文章信息
- 苏容, 李东民.
- Su Rong, Li Dongmin
- 我国男男性行为人群HIV自我检测及相关因素研究进展
- Progress in research on HIV self-testing and associated factors among men who have sex with men in China
- 中华流行病学杂志, 2023, 44(4): 683-688
- Chinese Journal of Epidemiology, 2023, 44(4): 683-688
- http://dx.doi.org/10.3760/cma.j.cn112338-20220830-00746
-
文章历史
收稿日期: 2022-08-30
HIV检测是艾滋病防控工作的第一步[1],检测不及时会增加HIV传播风险和艾滋病相关死亡风险[2-5]。联合国提出终结艾滋病流行的“三个95%”目标中,首要目标就是95%的HIV感染者能够得到确诊[6]。我国MSM的HIV感染率为5.7%左右,但是检测率偏低[7-8]。2019年,我国仅有56.4%的MSM做过HIV检测[9]。HIV自我检测(HIV自检)作为一种新型的HIV检测方式,克服了传统HIV检测的诸多不足,在MSM中接受度较高,有利于扩大MSM的HIV检测率[10]。本文对我国MSM的HIV自检情况及相关因素进行综述,为HIV自检在该人群中的推广提供依据。
一、HIV自检定义及检测试剂1. 定义:受检者不借助专业设备、不依靠专业人员,自行利用HIV自检工具包,采集样本、进行HIV检测并读取结果[11]。目前,全球约有70多个国家颁布了HIV自检政策或指南[12],我国于2019年发布了《艾滋病自我检测指导手册(第一版)》[13]。
2. 检测试剂:我国目前有尿液、唾液和血液3种HIV自检试剂可供选择。尿液HIV自检试剂是我国唯一一个获得国家药品监督管理局批准并上市的HIV自检试剂,易于操作,但检出率较低[14-15],MSM的使用率较低,如深圳市仅为3.4%[16]。唾液HIV自检试剂是取受检者的口腔黏膜渗出液进行检测,在MSM中的使用率高于尿液HIV自检试剂,上海市MSM的使用率为55.1%[17]。血液HIV自检试剂是采集受检者的指尖血进行检测,检出率高于另两类检测试剂[15],汤昀玥等[16]调查发现,深圳市72.7%的HIV自检使用者采用血液HIV自检试剂。
二、我国MSM的HIV自检现状我国有6.1%~71.4%的MSM做过HIV自检,不同地区间的HIV自检率存在差异。东部沿海地区为19.5%~71.4%[18-21],南部地区为6.1%~40.4%[22-23],西部地区为15.6%~19.7%[24-25],北部地区为39.7%~64.4%[26-27]。从整体看,西部地区MSM的HIV自检率较低。曾做过HIV自检的MSM中,约一半为首次HIV检测[28-29],说明HIV自检有助于扩大MSM的HIV检测率,推广HIV自检可促进实现“三个95%”目标。
三、HIV自检相关因素1. 个体因素:
(1)社会人口学因素:①年龄:≥30岁的MSM做过HIV自检的比例低于 < 30岁者[26, 30]。年龄较大者对新事物的接受能力不如年轻人,需要加强HIV自检在年龄较大者中的宣传力度,提高该人群对HIV自检的接受度。②户籍地:有研究显示,外省户籍的MSM做过HIV自检的比例是本省户籍的2.55(95%CI:1.02~6.38)倍[31]。主要原因是流动人口缺乏社会支持、获得医疗卫生服务的机会有限,做过传统HIV检测的比例较小[24],在该人群中推广HIV自检可获得较高效益。③文化程度:文化程度较高的MSM对HIV自检的接受度较高[32],大专及以上文化程度者做过HIV自检的比例是高中及以下者的2.89~4.36倍[33-34]。文化程度较高者理解能力也较强,HIV自检的操作过程和结果判读更准确,结果更具参考价值[35]。④婚姻状况:受传统家庭观念的影响,我国有大量MSM选择与女性结婚[36-37]。相比于单身MSM,已婚MSM风险意识较低[38],做过HIV自检的比例低(aOR=0.46,95%CI:0.21~0.99)[39]。但也有研究得出了相反的结论[40]。因此,婚姻状况是否会影响MSM的HIV自检还需进一步探讨。⑤收入:HIV自检试剂的购买需要MSM有一定的支付能力,收入较高者做过HIV自检的比例是收入较低者的1.49~1.76倍[26, 41]。
(2)行为学因素:
① 性行为因素:(a)性取向:同性恋的MSM通过社交网络寻找性伴的比例较高,性伴覆盖面广,通过性伴了解并使用HIV自检试剂的比例高[39]。双性恋的MSM的风险认知较低,做过HIV自检的比例较低[26]。(b)同性性角色:相比于插入方,被插入方的年龄较小,对HIV自检了解较少,做过HIV自检比例较低(aOR=0.05,95%CI:0.02~0.14)[29];而插入方的性伴数较多,做过HIV自检的比例较高[19, 42]。(c)高危性行为:多性伴、无保护肛交、商业性行为、群交等高危性行为与MSM的HIV自检存在关联[43-45]。其原因可能与MSM的风险认知有关,风险认知较高者做过HIV自检的比例较高[29, 46];也可能是由于HIV自检结果呈阴性促进了MSM发生高危性行为。因此,探索MSM的高危性行为与HIV自检的关系是将来的一个重要研究方向。
② 传统HIV检测史:做过传统HIV检测的MSM更关注自身健康,做过HIV自检的比例较高(aOR=4.56,95%CI:1.66~12.55)[31]。同时,HIV自检也会促进MSM做传统HIV检测[47-49]。一项综合了我国23项研究的荟萃分析结果显示,23.0%的MSM在HIV自检后增加了做传统HIV检测的频率(RR=3.95,95%CI:2.30~6.78)[50]。传统HIV检测与HIV自检的相互促进关系可以形成一个良性循环,将二者结合进行推广可以有效提高MSM的HIV检测率。
③ HIV暴露前预防(PrEP)用药:2021年版中国艾滋病诊疗指南建议,PrEP药物使用者每季度做一次HIV检测[51]。传统HIV检测耗时较长且有隐私泄露的风险[28],PrEP药物使用者倾向于选择HIV自检。对我国4个城市MSM进行的一项的研究显示,79.6%的PrEP药物使用者做过HIV自检[52]。与按需服药者相比,每日服药者做过HIV自检的比例较高[52-53],原因主要是每日服药者高危性行为的发生率较高。将MSM的HIV自检与PrEP服务整合,既能扩大该人群的HIV检测率,也能提高PrEP药物使用率。
④ 药物滥用(使用毒品或助性剂):药物滥用会促进MSM发生高危性行为,增加其感染HIV的风险[54]。药物滥用者具有聚集性,容易在同伴的带动下了解并使用HIV自检试剂[27]。调查显示,药物滥用者做过HIV自检的比例是非药物滥用者的6.32(95%CI:1.58~25.30)倍[55]。可充分利用药物滥用者的社交网络推广HIV自检,提高MSM的HIV检测率。
⑤ 对HIV/AIDS的认知:对HIV/AIDS的认知不足、对阳性结果恐惧的MSM做过HIV自检的比例较低[48, 56],对HIV/AIDS认知程度较高者做过HIV自检的比例较高(aOR=3.34,95%CI:2.62~4.25)[24]。研究发现,与社会组织联系较紧密的MSM对HIV/AIDS的认知程度较高[57]。要发挥MSM社会组织的影响力,促进MSM做HIV自检[58]。
2. 社会心理学因素:
(1)同伴影响:同伴的经验评估有助于MSM建立对HIV自检的信心[59],促进HIV自检(aOR=8.49,95%CI:5.78~12.48)[17]。同伴的阳性结果会加深MSM对自身易感性和HIV自检有效性的认识,提高MSM的HIV自检率(aOR=7.17,95%CI:1.40~36.60)[23]。另外,同伴影响还会促进HIV自检试剂的二次分发[49, 56],提高MSM的HIV检测率。因此,要充分发挥HIV自检使用者的桥梁作用,在其社交网络中大力推广HIV自检。
(2)性取向公开:MSM属于性少数群体,社会对其存在歧视[60]。传统HIV检测存在性取向公开的风险,担心性取向被公开的MSM做过HIV自检的比例较高[61]。主动公开性取向者具有更高的自我认同感[62],自我保护意识较强,做过HIV自检的比例是未主动公开者的1.42~1.72倍[63-64]。
(3)新型冠状病毒感染疫情:在疫情暴发期间,HIV检测的医务人员短缺、社区封控、担心感染新型冠状病毒等原因,促进了MSM做HIV自检[65-67]。对我国MSM的一项网络调查显示,疫情期间,MSM的HIV检测需求有84.1%是通过HIV自检得到满足[57]。因此,HIV自检是维持MSM HIV检测的重要方式。
3. HIV自检试剂相关因素:
(1)价格:HIV自检试剂的价格从十几元到几百元不等[68],对MSM中低收入群体尤其是学生的使用有重要影响[69]。研究显示,降低HIV自检试剂的价格可以促进MSM的使用。当价格低于50元时,使用者的人数会增加2.07(95%CI:1.05~4.04)倍[70],免费政策也能吸引更多的MSM参与HIV自检[20]。
(2)准确性:有调查显示,72.8%的MSM认为HIV自检的准确性不如传统HIV检测[31]。一方面,我国缺乏相应的市场监管体系,HIV自检试剂的质量参差不齐[70]。另一方面,文化程度低和理解能力差的MSM在HIV自检操作以及结果读取的过程中可能出现错误[71]。因此,完善市场监管体系、提供正确的使用指导对推广HIV自检十分必要。
(3)便利性:调查显示,25.7%~68.1%的MSM由于便利性高选择HIV自检[21, 26]。我国的电商平台和实体药店均有HIV自检试剂销售,MSM可根据自己的需求进行选择。受检者可自行决定检测时间和地点,操作简便,完成1次HIV自检仅需15~30 min[72],可极大减少MSM在检测过程中的焦虑心理。
(4)隐私性:MSM十分重视隐私保护,对医疗机构和医务人员不信任导致其不愿意做传统HIV检测[73]。HIV自检从购买试剂到检测、读取结果的全过程均可由受检者自行完成,极大降低了MSM对隐私泄露的担忧[74]。加强对HIV自检隐私性的宣传,可促进传统HIV检测无法接触到的MSM使用HIV自检。
(5)检测后咨询服务:检测后咨询服务缺乏是阻碍MSM做HIV自检的因素之一[15]。在我国MSM主要从电商平台购买HIV自检试剂,假阳性率较高[70]。若MSM的HIV自检结果呈阳性,却没有得到及时的咨询和有针对性的诊疗,极容易产生报复心理,甚至做出危害社会的行为[35]。因此,提供高质量的检测后咨询服务是推广HIV自检必不可少的一项内容。
四、小结综上所述,我国目前有3类HIV自检试剂可供选择,血液HIV自检试剂的操作难度大,检出率高,MSM的接受度高。不同地区MSM的HIV自检率不同,HIV自检者中首次HIV检测的比例较高,推广HIV自检有助于扩大HIV检测的覆盖面。HIV自检的相关因素主要有个体因素、社会心理学因素及HIV自检试剂相关因素。年龄较小、外省户籍、文化程度较高的MSM做过HIV自检的比例较高,高危性行为史、传统HIV检测史、使用PrEP药物等对MSM的HIV自检也有影响。MSM倾向于选择价格低廉、准确性高、便利性好、具有隐私性以及提供了检测后咨询服务的HIV自检试剂。
目前,HIV自检在我国的推广存在一定难度。因此,有关部门需要完善相应的监管体系,提高HIV自检试剂的质量,加强HIV自检试剂的使用培训。在推广HIV自检的同时,提供高质量的检测后咨询服务,以提升其有效性,降低不良事件的发生率。此外,需强调HIV自检仅可作为初步了解HIV感染状态的一种手段,鼓励MSM进一步进行确诊检测。
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