摘要
研究背景
云南省德宏傣族景颇族自治州(简称“德宏州”),是艾滋病重度流行区和国家艾滋病防控重点地区。截止2008年底,德宏州累计报告艾滋病病毒(HIV)感染者(包括艾滋病病人)14903例。HIV疫情监测数据显示,2005年以来,HIV流行形式发生了变化,新发现HIV感染者中经性途径感染HIV的比例超过经静脉注射吸毒感染HIV的比例,性传播成为主要的HIV传播途径。HIV感染状况不一致夫妻(简称“HIV单阳夫妻”)中的配偶,是经性途径感染HIV的高危人群,然而,该人群中性行为的现况,缺乏相关数据。除HIV感染的配偶这类HIV感染的高危人群外,一般人群中的性行为状况目前也不清楚。
研究目的
为了控制德宏州HIV经性传播的流行趋势,预防HIV单阳夫妻间及社区一般人群中HIV和性传播感染(STI)的流行,在云南省德宏州开展了此项研究,其具体目标为：(1)描述HIV单阳夫妻艾滋病相关危险行为特点和性行为网络特点,了解夫妻间危险性行为的发生率并分析其相关因素；(2)了解HIV单阳夫妻中STI流行情况并分析其影响因素,从而为减少HIV感染者二代传播的干预提供制定策略的依据；(3)了解该地农村社区居民HIV/STI流行及其相关因素,分析其性行为网络特点,为一般人群中的HIV干预策略提供科学依据。
研究方法
1.HIV单阳夫妻性行为网络研究和STI感染流行病学研究
以云南省德宏州为研究现场,整群抽取已婚有配偶、且配偶感染情况不详的HIV感染者人数在20及以上的34个乡镇,根据知情同意的原则在34个乡镇招募研究对象参与筛查。筛查时对HIV感染者的配偶进行HIV检测,确认为HIV阴性后,将夫妻双方纳入研究。对纳入研究的HIV单阳夫妻进行问卷调查,收集其人口学和行为学信息;抽取研究对象静脉血进行检测,HIV感染者进行CD4、HIV病毒载量(VL)、单纯疱疹病毒2型(Herpes Simplex Virus Type 2, HSV-2)和梅毒的检测,对HIV阴性配偶HSV-2和梅毒的检测。
2.农村社区居民性行为网络和HIV/STI感染流行病学研究
通过目标抽样,整群抽取陇川县某乡镇在地理位置上相连的10个村寨,招募所有16-55岁的常住居民参与研究,通过问卷调查收集人口学、行为学和艾滋病相关危险行为网络成员信息,并抽取静脉血检测HIV、HSV-2和梅毒。
研究结果
1.HIV单阳夫妻性行为网络研究
本研究招募合格的HIV单阳夫妻984对,HIV感染者中男性、女性比例分别为77.4%和22.6%。21.0%的夫妻最近3月内有性行为但不用或不坚持使用安全套(危险性行为),未发现夫妻间共用针具吸毒的行为。整体来说,HIV感染者夫妻性行为网络连接度低,但是,有少部分HIV感染者有共用针具行为,5.1%的HIV感染者最近一年有多性伴。
与夫妻危险性行为相关的因素有夫妻平均年龄、夫妻民族组合、子女情况、最近一年内免费安全套获取和医务人员定期随访。夫妻平均年龄在26岁以下者(OR=2.27,95%CI：1.08-4.74)、在26-35岁者(OR=2.15,95%CI：1.17-3.96)其危险性行为风险高于年龄在46岁以上者；夫妻双方均为景颇族者危险性行为风险是夫妻均为汉族者的2.29倍(OR=2.29,95%CI：1.40-3.75)；无子女夫妻危险性行为风险是有子女者3.64倍(OR=3.64,95%CI：2.30-5.76)；最近一年内未接受过医务人员定期随访的夫妻危险性行为的风险是接受随访者的1.45倍(OR=1.45,95%CI：1.04-2.04),未获得过免费安全套的夫妻是曾获得者的2.35倍(OR=2.35,95%CI：1.51-3.65)。
2.HIV单阳夫妻STI流行病学研究
976对单阳夫妻中,至少有一方感染HSV-2或梅毒的比例为47.5%。HIV感染者中,梅毒感染率3.1%,HSV-2感染率为39.0%;与HIV感染者HSV-2感染有关的因素有性别、年龄、民族、HIV感染途径和商业性行为史。女性HIV感染者HSV-2感染风险是男性的2.80倍(OR=2.80,95%CI：1.92-4.10)；与年龄在46岁及以上者相比,36-45岁年龄者HSV-2感染风险降低(OR=0.59,95%CI：0.38-0.91)；景颇族HSV-2感染风险比汉族低(OR=0.63,95%CI：0.42-0.94)；经异性性行为感染HIV者是经注射吸毒者的2.28倍(OR=2.28,95%CI：1.62-3.22);有过商业性行为史者HSV-2感染风险是无商业性行为史者的1.67倍(OR=1.67,95%CI：1.15-2.42)。
HIV阴性配偶中,梅毒感染率为1.4%,HSV-2感染率为30.8%；与HSV-2感染相关的因素有性别、文化程度以及HIV感染者的HSV-2感染状况。女性配偶HSV-2感染风险高于高于男性(OR=4.53,95%CI：2.91-7.04);小学(OR=1.68,95%CI：1.06-2.68)和初中及以上文化程度者(OR=1.76,95%CI：1.04-2.96)感染风险高于文盲的配偶；合并感染HSV-2的HIV感染者的配偶HSV-2感染风险高于未感染HSV-2感染者的配偶(OR=17.35,95%CI：11.97-25.16)。
3.农村社区居民性行为网络与HIV/STI流行病学研究
共招募研究对象591人,应答率80.4%,HIV感染率为5.5%,HSV-2感染率为19.9%。男性研究对象中,HIV感染率为7.1%,HSV-2感染率为18.0%；与男性HIV感染相关的因素是吸毒(OR=13.11,95%CI：2.49-68.90),与男性HSV-2感染相关的因素为再婚,再婚者HSV-2感染风险是初婚者的3.22倍(OR=3.22,95%CI：1.02-10.20)。女性研究对象中,HIV感染率为3.5%,HSV-2感染率为21.7%；与女性HIV感染的相关因素为多性伴(OR=28.11,95%CI：2.43-325.19),与女性HSV-2感染相关的因素为文化程度,文盲者HSV-2感染风险比初中及以上者低(OR=0.29,95%CI：0.09-0.93)。
有过性行为的研究对象中,32.5%报告有过两个及以上性伴。2005年以来,73.1%的夫妻性行为时从未使用安全套;该地区性行为网络连接度低,39.3%的性关系中性伴为外地性伴,即性行为网络地域跨度大。
研究结论
HIV单阳夫妻间存在HIV传播的风险,年轻、双方都为景颇族、无子女以及接受干预少的夫妻是高风险人群；部分HIV感染者有吸毒和多性伴行为,有传播HIV的风险。针对HIV单阳夫妻的干预应该继续强化夫妻间安全套使用,尤其是针对年轻、无子女和景颇族的夫妻。
HIV单阳夫妻中STI感染率高,夫妻间有HIV和STI传播的双重风险；建议在HIV单阳夫妻间进行STI的检测和治疗,以降低HIV传播风险。
农村社区居民中HIV和HSV-2感染率高,性行为整体网络连接度低,但某些个体的性行为网络复杂。在社区一般人群中的HIV干预,应该强调夫妻间安全套的使用；对男性、景颇族等高危人群,重点在于减少多性伴行为、降低吸毒危害。
Objectives
The study was conducted in Dehong prefecture, Yunnan province with specific aims (1) to evaluate the risk behavior of HIV transmission within HIV-serodiscordant heterosexual couples (hereafter referred to as "DC couple") and examine the correlates of the risk behavior, and describe the HIV related risky networks of these couples, (2) to investigate the sero-prevalence and correlates of STI among DC couples, and (3) to examine the sero-prevalence and correlates of HIV/STI among general rural populations and to profile their sexual networks.
Methods
(1) The study of DC couples was conducted in Dehong prefectures, and DC couples were enrolled from 34 townships clustered with 20 or more HIV infected individuals. All the couples participatd in the study were interviewed to collect demography and behavior information, HIV infected subjects were tested for HIV viral load, CD4 count, HSV-2 and syphilis, and HIV negative parters were tested for HSV-2 and syphilis.
(2) The study among general rural populatioins was conducted in a rural community cluster with 10 villages geographically continued. All permanent residents aged 16 to 55 who were able to provide informed consent were recruited for the study. All subjects were interviewed and tested for HIV, syphilis and HSV-2.
Results
(1) Of the 984 DC couples enrolled,77.4% of the HIV-1 infected partners were male and 22.6% were female. Of the DC couples,21.0% had sex but inconsistently used condoms within three months; needle sharing was not observed within these couples. The couples' average age was correlated with inconsistent condom use, those aged less than 26 (OR=2.27, 95%CI:1.08-4.74) and aged 26-35 (OR=2.15,95%CI:1.17-3.96) were more likely to involve inconsistentt condom use than those aged above 46 years old. Jingpo couples were 2.29 fold more likey to inconsistently use condoms than Han couples were (OR=2.29,95%CI: 1.40-3.75). The couples without offspring had a higher proportion of inconsistent condom use than those with offspring (OR=3.64,95%CI:2.30-5.76). Inconsistent condom use were more common among couples who were not followed by medical staff regularly (OR=1.45, 95%CI:1.04-2.04) and who were not provided free condoms (OR=2.35,95%CI:1.51-3.65). A few HIV-infected subjects shared needles and a percent of 5.2 had multiple sexual partners within 12 months.
(2) Of 976 couples enrolled and tested,47.5% were infected with either HSV-2 or syphilis. Of the HIV-infected subjects,3.1% were tested syphilis positive, and 39.0% were tested HSV-2 positive and the correlates of HSV-2 infection were gender, age, ethnic and HIV transmission route. Females subjects were 2.80-fold more likely to have HSV-2 than males (OR=2.80,95% CI:1.92-4.10), HSV-2 were less common among those aged 36-45 years old than those over 46 years old (OR=0.59; 95% CI:0.38-0.91), and were less common among Jingpos (OR=0.63,95% CI:0.42-0.94) than Hans, those acquired HIV through heterosexual behavior had a higher prevalence than those infected through injection drug use (OR=2.28, 95% CI:1.62-3.22), and those reporting any commercial sex had 1.67 fold more likely to have HSV-2 than those without commercial sex. Among HIV negative partners, the prevalence of syphilis was 1.4% and HSV-2 was 30.8%. The correlates of HSV-2 among them were gender, education, and their partner's HSV infection status. Females were more likely to be infected with HSV-2 (OR=4.53,95% CI:2.91-7.04), HSV-2 were more common among those with primary school level (OR=1.68,95% CI:1.06-2.68) and junior high school or above (OR=1.76,95% CI:1.04-2.96) than the illiterates, subjects with an HSV-2 positive partner had a 17.35 (OR=17.35,95% CI:11.97-25.16) fold more likely to had HSV-2.
(3) The overall HIV prevalence among rural general population was 5.5%; the Jingpo minority had the highest prevalence (7.6%). Most participants were sexually experienced and 32.5% had had multiple sex partners. About 18.8% had used drugs, with the highest proportion among the Jingpo minority. HIV infection was independently correlated with drug use among males and with multiple sex partners among females. A total of 336 independent sexual network components (mostly small, linear, and acyclic) were constructed. Eighty-percent were dyads involving two members and 20% involved 3 to 71 members. Several HIV-infected participants presented relatively complex sexual networks.
Conclusions
There was potential risk of HIV transmission among DC couples and those youger, Jingpo and those without offspring were at higher risk of transmission. A few HIV infected partners from DC couples engaged in risky behavior such as sharing needles and multiple seuxla partners, and had potential risk of HIV spread. STI were common among DC couples. Awareness of STI correlates and treatment of both partners may reduce HIV-1 transmission. Coupled with the promotion of condom use, gender-specific efforts are needed for HIV prevention targeting ethnic minorities in Yunnan Province:to prevent drug use among males and to decrease having concurrent multiple sex partners (including those who use drugs) among females.
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