% CI0.43-0.94)、认为自己有感染STIs危险(HR=0.7,95% CI 0.46-0.96)。
结论开放式和封闭式队列研究方法估计FSWs人群HIV/STIs发病密度是一致的。由于FSWs较高的流动性,开展封闭式队列研究较困难,应通过系列横断面调查形成开放式队列研究,从而进行HIV/STIs发病密度及其流行因素分析和评估干预措施效果。FSWs人群整体流动性较大,低档FSWs人群流动性相对较小但有较高的风险感染和传播HIV/STIs,对于不同档次的FSWs人群,需要采取不同的针对性干预措施,并且重点加强对低档FSWs人群的干预工作。低档FSWs和HIV阳性FSWs中发生吸毒行为的风险较高,需要提供社会支持机制和良好的检测咨询工作以降低吸毒行为发生率,尤其是HIV阳性FSWs。开远市FSWs人群HIV发病密度处于较高水平,性传播途径已成为开远市FSWs人群主要传播途径。
Background Sexual transmission has become the dominant route of human immunodeficiency virus (HIV) spread in China. HIV epidemic have been transmitted into general population, and female sex workers (FSWs) are important bridge population of HIV and sexually transmiited infections (STIs) transmission. In China, HIV/STIs prevalence among FSWs is ascending gradually, but HIV/STIs incidence among FSWs is exiguous.
Objectives To estimate HIV/STIs incidence among FSWs and identify the risk factors related to HIV/STIs seroconversion. To investigate HIV/STIs prevalence, longitudinal trend and to explore the factors associated with HIV/STIs prevalence. Factors associated with drug initiation were analyzed among FSWs open cohort. To estimate the mobility of FSWs, and to investigate mobility pattern and the factors related to FSWs mobility.
Methods Six-stage serial cross-sectional surveys were carried out every 6 months among FSWs between March 2006 and October in Kaiyuan city, Yunnan provice. The subjects who repeatedly participated in two or more serial cross-sectional surveys comprised an open-cohort. We collected information about socio-demographic characteristics, mobility, drug use behavior, reproductive health, health seeking and sexual behaviors. The blood was collected to test for HIV, herpes simplex virus-2 (HSV-2) and syphilis, urine specimen was collected to test for morphine, cervical secretions was collected to test for Gonorrhoea and Chlamydia trachomatis, vaginal secretions was collected to test for Trichomonas vaginalis.270 FSWs in a closed-cohort were recruited from subjects who have participated in the first cross-sectional survey. Once the participants were recruited into the cohort, they would be interviewed by telephone every month in the following 12 months. Logistic generalized estimating equations (GEE) model was used to determine the factors associated with prevalent HIV/STIs. And Cox proportional hazards regression model with time dependent variables was used to measure the associations between incident HIV/STIs, drug initiation and independent variables.
Results (1) HIV prevalence were 10.3%(95% CI,8.2-12.7),11.9%(95% CI, 9.7-14.5)、3.1%(95% CI,10.7-15.8)、2.3%(95% CI,9.3-15.9)、11.7%(95% CI, 9.2-14.6) and 12.2% (95% CI,9.6-15.2) among FSWs in six-stage serial cross-sectional surveys respectively. Analyzed with multivariate logistic GEE model, the factors associated with HIV infection were 21-25 years old (odds ratio, OR=2.0), 26-54 years old (OR=2.1), with registered permanent residence in other cities of Yunnan province (OR=1.9), working in low level entertainment (OR=1.5), extracting/filling/cleaning tooth (OR=1.5), injection drug users (IDUs, OR=9.2), non-injection drug users (OR=1.9), duration of sex work being 5 years or more (OR=1.6), perceived vulnerable to HIV infection (OR=1.3), emerging genital ulcers or wart last year (OR=2.4) and HSV-2 sero-positivity (OR=2.2). (2) In FSWs open cohort, the incidence density of HIV, HSV-2, syphilis, trichomonas vaginalis, neisseria gonorrhoeae, and chlamydia trachomatis were 1.2 cases per 100 person years (95%CI 0.62-2.20),26.1 cases per 100 person years (95% CI 20.7-32.1),1.3 cases per 100 person years (95% CI 0.67-2.24),6.3 cases per 100 person years (95% CI 4.80-8.12),5.6 cases per 100 person years (95% CI 4.17-7.25), and 16.8 cases per 100 person years (95% CI 14.1-19.7), respectively. Analyzed with Cox proportional hazard regression model, the factors associated with HIV seroconversion were non-injection drug users (hazard ration, HR=5.5,95% CI 1.37-22.30), the number of clients last week≥7 (HR=4.5,95% CI 1.34-14.85), syphilis sero-positivity (HR=4.3, 95% CI 1.06-17.61) and being infected with neisseria gonorrhoeae (HR=4.1,95% CI 1.04-16.26). (3) Totally 50 subjects initiated drug use among non-drug users FSWs, the incidence density of drug initiation was 6.7 cases per 100 person years (95% CI 5.04-8.79), and the factors related to drug initiation included low level entertainment (HR=1.8,95% CI 1.04-3.15), age of first sex≥18 years (HR=0.5,95% CI 0.27-0.81) and HIV sero-positive (HR=2.8,95% CI 1.24-6.13). (4) In FSWs close-cohort,117 (43.3%) FSWs moved to other cities to engage in sex work during the follow-up period and the incidence density of mobility was 5.1 cases per 100 person years (95% CI 4.27-6.12). Factors significantly coHRelated with FSWs mobility were low level entertainment (HR=0.6,95% CI 0.43-0.94) and perceived vulnerable to STIs infection (HR=0.7,95% CI 0.46-0.96).
Conclusions HIV/STIs inicdeces among FSWs estimated separately by open cohort and closed cohort were unanimous. Because of the high mobility of FSWs, it was difficult to carry out closed cohort among FSWs, so open cohort shaped by serial cross-sectional studies should be used to estimate HIV/STIs incidence, analyze related factors and evaluate intervention efficacy. The overall mobility was high among FSWs, and the FSWs working in low level entertainment were less mobile, but with higher risk of being infected with HIV/STIs and HIV/STIs transmission, so specific interventions should be implemented according to the level of FSWs, focusing on FSWs who work in low level entertainment. FSWs in low level entertainment and HIV-positive subjectes were more likely to initiate drug use, so social supporting mechanism and better voluntary counseling and testing should be provided to reduce the incidence of drug initiation, especially for HIV-positive FSWs. HIV incidence was particularly high among FSWs in Kaiyuan city, Yunnan province, and sexual transmission has become the dominant route of HIV transmission among FSWs in Kaiyuan.
目的估计FSWs人群HIV/STIs发病密度并分析其危险因素；了解FSWs人群HIV/STIs感染率及变化趋势,并探讨HIV/STIs感染相关因素；了解影响FSWs人群产生吸毒行为的影响因素；和探讨FSWs人群的流动模式以及影响因素。
方法于2006年3月-2008年10月,每隔6个月在开远市FSWs人群中进行一次横断面调查,连续进行六次系列横断面调查；重复参加系列横断面调查的FSWs构成了一个FSWs开放式队列。每次横断面调查中,收集社会人口学特征、流动情况、、毒品使用情况、生殖健康和求医行为以及性行为等信息。采集调查对象的静脉血进行HIV、单纯疱疹病毒2型(HSV-2)、梅毒血清学检测,采集尿液用于尿吗啡检测,采集宫颈分泌物进行淋球菌和沙眼衣原体检测,采集阴道分泌物进行阴道毛滴虫的检测。在参加第一次调查的FSWs中招募270例研究对象参加封闭式队列研究,每个月进行一次电话随访,连续随访12个月。采用logistic回归广义估计方程(GEE)分析HIV/STIs感染相关因素。采用带时变协变量的Cox回归模型分析HIV/STIs新发感染和发生吸毒行为的危险因素。
结果(1)六次横断面调查中HIV感染率依次为10.3%(95% CI,8.2-12.7)、11.9%(95% CI,9.7-14.5)、13.1%(95% CI,10.7-15.8)、12.3%(95% CI,9.3-15.9)、11.7%(95% CI,9.2-14.6)、12.2%(95% CI,9.6-15.2)。多变量logistic回归GEE模型分析显示,HIV感染相关因素为年龄21-25岁(比值比(OR)=2.0)、年龄26-54岁(OR=2.1)、本省非本市户籍(OR=1.9)、低档性服务场所(OR=1.5)、拔牙/补牙或洗牙(OR=1.5)、静脉注射吸毒(OR=9.2)、口吸(OR=1.9)、从事性服务的时间≥5年(OR=1.6)、认为自己有感染HIV危险(OR=1.3)、过去1年出现过生殖器溃疡或增生物(OR=2.4)、HSV-2检测阳性(OR=2.2)。(2)FSWs开放式队列中HIV、HSV-2、梅毒、阴道毛滴虫、淋球菌、沙眼衣原体发病密度依次为1.2(95%CI0.62-2.20)／100人年、26.1(95%CI 20.7-32.1)／100人年、1.3(95%CI0.67-2.24)／100人年、6.3(95%CI 4.80-8.12)／100人年、5.6(95%CI4.17-7.25)／100人年、16.8(95%CI 14.1-19.7)／100人年。多因素Cox回归模型分析显示,HIV新发感染的危险因素为经口吸毒(风险比(HR)=5.5,95%CI1.37-22.30)、最近1周嫖客数≥7(HR=4.5,95%CI 1.34-14.85)、梅毒检测阳性(HR=4.3,95%CI 1.06-17.61)、淋球菌检测阳性(HR=4.1,95%CI 1.04-16.26)。(3)共有50例研究对象在随访过程中发生吸毒行为,吸毒行为发生率为6.7(95% CI5.04-8.79)／100人年。与吸毒行为显著相关的因素为低档性服务场所(HR=1.8,95%CI 1.04-3.15)、第一次性行为年龄≥18岁(HR=0.5,95% CI 0.27-0.81)、HIV阳性(HR=2.8，95%CI 1.24-6.13)。(4)FSWs封闭式队列中,117(43.3%)例研究对象流动到其它城市从事性服务工作。流动性发生率为5.1(95% CI 4.27-6.12)/100人月。与FSWs流动性显著相关的因素为低档性服务场所(HR=0.6,95% CI0.43-0.94)、认为自己有感染STIs危险(HR=0.7,95% CI 0.46-0.96)。
结论开放式和封闭式队列研究方法估计FSWs人群HIV/STIs发病密度是一致的。由于FSWs较高的流动性,开展封闭式队列研究较困难,应通过系列横断面调查形成开放式队列研究,从而进行HIV/STIs发病密度及其流行因素分析和评估干预措施效果。FSWs人群整体流动性较大,低档FSWs人群流动性相对较小但有较高的风险感染和传播HIV/STIs,对于不同档次的FSWs人群,需要采取不同的针对性干预措施,并且重点加强对低档FSWs人群的干预工作。低档FSWs和HIV阳性FSWs中发生吸毒行为的风险较高,需要提供社会支持机制和良好的检测咨询工作以降低吸毒行为发生率,尤其是HIV阳性FSWs。开远市FSWs人群HIV发病密度处于较高水平,性传播途径已成为开远市FSWs人群主要传播途径。
Background Sexual transmission has become the dominant route of human immunodeficiency virus (HIV) spread in China. HIV epidemic have been transmitted into general population, and female sex workers (FSWs) are important bridge population of HIV and sexually transmiited infections (STIs) transmission. In China, HIV/STIs prevalence among FSWs is ascending gradually, but HIV/STIs incidence among FSWs is exiguous.
Objectives To estimate HIV/STIs incidence among FSWs and identify the risk factors related to HIV/STIs seroconversion. To investigate HIV/STIs prevalence, longitudinal trend and to explore the factors associated with HIV/STIs prevalence. Factors associated with drug initiation were analyzed among FSWs open cohort. To estimate the mobility of FSWs, and to investigate mobility pattern and the factors related to FSWs mobility.
Methods Six-stage serial cross-sectional surveys were carried out every 6 months among FSWs between March 2006 and October in Kaiyuan city, Yunnan provice. The subjects who repeatedly participated in two or more serial cross-sectional surveys comprised an open-cohort. We collected information about socio-demographic characteristics, mobility, drug use behavior, reproductive health, health seeking and sexual behaviors. The blood was collected to test for HIV, herpes simplex virus-2 (HSV-2) and syphilis, urine specimen was collected to test for morphine, cervical secretions was collected to test for Gonorrhoea and Chlamydia trachomatis, vaginal secretions was collected to test for Trichomonas vaginalis.270 FSWs in a closed-cohort were recruited from subjects who have participated in the first cross-sectional survey. Once the participants were recruited into the cohort, they would be interviewed by telephone every month in the following 12 months. Logistic generalized estimating equations (GEE) model was used to determine the factors associated with prevalent HIV/STIs. And Cox proportional hazards regression model with time dependent variables was used to measure the associations between incident HIV/STIs, drug initiation and independent variables.
Results (1) HIV prevalence were 10.3%(95% CI,8.2-12.7),11.9%(95% CI, 9.7-14.5)、3.1%(95% CI,10.7-15.8)、2.3%(95% CI,9.3-15.9)、11.7%(95% CI, 9.2-14.6) and 12.2% (95% CI,9.6-15.2) among FSWs in six-stage serial cross-sectional surveys respectively. Analyzed with multivariate logistic GEE model, the factors associated with HIV infection were 21-25 years old (odds ratio, OR=2.0), 26-54 years old (OR=2.1), with registered permanent residence in other cities of Yunnan province (OR=1.9), working in low level entertainment (OR=1.5), extracting/filling/cleaning tooth (OR=1.5), injection drug users (IDUs, OR=9.2), non-injection drug users (OR=1.9), duration of sex work being 5 years or more (OR=1.6), perceived vulnerable to HIV infection (OR=1.3), emerging genital ulcers or wart last year (OR=2.4) and HSV-2 sero-positivity (OR=2.2). (2) In FSWs open cohort, the incidence density of HIV, HSV-2, syphilis, trichomonas vaginalis, neisseria gonorrhoeae, and chlamydia trachomatis were 1.2 cases per 100 person years (95%CI 0.62-2.20),26.1 cases per 100 person years (95% CI 20.7-32.1),1.3 cases per 100 person years (95% CI 0.67-2.24),6.3 cases per 100 person years (95% CI 4.80-8.12),5.6 cases per 100 person years (95% CI 4.17-7.25), and 16.8 cases per 100 person years (95% CI 14.1-19.7), respectively. Analyzed with Cox proportional hazard regression model, the factors associated with HIV seroconversion were non-injection drug users (hazard ration, HR=5.5,95% CI 1.37-22.30), the number of clients last week≥7 (HR=4.5,95% CI 1.34-14.85), syphilis sero-positivity (HR=4.3, 95% CI 1.06-17.61) and being infected with neisseria gonorrhoeae (HR=4.1,95% CI 1.04-16.26). (3) Totally 50 subjects initiated drug use among non-drug users FSWs, the incidence density of drug initiation was 6.7 cases per 100 person years (95% CI 5.04-8.79), and the factors related to drug initiation included low level entertainment (HR=1.8,95% CI 1.04-3.15), age of first sex≥18 years (HR=0.5,95% CI 0.27-0.81) and HIV sero-positive (HR=2.8,95% CI 1.24-6.13). (4) In FSWs close-cohort,117 (43.3%) FSWs moved to other cities to engage in sex work during the follow-up period and the incidence density of mobility was 5.1 cases per 100 person years (95% CI 4.27-6.12). Factors significantly coHRelated with FSWs mobility were low level entertainment (HR=0.6,95% CI 0.43-0.94) and perceived vulnerable to STIs infection (HR=0.7,95% CI 0.46-0.96).
Conclusions HIV/STIs inicdeces among FSWs estimated separately by open cohort and closed cohort were unanimous. Because of the high mobility of FSWs, it was difficult to carry out closed cohort among FSWs, so open cohort shaped by serial cross-sectional studies should be used to estimate HIV/STIs incidence, analyze related factors and evaluate intervention efficacy. The overall mobility was high among FSWs, and the FSWs working in low level entertainment were less mobile, but with higher risk of being infected with HIV/STIs and HIV/STIs transmission, so specific interventions should be implemented according to the level of FSWs, focusing on FSWs who work in low level entertainment. FSWs in low level entertainment and HIV-positive subjectes were more likely to initiate drug use, so social supporting mechanism and better voluntary counseling and testing should be provided to reduce the incidence of drug initiation, especially for HIV-positive FSWs. HIV incidence was particularly high among FSWs in Kaiyuan city, Yunnan province, and sexual transmission has become the dominant route of HIV transmission among FSWs in Kaiyuan.
引文
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