艾滋病病毒感染者/患者发现晚影响因素及对策研究
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摘要
目的
（1）通过横断面调查，了解柳州市艾滋病病毒感染者/患者发现晚的发生状况和流行病学特征；
（2）通过单因素和多因素Logistic回归分析，识别影响HIV/AIDS发现晚的独立危险因素和保护因素；
（3）通过定性研究，了解HIV/AIDS发现晚的原因及对策；
（4）结合定量和定性研究结果，探讨促进HIV感染者早期发现的对策与措施。
方法
采用普查方法，对现住址为柳州本地，在2009年1月1日-2010年6月30日期间新报告的能够随访到的HIV/AIDS进行定量调查。发现晚病例定义为：报告时即已发展为艾滋病病人或者报告时是艾滋病病毒感染者但一年内即转化为艾滋病病人。定量调查内容包括：基本信息、高危行为史、HIV检测史及个人对HIV检测服务的利用情况、就医情况、艾滋病相关知识知晓情况等。同时采用定性访谈方法，分别采用不同的访谈提纲对HIV/AIDS、疾控中心艾防科工作人员、抗病毒治疗点医生/随访人员、社区卫生服务中心/乡镇卫生院随访人员、VCT点工作人员等进行个人深入访谈。定量调查资料采用EpiData3.02软件进行数据录入和SPSS13.0软件进行数据分析，以是否发现晚将HIV/AIDS分为两组，采用单因素和多因素分析方法进行分析，其中单因素分析采用χ2检验，多因素分析采用非条件Logistic回归分析。定性访谈资料分析则先把录音转录成文字，然后再根据访谈提纲的条目进行归纳总结。
结果
（1）调查的917例HIV/AIDS中，658例存在发现晚，占71.8%。
（2）发现晚病例的流行病学特征：感染途径以异性性传播为主，占86.9%；检测样本来源以“其他就诊者检测”为主，接近60%；83.3%有异性固定性伴性行为史，其中54.6%不知道其固定性伴的HIV感染状况；66.6%有非固定异性性行为史，其中97.0%不知道其非固定性伴的HIV感染状况；仅0.4%有男男同性性行为史；约10%有共用针具注射吸毒史；1%左右有献血浆史；还有近2%有输血/血制品史；仅8.6%在查出感染HIV之前有做HIV检测的想法，还有91.4%在查出感染HIV之前没有做HIV检测的想法，没有检测想法的原因以“从未想过自己会感染”、“自觉身体状况很好，不可能感染”、“没有听说过艾滋病”、“担心检测阳性受到歧视”为主；75%以上在查出感染HIV之前出现一种及以上HIV相关症状，出现的症状以“不明原因的体重减轻，3个月内进行性体重下降>10”、“不明原因的发热，间歇性或持续性>1个月”、“反复发作的上呼吸道感染，6个月内≥2次”和“反复发生的不明原因咳嗽/咳痰/胸闷/胸痛等（肺炎）症状>1个月”为主；85.0%出现任何HIV相关症状后便就医，其中77.4%选择在综合医院就诊，仅2/3左右的综合医院为这些就诊者进行了HIV检测；在查出感染HIV之前对艾滋病传播途径知识了解较少，总知晓率仅56.8%；在查出感染HIV之前对艾滋病“四免一关怀”政策虽然有一定的了解，70.3%知道“四免一关怀”政策的相关内容，但还有50%以上不知道自愿咨询检测门诊可以做免费的HIV初筛检测。
（3）发现晚的危险因素：家庭年度总收入低、检测样本来源于“其他就诊者检测”、认为自己不可能从异性固定性伴那里感染HIV、查出感染HIV之前没有做HIV检测的想法、查出感染HIV之前出现“不明原因的体重减轻，3个月内进行性体重下降>10%”、出现“不明原因的发热，间歇性或持续性>1个月”、出现“口角炎、唇炎口腔粘膜毛状白斑”、以及针对“偶尔的共用针具注射毒品是否会传播HIV”这个知识点回答错误或回答“不清楚”。其中，检测样本来源于“其他就诊者检测”（OR=2.351,P=0.020）、出现“不明原因的体重减轻，3个月内进行性体重下降>10%”（OR=2.577,P＜0.001）、出现“不明原因的发热，间歇性或持续性>1个月”（OR=2.111,P=0.004）、出现“口角炎、唇炎口腔粘膜毛状白斑”（OR=2.860,P=0.042）是发现晚的重要危险因素。
（4）发现晚的有利因素：检测样本来源于“强制/劳教戒毒人员检测”；检测样本来源于“强制/劳教戒毒人员检测”（OR=0.203,P=0.013）其发生发现晚的风险较小。
（5）访谈得知导致HIV/AIDS发现晚的原因：①对艾滋病不了解，因此从没想过自己会得艾滋病；②觉得自己身体很好，不可能感染艾滋病；③觉得自己没有高危行为，不可能感染艾滋病；④不知道艾滋病传得这么厉害；⑤有侥幸心理；⑥害怕查出艾滋病，所以一直逃避，如：配偶阳性者；⑦对艾滋病认识不足，大多数只停留在表面，且大多数人觉得艾滋病离自己很远；⑧经济比较困难，没有出现明显症状一般不会去医院看病，大多数是直到出现临床症状或者有病后到医院看病时才检查出来的；⑨艾滋病歧视现象比较严重，害怕被歧视；⑩HIV检测力度不够，目前的检测仍是以被动检测为主。
（6）早期发现HIV感染者的对策与措施：①加大艾滋病宣传的深度和广度，尤其是农村地区，同时还应让普通人群了解当地艾滋病疫情状况的严重性，以提高其HIV感染风险意识；②加强反歧视宣传教育工作，减少或消除对艾滋病病人的歧视，同时还应加强保证检测结果保密性的宣传工作；③在高危人群中宣传工作必须到位，让更多的高危人群主动进行HIV检测，同时还应采取各种方法吸引高危人群进行HIV检测，如：在暗娼人群中采取多样免费检测项目（血糖、尿糖、血型、免费妇科检查等）来吸引该人群做检测；④扩大VCT点覆盖面，同时加大对VCT服务的宣传，让更多的人了解VCT，以增加HIV检测率；⑤采用多种快速检测方法，缩短检测结果的等待时间，以利于HIV阳性者的后续随访管理工作；⑥医院是发现HIV/AIDS的大平台，应该在医院开展PITC工作，同时加强对临床医务人员，尤其是皮肤性病科、呼吸科、感染科、内科、发热门诊医务人员的HIV相关症状和艾滋病高危行为的培训，以提高其主动提供HIV检测的意识；⑦加强性伴告知与检测工作，如：由地方政府出台“HIV阳性者的配偶/固定性伴告知与检测”政策，要求HIV阳性者必须在一个月内将阳性结果告知其配偶/固定性伴，否则将由当地疾控工作人员强制执行配偶/固定性伴告知服务；⑧地方政府应给予政策支持，选择疫情严重的地区（如：鹿寨县）进行艾滋病普查，方法可以借鉴四川凉山州布托县和昭觉县的艾滋病普查；⑨充分发挥现有HIV/AIDS发现平台的作用，完善各HIV/AIDS发现平台与疾控中心之间的部门协调与合作机制，以加强对已发现HIV/AIDS的后续随访管理工作，让HIV/AIDS定期进行CD4检测和及时接受抗病毒治疗。
结论
柳州地区HIV/AIDS中发现晚的状况比较严重。艾滋病传播途径知识知晓率低、在查出感染HIV之前没有做HIV检测的想法、检测样本来源于“其他就诊者检测”、在查出感染HIV之前出现HIV相关症状是发现晚的独立危险因素，应该作为HIV/AIDS发现晚的预防和干预因素之一。检测样本来源于“强制/劳教戒毒人员检测”发生发现晚的风险较小，提示对强制/劳教戒毒人员进行HIV检测有助于感染者的早期发现，因此，在今后的艾滋病防治工作中，应继续加强对该人群进行入狱前HIV检测，同时还应该加强对有艾滋病高危行为的其他收押人员的入狱前HIV检测。此外，还应该以本研究针对早期发现HIV感染者而提出的对策与措施为指导方针，进一步有效开展HIV感染者的检测发现工作，并加强对已发现HIV/AIDS的后续随访工作，让HIV/AIDS定期进行CD4检测和及时接受抗病毒治疗。
Objectives
(1) To understand the status and epidemiologic characteristics of late HIVdiagnosis in Liuzhou city of Guangxi Zhuang Autonomous Region.
(2) To identify the factors associated with late HIV diagnosis by univariate andmultivariate logistic regression analysis.
(3) To identify the reasons for late HIV diagnosis and measures for detectingHIV infections earlier by qualitative research.
(4) To explore the measures and strategies for detecting HIV infections earlierby combining quantitative and qualitative research results.
Methods
A census method was used to select the study individuals. All individuals whowere newly diagnosed with HIV infection between1January2009and30June2010and lived in Liuzhou city were eligible. Late HIV diagnosis was defined as:an AIDS diagnosis when HIV diagnosed or developed AIDS within one year ofHIV diagnosis. The questionnaire included general information, high-riskexposure history, HIV testing history, medical history and HIV/AIDS-relatedknowledge. Moreover, a qualitative method was used to collect the reasons forlate HIV diagnosis and measures for detecting HIV infections earlier.Quantitative data were entered using EpiData3.02software and analyzed usingSPSS13.0software. Chi-square test were used for categorical variables. Multivariate logistic regression was used to identify factors independentlyassociated with late HIV diagnosis. Recording was transcribed into text firstly,and then a summary method was used to analyze the qualitative data.
Results
(1) Of the917study individuals,658(71.8%) had a late HIV diagnosis.
(2)The epidemiologic characteristics of late HIV diagnosis individuals were asfollows: the most common HIV transmission route was heterosexualtransmission(86.9%); the blood sample source was dominated by “HIV testingfor persons sought medical treatment for illness”(57.6%);83.3%had a regularheterosexual partner, and54.6%did not know their regular heterosexualpartners’ HIV statuses;66.6%had casual heterosexual partners, and most ofthem(97.0%) did not know their casual heterosexual partners’ HIV statuses; only0.4%had male homosexual partners;9.2%had a history of needle sharing forinjecting drugs,0.8%had a history of plasma donation and1.7%had a history ofblood transfusion; majority (91.4%) did not have the idea of taking HIV testingbefore HIV diagnosis, the main reasons for not having the idea of taking HIVtesting were “Never thought I would be HIV-infected”,“I didn’t feel sick, so it wasimpossible to be infected with HIV”,“I have never heard of AIDS” and “I wasworry the discrimination from HIV-infection”;76.6%had one or more HIV-relatedsymptoms before HIV diagnosis, the most common symptoms were unexplainedweight loss, unexplained prolonged fever, recurrent respiratory tract infectionand recurrent cough/chest distress;85.0%sought medical treatment after thepresence of HIV-related symptoms, and most of them(77.4%) sought medicaltreatment at general hospitals, however, only nearly two thirds of the generalhospitals have offered HIV testing for these persons; majority knew few aboutHIV/AIDS-related knowledge before HIV diagnosis, and the total rate of questions about HIV/AIDS answered correctly was56.8%;70.3%knew someabout AIDS “Four Frees and One Care” policy before HIV diagnosis, but stillmore than half did not know the VCT clinic could offer free HIV testing.
(3) The risk factors of late HIV diagnosis: lower annual household income,whose blood sample source was “HIV testing for persons sought medicaltreatment for illness”, thought themselves could not be infected with HIV fromtheir regular heterosexual partners, did not have the idea of taking HIV testingbefore HIV diagnosis, had unexplained weight loss or unexplained prolongedfever or angular cheilitis before HIV diagnosis, did not know whether needlesharing for injecting drugs occasionally could transmit HIV or thought needlesharing for injecting drugs occasionally could not transmit HIV. Among thesefactors, whose blood sample source was “HIV testing for persons soughtmedical treatment for illness”(OR=2.351, P=0.020), had unexplained weightloss(OR=2.577, P＜0.001) or unexplained prolonged fever(OR=2.111, P=0.004)or angular cheilitis(OR=2.860, P=0.042) before HIV diagnosis were importantrisk factors.
(4) The protective factors of late HIV diagnosis: Those blood sample sourcewas “HIV testing for compulsory detoxification prisoners”(OR=0.203, P=0.013)were less likely to have late HIV diagnosis.
(5) The reasons for late HIV diagnosis:①Knew few about AIDS, and neverthought I would be HIV-infected.②I didn’t feel sick, so it was impossible to beinfected with HIV.③I didn’t have high-risk behavior, so it was impossible to beinfected with HIV.④Did not know AIDS spreading so seriously.⑤Some peopletook some chances.⑥Some people were afraid to be testing HIV-infected, sothey did not take HIV testing always, such as having a HIV-infected spouse.⑦Knew some about AIDS, and most thought that AIDS was far away from theirown, so few took HIV testing on their own initiative.⑧Because of lower income, the majority sought medical treatment untill the presence of clinical symptoms orsick bad, and then got the HIV-positive result.⑨Worried the discrimination fromHIV-infection.⑩The current HIV testing scale was not enough, it was stilldominated by passive testing, the initiative testing was few.
(6) The measures and strategies for detecting HIV infections earlier:①Although the AIDS health education work has been done for many years, itstill needs to improve the depth and extent of this work. It is essential tostrengthen the AIDS health education programs among the general population,especially in rural areas, to improve the risk perception of HIV infection.②Itneed to strengthen the anti-discrimination publicity, to reduce or eliminate thediscrimination against HIV/AIDS patients. Moreover, it is also important tostrengthen and ensure the confidentiality of HIV test results.③Greater effortsneed to be made to strengthen the AIDS health education programs amonghigh-risk groups, to let more high-risk groups to take HIV testing on their owninitiative. Moreover, it should take a variety of methods to attract high-risk groupsfor HIV testing. For example, taking manifold free testing project (including bloodsugar, urine sugar, blood type, free gynecologic examination) among FSW.④Expand the coverage of VCT and strengthen the publicity for VCT services, tolet more people understand the VCT services.⑤It should adopt a variety ofrapid testing methods, to shorten the time for test results, in order to facilitate thesubsequent follow-up and management for HIV/AIDS cases.⑥It is essential tostart PITC in hospitals. And, it is necessary to train the clinicians to improve theirrecognition of clinical presentations for underlying HIV infection and perform HIVtesting for these patients, especially the dermatology, respiratory, infectiousdiseases, internal medicine, fever clinics clinicians.⑦It need to promotespouse/sexual-partner notification for HIV-infected persons and to strengthenHIV testing for HIV-infected persons’ spouses/sexual-partners. For example, Guangxi Zhuang Autonomous Region government formulates the “GuangxiZhuang Autonomous Region regulations on HIV/AIDS patients’spouse/sexual-partners notification”, to require the HIV/AIDS patients to notifytheir spouse/sexual-partners about their HIV-positive results within one month, ifnot, they will be notified by the local CDC.⑧The local government should givepolicy support, and selected an area with serious HIV epidemic to make HIVcensus, such as Luzhai county. The investigation method could learn of the HIVepidemiologic survey for Butuo and Zhaojue counties of Liangshan Prefecture,Sichuan Province.⑨It should give full play to the existing HIV/AIDS detectedinstitutions, and perfect the cooperation mechanism between the HIV/AIDSdetected institutions and CDC, in order to strengthen the subsequent follow-upfor those detected HIV/AIDS cases and let them take CD4testing regularly andreceive antiretroviral treatment timely.
Conclusions
The status of late HIV diagnosis in Liuzhou city is rather serious. Lowknowledge awareness about HIV transmission route, not having the idea oftaking HIV testing before HIV diagnosis, whose blood sample source was “HIVtesting for persons sought medical treatment for illness”, having HIV-relatedsymptoms before HIV diagnosis are the independent risk factors of late HIVdiagnosis, so much attention should be given to the HIV/AIDS with this kind toprevent and intervene late HIV diagnosis. Those blood sample source was “HIVtesting for compulsory detoxification prisoners” were less likely to have late HIVdiagnosis, suggesting that offering HIV testing for compulsory detoxificationprisoners is beneficial for earlier HIV diagnosis. And, compulsory testing forother types of prisoners with HIV risk factors may improve the rate of early HIVdiagnosis. Meanwhile, it should take the measures and strategies for detecting HIV infections earlier in this study as the guidelines, to further start the detectionof HIV infections effectively and strengthen the subsequent follow-up for thosedetected HIV/AIDS cases, to let them take CD4testing regularly and receiveantiretroviral treatment timely.
（1）通过横断面调查，了解柳州市艾滋病病毒感染者/患者发现晚的发生状况和流行病学特征；
（2）通过单因素和多因素Logistic回归分析，识别影响HIV/AIDS发现晚的独立危险因素和保护因素；
（3）通过定性研究，了解HIV/AIDS发现晚的原因及对策；
（4）结合定量和定性研究结果，探讨促进HIV感染者早期发现的对策与措施。
方法
采用普查方法，对现住址为柳州本地，在2009年1月1日-2010年6月30日期间新报告的能够随访到的HIV/AIDS进行定量调查。发现晚病例定义为：报告时即已发展为艾滋病病人或者报告时是艾滋病病毒感染者但一年内即转化为艾滋病病人。定量调查内容包括：基本信息、高危行为史、HIV检测史及个人对HIV检测服务的利用情况、就医情况、艾滋病相关知识知晓情况等。同时采用定性访谈方法，分别采用不同的访谈提纲对HIV/AIDS、疾控中心艾防科工作人员、抗病毒治疗点医生/随访人员、社区卫生服务中心/乡镇卫生院随访人员、VCT点工作人员等进行个人深入访谈。定量调查资料采用EpiData3.02软件进行数据录入和SPSS13.0软件进行数据分析，以是否发现晚将HIV/AIDS分为两组，采用单因素和多因素分析方法进行分析，其中单因素分析采用χ2检验，多因素分析采用非条件Logistic回归分析。定性访谈资料分析则先把录音转录成文字，然后再根据访谈提纲的条目进行归纳总结。
结果
（1）调查的917例HIV/AIDS中，658例存在发现晚，占71.8%。
（2）发现晚病例的流行病学特征：感染途径以异性性传播为主，占86.9%；检测样本来源以“其他就诊者检测”为主，接近60%；83.3%有异性固定性伴性行为史，其中54.6%不知道其固定性伴的HIV感染状况；66.6%有非固定异性性行为史，其中97.0%不知道其非固定性伴的HIV感染状况；仅0.4%有男男同性性行为史；约10%有共用针具注射吸毒史；1%左右有献血浆史；还有近2%有输血/血制品史；仅8.6%在查出感染HIV之前有做HIV检测的想法，还有91.4%在查出感染HIV之前没有做HIV检测的想法，没有检测想法的原因以“从未想过自己会感染”、“自觉身体状况很好，不可能感染”、“没有听说过艾滋病”、“担心检测阳性受到歧视”为主；75%以上在查出感染HIV之前出现一种及以上HIV相关症状，出现的症状以“不明原因的体重减轻，3个月内进行性体重下降>10”、“不明原因的发热，间歇性或持续性>1个月”、“反复发作的上呼吸道感染，6个月内≥2次”和“反复发生的不明原因咳嗽/咳痰/胸闷/胸痛等（肺炎）症状>1个月”为主；85.0%出现任何HIV相关症状后便就医，其中77.4%选择在综合医院就诊，仅2/3左右的综合医院为这些就诊者进行了HIV检测；在查出感染HIV之前对艾滋病传播途径知识了解较少，总知晓率仅56.8%；在查出感染HIV之前对艾滋病“四免一关怀”政策虽然有一定的了解，70.3%知道“四免一关怀”政策的相关内容，但还有50%以上不知道自愿咨询检测门诊可以做免费的HIV初筛检测。
（3）发现晚的危险因素：家庭年度总收入低、检测样本来源于“其他就诊者检测”、认为自己不可能从异性固定性伴那里感染HIV、查出感染HIV之前没有做HIV检测的想法、查出感染HIV之前出现“不明原因的体重减轻，3个月内进行性体重下降>10%”、出现“不明原因的发热，间歇性或持续性>1个月”、出现“口角炎、唇炎口腔粘膜毛状白斑”、以及针对“偶尔的共用针具注射毒品是否会传播HIV”这个知识点回答错误或回答“不清楚”。其中，检测样本来源于“其他就诊者检测”（OR=2.351,P=0.020）、出现“不明原因的体重减轻，3个月内进行性体重下降>10%”（OR=2.577,P＜0.001）、出现“不明原因的发热，间歇性或持续性>1个月”（OR=2.111,P=0.004）、出现“口角炎、唇炎口腔粘膜毛状白斑”（OR=2.860,P=0.042）是发现晚的重要危险因素。
（4）发现晚的有利因素：检测样本来源于“强制/劳教戒毒人员检测”；检测样本来源于“强制/劳教戒毒人员检测”（OR=0.203,P=0.013）其发生发现晚的风险较小。
（5）访谈得知导致HIV/AIDS发现晚的原因：①对艾滋病不了解，因此从没想过自己会得艾滋病；②觉得自己身体很好，不可能感染艾滋病；③觉得自己没有高危行为，不可能感染艾滋病；④不知道艾滋病传得这么厉害；⑤有侥幸心理；⑥害怕查出艾滋病，所以一直逃避，如：配偶阳性者；⑦对艾滋病认识不足，大多数只停留在表面，且大多数人觉得艾滋病离自己很远；⑧经济比较困难，没有出现明显症状一般不会去医院看病，大多数是直到出现临床症状或者有病后到医院看病时才检查出来的；⑨艾滋病歧视现象比较严重，害怕被歧视；⑩HIV检测力度不够，目前的检测仍是以被动检测为主。
（6）早期发现HIV感染者的对策与措施：①加大艾滋病宣传的深度和广度，尤其是农村地区，同时还应让普通人群了解当地艾滋病疫情状况的严重性，以提高其HIV感染风险意识；②加强反歧视宣传教育工作，减少或消除对艾滋病病人的歧视，同时还应加强保证检测结果保密性的宣传工作；③在高危人群中宣传工作必须到位，让更多的高危人群主动进行HIV检测，同时还应采取各种方法吸引高危人群进行HIV检测，如：在暗娼人群中采取多样免费检测项目（血糖、尿糖、血型、免费妇科检查等）来吸引该人群做检测；④扩大VCT点覆盖面，同时加大对VCT服务的宣传，让更多的人了解VCT，以增加HIV检测率；⑤采用多种快速检测方法，缩短检测结果的等待时间，以利于HIV阳性者的后续随访管理工作；⑥医院是发现HIV/AIDS的大平台，应该在医院开展PITC工作，同时加强对临床医务人员，尤其是皮肤性病科、呼吸科、感染科、内科、发热门诊医务人员的HIV相关症状和艾滋病高危行为的培训，以提高其主动提供HIV检测的意识；⑦加强性伴告知与检测工作，如：由地方政府出台“HIV阳性者的配偶/固定性伴告知与检测”政策，要求HIV阳性者必须在一个月内将阳性结果告知其配偶/固定性伴，否则将由当地疾控工作人员强制执行配偶/固定性伴告知服务；⑧地方政府应给予政策支持，选择疫情严重的地区（如：鹿寨县）进行艾滋病普查，方法可以借鉴四川凉山州布托县和昭觉县的艾滋病普查；⑨充分发挥现有HIV/AIDS发现平台的作用，完善各HIV/AIDS发现平台与疾控中心之间的部门协调与合作机制，以加强对已发现HIV/AIDS的后续随访管理工作，让HIV/AIDS定期进行CD4检测和及时接受抗病毒治疗。
结论
柳州地区HIV/AIDS中发现晚的状况比较严重。艾滋病传播途径知识知晓率低、在查出感染HIV之前没有做HIV检测的想法、检测样本来源于“其他就诊者检测”、在查出感染HIV之前出现HIV相关症状是发现晚的独立危险因素，应该作为HIV/AIDS发现晚的预防和干预因素之一。检测样本来源于“强制/劳教戒毒人员检测”发生发现晚的风险较小，提示对强制/劳教戒毒人员进行HIV检测有助于感染者的早期发现，因此，在今后的艾滋病防治工作中，应继续加强对该人群进行入狱前HIV检测，同时还应该加强对有艾滋病高危行为的其他收押人员的入狱前HIV检测。此外，还应该以本研究针对早期发现HIV感染者而提出的对策与措施为指导方针，进一步有效开展HIV感染者的检测发现工作，并加强对已发现HIV/AIDS的后续随访工作，让HIV/AIDS定期进行CD4检测和及时接受抗病毒治疗。
Objectives
(1) To understand the status and epidemiologic characteristics of late HIVdiagnosis in Liuzhou city of Guangxi Zhuang Autonomous Region.
(2) To identify the factors associated with late HIV diagnosis by univariate andmultivariate logistic regression analysis.
(3) To identify the reasons for late HIV diagnosis and measures for detectingHIV infections earlier by qualitative research.
(4) To explore the measures and strategies for detecting HIV infections earlierby combining quantitative and qualitative research results.
Methods
A census method was used to select the study individuals. All individuals whowere newly diagnosed with HIV infection between1January2009and30June2010and lived in Liuzhou city were eligible. Late HIV diagnosis was defined as:an AIDS diagnosis when HIV diagnosed or developed AIDS within one year ofHIV diagnosis. The questionnaire included general information, high-riskexposure history, HIV testing history, medical history and HIV/AIDS-relatedknowledge. Moreover, a qualitative method was used to collect the reasons forlate HIV diagnosis and measures for detecting HIV infections earlier.Quantitative data were entered using EpiData3.02software and analyzed usingSPSS13.0software. Chi-square test were used for categorical variables. Multivariate logistic regression was used to identify factors independentlyassociated with late HIV diagnosis. Recording was transcribed into text firstly,and then a summary method was used to analyze the qualitative data.
Results
(1) Of the917study individuals,658(71.8%) had a late HIV diagnosis.
(2)The epidemiologic characteristics of late HIV diagnosis individuals were asfollows: the most common HIV transmission route was heterosexualtransmission(86.9%); the blood sample source was dominated by “HIV testingfor persons sought medical treatment for illness”(57.6%);83.3%had a regularheterosexual partner, and54.6%did not know their regular heterosexualpartners’ HIV statuses;66.6%had casual heterosexual partners, and most ofthem(97.0%) did not know their casual heterosexual partners’ HIV statuses; only0.4%had male homosexual partners;9.2%had a history of needle sharing forinjecting drugs,0.8%had a history of plasma donation and1.7%had a history ofblood transfusion; majority (91.4%) did not have the idea of taking HIV testingbefore HIV diagnosis, the main reasons for not having the idea of taking HIVtesting were “Never thought I would be HIV-infected”,“I didn’t feel sick, so it wasimpossible to be infected with HIV”,“I have never heard of AIDS” and “I wasworry the discrimination from HIV-infection”;76.6%had one or more HIV-relatedsymptoms before HIV diagnosis, the most common symptoms were unexplainedweight loss, unexplained prolonged fever, recurrent respiratory tract infectionand recurrent cough/chest distress;85.0%sought medical treatment after thepresence of HIV-related symptoms, and most of them(77.4%) sought medicaltreatment at general hospitals, however, only nearly two thirds of the generalhospitals have offered HIV testing for these persons; majority knew few aboutHIV/AIDS-related knowledge before HIV diagnosis, and the total rate of questions about HIV/AIDS answered correctly was56.8%;70.3%knew someabout AIDS “Four Frees and One Care” policy before HIV diagnosis, but stillmore than half did not know the VCT clinic could offer free HIV testing.
(3) The risk factors of late HIV diagnosis: lower annual household income,whose blood sample source was “HIV testing for persons sought medicaltreatment for illness”, thought themselves could not be infected with HIV fromtheir regular heterosexual partners, did not have the idea of taking HIV testingbefore HIV diagnosis, had unexplained weight loss or unexplained prolongedfever or angular cheilitis before HIV diagnosis, did not know whether needlesharing for injecting drugs occasionally could transmit HIV or thought needlesharing for injecting drugs occasionally could not transmit HIV. Among thesefactors, whose blood sample source was “HIV testing for persons soughtmedical treatment for illness”(OR=2.351, P=0.020), had unexplained weightloss(OR=2.577, P＜0.001) or unexplained prolonged fever(OR=2.111, P=0.004)or angular cheilitis(OR=2.860, P=0.042) before HIV diagnosis were importantrisk factors.
(4) The protective factors of late HIV diagnosis: Those blood sample sourcewas “HIV testing for compulsory detoxification prisoners”(OR=0.203, P=0.013)were less likely to have late HIV diagnosis.
(5) The reasons for late HIV diagnosis:①Knew few about AIDS, and neverthought I would be HIV-infected.②I didn’t feel sick, so it was impossible to beinfected with HIV.③I didn’t have high-risk behavior, so it was impossible to beinfected with HIV.④Did not know AIDS spreading so seriously.⑤Some peopletook some chances.⑥Some people were afraid to be testing HIV-infected, sothey did not take HIV testing always, such as having a HIV-infected spouse.⑦Knew some about AIDS, and most thought that AIDS was far away from theirown, so few took HIV testing on their own initiative.⑧Because of lower income, the majority sought medical treatment untill the presence of clinical symptoms orsick bad, and then got the HIV-positive result.⑨Worried the discrimination fromHIV-infection.⑩The current HIV testing scale was not enough, it was stilldominated by passive testing, the initiative testing was few.
(6) The measures and strategies for detecting HIV infections earlier:①Although the AIDS health education work has been done for many years, itstill needs to improve the depth and extent of this work. It is essential tostrengthen the AIDS health education programs among the general population,especially in rural areas, to improve the risk perception of HIV infection.②Itneed to strengthen the anti-discrimination publicity, to reduce or eliminate thediscrimination against HIV/AIDS patients. Moreover, it is also important tostrengthen and ensure the confidentiality of HIV test results.③Greater effortsneed to be made to strengthen the AIDS health education programs amonghigh-risk groups, to let more high-risk groups to take HIV testing on their owninitiative. Moreover, it should take a variety of methods to attract high-risk groupsfor HIV testing. For example, taking manifold free testing project (including bloodsugar, urine sugar, blood type, free gynecologic examination) among FSW.④Expand the coverage of VCT and strengthen the publicity for VCT services, tolet more people understand the VCT services.⑤It should adopt a variety ofrapid testing methods, to shorten the time for test results, in order to facilitate thesubsequent follow-up and management for HIV/AIDS cases.⑥It is essential tostart PITC in hospitals. And, it is necessary to train the clinicians to improve theirrecognition of clinical presentations for underlying HIV infection and perform HIVtesting for these patients, especially the dermatology, respiratory, infectiousdiseases, internal medicine, fever clinics clinicians.⑦It need to promotespouse/sexual-partner notification for HIV-infected persons and to strengthenHIV testing for HIV-infected persons’ spouses/sexual-partners. For example, Guangxi Zhuang Autonomous Region government formulates the “GuangxiZhuang Autonomous Region regulations on HIV/AIDS patients’spouse/sexual-partners notification”, to require the HIV/AIDS patients to notifytheir spouse/sexual-partners about their HIV-positive results within one month, ifnot, they will be notified by the local CDC.⑧The local government should givepolicy support, and selected an area with serious HIV epidemic to make HIVcensus, such as Luzhai county. The investigation method could learn of the HIVepidemiologic survey for Butuo and Zhaojue counties of Liangshan Prefecture,Sichuan Province.⑨It should give full play to the existing HIV/AIDS detectedinstitutions, and perfect the cooperation mechanism between the HIV/AIDSdetected institutions and CDC, in order to strengthen the subsequent follow-upfor those detected HIV/AIDS cases and let them take CD4testing regularly andreceive antiretroviral treatment timely.
Conclusions
The status of late HIV diagnosis in Liuzhou city is rather serious. Lowknowledge awareness about HIV transmission route, not having the idea oftaking HIV testing before HIV diagnosis, whose blood sample source was “HIVtesting for persons sought medical treatment for illness”, having HIV-relatedsymptoms before HIV diagnosis are the independent risk factors of late HIVdiagnosis, so much attention should be given to the HIV/AIDS with this kind toprevent and intervene late HIV diagnosis. Those blood sample source was “HIVtesting for compulsory detoxification prisoners” were less likely to have late HIVdiagnosis, suggesting that offering HIV testing for compulsory detoxificationprisoners is beneficial for earlier HIV diagnosis. And, compulsory testing forother types of prisoners with HIV risk factors may improve the rate of early HIVdiagnosis. Meanwhile, it should take the measures and strategies for detecting HIV infections earlier in this study as the guidelines, to further start the detectionof HIV infections effectively and strengthen the subsequent follow-up for thosedetected HIV/AIDS cases, to let them take CD4testing regularly and receiveantiretroviral treatment timely.
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22. Castilla J, Sobrino P, De La Fuente L, et al. Late diagnosis of HIV infection inthe eraof highly active antiretroviral therapy: consequences for AIDS incidence.AIDS.2002.16(14):1945-1951.
23. Br nnstr m J, Akerlund B, Arneborn M, et al. Patients unaware of their HIVinfection until AIDS diagnosis in Sweden1996-2002--a remaining problem inthehighly active antiretroviral therapy era. Int J STD AIDS.2005.16(10):702-706.
24. Jean-Jacques M, Walensky RP, Aaronson WH, et al. Late diagnosis of HIVinfection attwo academic medical centers:1994-2004. AIDS Care.2008.20(8):977-983.
25. Ndiaye B, Salleron J, Vincent A, et al. Factors associated with presentationto carewith advanced HIV disease in Brussels and Northern France:1997-2007.BMC InfectDis.2011.11:11.
26. Delpierre C, Lauwers-Cances V, Pugliese P, et al. Characteristics trends,mortalityand morbidity in persons newly diagnosed HIV positive during the lastdecade: theprofile of new HIV diagnosed people. Eur J Public Health.2008.18(3):345-347.
27. Bonjour MA, Montaqne M, Zambrano M, et al. Determinants of latedisease-stagepresentation at diagnosis of HIV infection in Venezuela: a case-casecomparison.AIDS Res Ther.2008.5:6.
28. Torrone EA, Thomas JC, Leone PA, et al. Late diagnosis of HIV in youngmen in NorthCarolina. Sex Trans Dis.2007.34(11):846-848.
29. Ulett KB, Willig JH, Lin H-Y, et al. The therapeutic implications of timelylinkage andearly retention in HIV care. AIDS Patient Care STDS.2009.23(1):41-49.
30. Bamford LP, Ehrenhranz PD, Eberhart MG, et al. Factors associated withdelayedentry into primary HIV medical care after HIV diagnosis. AIDS.2010.24(6):928-920.
31. Althoff KN, Gebo KA, Gange SJ, et al. CD4count at presentation for HIVcare in theUnited States and Canada: are those over50years more likely to have adelayedpresentation? AIDS Res Ther.2010.7:45.
32. Thanawuth N, Chongsuvivatwong V. Late HIV diagnosis and delay in CD4countmeasurement among HIV-infected patients in Southern Thailand. AIDS Care.2008.20(1):43-50.
33. Gupta SB, Gilbert RL, Brady AR, et al. CD4cell counts in adults with newlydiagnosed HIV infection: Results of surveillance in England and Wales,1990-1998.CD4Surveillance Scheme Advisory Group. AIDS.2000.14(7):853-861.
34. Delpierre C, Cuzin L, Lauwers-Cances V, et al. High-risk groups for latediagnosis ofHIV infection: A need for rethinking testing policy in the general population.AIDSPatient Care STDS.2006.20(12):838-847.
35. Delpierre C, Cuzin L, Lert F. Routine testing to reduce late HIV diagnosis inFrance.BMJ.2007.334(7608):1354-1356.
36. Castelnuovo B, Chiesa E, Rusconi S, et al. Declining incidence of AIDS andincreasingprevalence of AIDS presenters among AIDS patients in Italy. Eur J ClinMicrobiolInfect Dis.2003.22(11):663-669.
37. Centers for Disease Control and Prevention. Missed opportunities for earlierdiagnosis of HIV infection--South Carolina,1997-2005. MMWR Morb andMortalWkly Rep.2006.55(47):1269-1272.
38. Mayben JK, Kramer JR, Kallen MA, et al. Predictors of delayed HIVdiagnosis in arecently diagnosed cohort. AIDS Patient Care STDS.2007.21(3):195-204.
39. Samet JH, Freedberg KA, Savetsky JB, et al. Understanding delay tomedical care forHIV infection: The long-term non-presenter. AIDS.2001.15(1):77-85.
40. Krentz HB, Auld MC, Gill MJ. The high cost of medical care for patients whopresentlate (CD4<200cells/microL) with HIV infection. HIV Med.2004.5(2):93-98.
41. Baratin D, Marceillac E, Trepo C, et al. Characteristics of patients diagnosedwithAIDS shortly after first detection of HIV antibodies in Lyon Universityhospitals from1985to2001. HIV Med.2004.5(4):273-277.
42. Rotily M, Bentz L, Pradier C, et al. Factors related to delayed diagnosis ofHIVinfection in southeastern France. EVALVIH group. Int J STD AIDS.2000.11(8):531-535.
43. Boyd AE, Murad S, O’Shea S, et al. Ethnic differences in stage ofpresentation ofadults newly diagnosed with HIV-1infection in south London. HIV Med.2005.6(2):59-65.
44. Sullivan AK, Curtis H, Sabin CA, et al. Newly diagnosed HIV infections:review in UKand Ireland. BMJ.2005.330(7503):1301-1302.
45. Hogan C, Dobkin J, Brudney K, et al. Late presentation of HIV disease in theera ofpotent therapy. Paper presented at the1st International AIDS Societyconferenceon HIV pathogenesis and treatment. Buenos Aires, Argentina,2001.Retrieved fromhttp://www. iasociety.org/Abstracts/A315.aspx. Accessed October15,2007.
46. Hocking JS, Rodger AJ, Rhodes DG, et al. Late presentation of HIV infectionassociated with prolonged survival following AIDS diagnosis-characteristicsofindividuals. Int J STD AIDS.2000.11(8):503-508.
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49. Carrizosa CM, Blumberg EJ, Hovell MF, et al. Determinants and prevalenceof lateHIV testing in Tijuana, Mexico. AIDS Patient Care STDS.2010.24(5):333-340.
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4. Yang B, Chan SK, Mohammad N, et al. Late HIV diagnosis in Houston/HarrisCounty,Texas,2000-2007. AIDS Care.2010.22(6):766-774.
5. Mugavero MJ, Castellano C, Edelman D, et al. Late Diagnosis of HIV Infection:theRole of Age and Gender. Am J Med.2007.120(4):370-373.
6. Grigoryan A, Hall HI, Durant T, et al. Late HIV diagnosis and determinants ofprogression to AIDS or death after HIV diagnosis among injection drug users,33USStates,1996-2004. PLoS One.2009.4(2):e4445.
7. Carnicer-Pont D, de Olalla PG, Cayl JA, et al. HIV infection late detection inAIDSpatients of an European city with increased immigration since mid1990s. CurrHIV Res.2009.7(2):237-243.
8. Kivel PS, Krol A, Salminen MO, et al. Determinants of late HIV diagnosisamongdifferent transmission groups in Finland from1985to2005. HIV Med.2010.11(6):360-367.
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12. Lo YC, Wu PY, Hsieh CY, et al. Late diagnosis of human immunodeficiencyvirusinfection in the era of highly active antiretroviral therapy: role ofsocio-behavioralfactors and medical encounters. J Formos Med Assoc.2011.110(5):306-315.
13. Lemoh C, Guy R, Yohannes K, et al. Delayed diagnosis of HIV infection inVictoria1994to2006. Sex Health.2009.6(2):117-122.
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18. Longo B, Pezzotti P, Boros S, et al. Increasing proportion of late testersamong AIDScases in Italy,1996-2002. AIDS Care.2005.17(7):834-841.
19. Girardi E, Sampaolesi A, Gentile M, et al. Increasing proportion of latediagnosis ofHIV infection among patients with AIDS in Italy following introduction ofcombination antiretroviral therapy. J Acquir Immune Defic Syndr.2000.25(1):71-76.
20. Wolbers M, Bucher HC, Furrer H, et al. Delayed diagnosis of HIV infectionand lateinitiation of antiretroviral therapy in the Swiss HIV Cohort Study. HIV Med.2008.9(6):397-405.
21. Girardi E, Aloisi MS, Arici C, et al. Delayed presentation and late testing forHIV:demographic and behavioral risk factors in a multicenter study in Italy. JAcquir Immune Defic Syndr.2004.36(4):951-959.
22. Castilla J, Sobrino P, De La Fuente L, et al. Late diagnosis of HIV infection inthe eraof highly active antiretroviral therapy: consequences for AIDS incidence.AIDS.2002.16(14):1945-1951.
23. Br nnstr m J, Akerlund B, Arneborn M, et al. Patients unaware of their HIVinfection until AIDS diagnosis in Sweden1996-2002--a remaining problem inthehighly active antiretroviral therapy era. Int J STD AIDS.2005.16(10):702-706.
24. Jean-Jacques M, Walensky RP, Aaronson WH, et al. Late diagnosis of HIVinfection attwo academic medical centers:1994-2004. AIDS Care.2008.20(8):977-983.
25. Ndiaye B, Salleron J, Vincent A, et al. Factors associated with presentationto carewith advanced HIV disease in Brussels and Northern France:1997-2007.BMC InfectDis.2011.11:11.
26. Delpierre C, Lauwers-Cances V, Pugliese P, et al. Characteristics trends,mortalityand morbidity in persons newly diagnosed HIV positive during the lastdecade: theprofile of new HIV diagnosed people. Eur J Public Health.2008.18(3):345-347.
27. Bonjour MA, Montaqne M, Zambrano M, et al. Determinants of latedisease-stagepresentation at diagnosis of HIV infection in Venezuela: a case-casecomparison.AIDS Res Ther.2008.5:6.
28. Torrone EA, Thomas JC, Leone PA, et al. Late diagnosis of HIV in youngmen in NorthCarolina. Sex Trans Dis.2007.34(11):846-848.
29. Ulett KB, Willig JH, Lin H-Y, et al. The therapeutic implications of timelylinkage andearly retention in HIV care. AIDS Patient Care STDS.2009.23(1):41-49.
30. Bamford LP, Ehrenhranz PD, Eberhart MG, et al. Factors associated withdelayedentry into primary HIV medical care after HIV diagnosis. AIDS.2010.24(6):928-920.
31. Althoff KN, Gebo KA, Gange SJ, et al. CD4count at presentation for HIVcare in theUnited States and Canada: are those over50years more likely to have adelayedpresentation? AIDS Res Ther.2010.7:45.
32. Thanawuth N, Chongsuvivatwong V. Late HIV diagnosis and delay in CD4countmeasurement among HIV-infected patients in Southern Thailand. AIDS Care.2008.20(1):43-50.
33. Gupta SB, Gilbert RL, Brady AR, et al. CD4cell counts in adults with newlydiagnosed HIV infection: Results of surveillance in England and Wales,1990-1998.CD4Surveillance Scheme Advisory Group. AIDS.2000.14(7):853-861.
34. Delpierre C, Cuzin L, Lauwers-Cances V, et al. High-risk groups for latediagnosis ofHIV infection: A need for rethinking testing policy in the general population.AIDSPatient Care STDS.2006.20(12):838-847.
35. Delpierre C, Cuzin L, Lert F. Routine testing to reduce late HIV diagnosis inFrance.BMJ.2007.334(7608):1354-1356.
36. Castelnuovo B, Chiesa E, Rusconi S, et al. Declining incidence of AIDS andincreasingprevalence of AIDS presenters among AIDS patients in Italy. Eur J ClinMicrobiolInfect Dis.2003.22(11):663-669.
37. Centers for Disease Control and Prevention. Missed opportunities for earlierdiagnosis of HIV infection--South Carolina,1997-2005. MMWR Morb andMortalWkly Rep.2006.55(47):1269-1272.
38. Mayben JK, Kramer JR, Kallen MA, et al. Predictors of delayed HIVdiagnosis in arecently diagnosed cohort. AIDS Patient Care STDS.2007.21(3):195-204.
39. Samet JH, Freedberg KA, Savetsky JB, et al. Understanding delay tomedical care forHIV infection: The long-term non-presenter. AIDS.2001.15(1):77-85.
40. Krentz HB, Auld MC, Gill MJ. The high cost of medical care for patients whopresentlate (CD4<200cells/microL) with HIV infection. HIV Med.2004.5(2):93-98.
41. Baratin D, Marceillac E, Trepo C, et al. Characteristics of patients diagnosedwithAIDS shortly after first detection of HIV antibodies in Lyon Universityhospitals from1985to2001. HIV Med.2004.5(4):273-277.
42. Rotily M, Bentz L, Pradier C, et al. Factors related to delayed diagnosis ofHIVinfection in southeastern France. EVALVIH group. Int J STD AIDS.2000.11(8):531-535.
43. Boyd AE, Murad S, O’Shea S, et al. Ethnic differences in stage ofpresentation ofadults newly diagnosed with HIV-1infection in south London. HIV Med.2005.6(2):59-65.
44. Sullivan AK, Curtis H, Sabin CA, et al. Newly diagnosed HIV infections:review in UKand Ireland. BMJ.2005.330(7503):1301-1302.
45. Hogan C, Dobkin J, Brudney K, et al. Late presentation of HIV disease in theera ofpotent therapy. Paper presented at the1st International AIDS Societyconferenceon HIV pathogenesis and treatment. Buenos Aires, Argentina,2001.Retrieved fromhttp://www. iasociety.org/Abstracts/A315.aspx. Accessed October15,2007.
46. Hocking JS, Rodger AJ, Rhodes DG, et al. Late presentation of HIV infectionassociated with prolonged survival following AIDS diagnosis-characteristicsofindividuals. Int J STD AIDS.2000.11(8):503-508.
47. McDonald AM, Li Y, Dore GJ, et al. Late HIV presentation among AIDScases inAustralia,1992-2001. Aust N Z J Public Health.2003.27(6):608-613.
48. Kigozi IM, Dobkin LM, Martin JN, et al. Late-disease stage at presentation toan HIVclinic in the era of free antiretroviral therapy in sub-Saharan Africa. J Acquir.Immune Defic Syndr.2009.52(2):280-289.
49. Carrizosa CM, Blumberg EJ, Hovell MF, et al. Determinants and prevalenceof lateHIV testing in Tijuana, Mexico. AIDS Patient Care STDS.2010.24(5):333-340.