【作者】 罗皓；

【导师】 梁浩；

【作者基本信息】 广西医科大学 ， 流行病与卫生统计学， 2012， 博士

【摘要】 第一部分广西男性吸毒人群HIV感染危险行为的调查研究目的了解广西艾滋病疫情比较严重地区男性吸毒人群HIV感染的危险行为,为制定更有效的干预策略提供依据。方法以男性吸毒人群为调查对象,采取当面一对一询问的方式,由经统一培训的合格的调查员进行调查,通过问卷调查收集人口学特征、行为学和艾滋病相关危险行为信息,并进行单因素和多因素的Logistic回归分析。结果本次研究共招募到511名符合纳入标准的研究对象。(1)对研究对象吸毒史的分析发现,首次吸毒和注射吸毒年龄中位数分别为21岁和24岁,在不同年龄段及不同的婚姻状况中分布差异均有统计学意义；482名注射过毒品的研究对象,41.3%与别人共用过针具,平均月收入是影响共用针具的主要因素(z2=22.064,P=0.000),平均月收入越低共用针具的比例越高。(2)分析研究对象性行为年龄及固定性伴情况发现,首次性行为年龄中位数为18岁,在不同年龄段差异有统计学意义,随着年龄降低,首次性行为年龄有年轻的趋势(J=51813.5,P=0.000)；平均月收入低于500元者首次性行为年龄高于其他组(χ2=8.427,P=0.015)504名有过性行为经历的研究对象中,274人有固定性伴。单因素分析显示,婚姻状况(χ2=362.730,P=0.000)、文化程度(χ2=12.279,P=0.002)、职业(χ2=16.221,P=0.000)和平均月收入(z2=22.064,P=0.000)者的固定性伴的比例差异有统计学意义,已婚、文化程度为高中以上、职业为家务及待业以及平均月收入大于1000元者的固定性伴的比例较高；多因素Logistic回归模型分析显示,未婚同居(OR=0.014,95%CI=0.004-0.057)和已婚(OR=0.003,95%CI=0.001～0.011)者更倾向有固定性伴；平均月收入小于500元的研究对象非固定性伴风险增加(OR=2.858,95%CI=1.562～5.228)。(3)对研究对象安全套使用情况分析发现,407名研究对象报告了吸毒前后发生性行为时的安全套使用情况,从未使用安全套的比例吸毒后有所下降(χ2=100.925,P=0.000)；251名对象报告了与配偶或同居者发生性行为时的安全套使用情况,从未使用安全套的比例在年龄(χ2=16.001,P=0.000)和平均月收入(χ2=9.525,P=-0.009)方面差异有统计学意义,随着年龄和平均月收入的增加,从未使用安全套的比例增加；对不同的社会人口学特征与临时性行为的关系进行分析发现,不同年龄(χ2=13.004,P=0.002)和婚姻状况(χ2=9.808,P=0.020)中有临时性行为的比例差异有统计学意义,21-30岁年龄段的研究对象有临时性行为的比例高于其它年龄段,同时未婚同居发生临时性行为的比例亦高于其他婚姻状况者,而多因素分析结果显示年龄在31～40岁者(OR=0. 314,95%CI=0.132～0.748)、41-56岁者(OR=0.495,95%CI=0.267～9.918)有临时性伴的风险降低；离异或丧偶(OR=2.564,95%CI=1.118～5.881)有临时性行为的风险增高。(4)511名研究对象中,HIV感染率为36.6%(187/511)。(5)对性关系特征分析发现,不同类型的性关系中,安全套使用情况差异有统计学意义(P=0.000),47.8%的已婚或同居者/固定性伴关系从未使用安全套,46.3%的临时性关系中每次都使用安全套,而商业性关系中每次都用的比例为72.5%;分析得知自己感染HIV前后发生性行为使用安全套情况发现,得知自己感染HIV后从未使用安全套的比例有所下降(χ2：10.334,P=0.001)。结论(1)广西男性吸毒人群首次吸毒、注射吸毒及性行为年龄有年轻化趋势。(2)社会人口学特征在一定程度上是影响该人群的行为因素。(3)目标人群存在不安全性行为和共用针具等HIV感染危险行为,该人群吸毒前后和得知自己感染HIV前后不安全性行为有所改善。第二部分广西男性吸毒人群HIV感染因素的病例对照研究目的研究广西艾滋病疫情比较严重地区男性吸毒人群HIV感染的影响因素,了解包皮环切作为艾滋病预防技术产品与吸毒人群HIV感染的关系,为制定更有效的干预策略,以达到有效降低HIV新发感染率。方法以男性吸毒人群为研究对象进行病例对照研究,以吸毒人群中的HIV感染者为病例组,非感染者为对照组,采取当面一对一询问的方式,由经统一培训的合格的调查员对其人口学特征、艾滋病相关知识和态度、吸毒史、吸毒前后性行为及感染前后行为的改变、性病史、是否做过包皮环切手术等信息进行回顾性的调查,同时,对报告曾实施过环切手术的对象进行生殖健康体检,比较两组研究对象包皮环切术的暴露比例,考察其HIV感染的相对危险度。结果共调查了505名吸毒人员,其中187名为HIV感染者,另外318名为非感染者。(1)研究对象社会人口学特征与HIV感染的关系：单因素分析结果表明,两组的婚姻状况(χ2=14.316,P=0.003)、文化程度(χ2=19.681,P=0.000)、职业(χ2=21.830,P=0.000)和平均月收入(χ2=63.272,P=0.000)差异有统计学意义,病例组未婚和离异或丧偶、初中以下文化程度、职业是家务及待业、平均月收入低于500元的比例均高于对照组。(2)对研究对象艾滋病知识得分情况与HIV感染的关系进行分析,发现两组人群对艾滋病基本知识的掌握程度差异有统计学意义(χ2=3.870,P=0.049),病例组的吸毒人员对艾滋病基本知识的掌握程度比对照组高。(3)对研究对象吸毒史与HIV感染的关系分析发现,两组在首次吸毒(t=-3.464,P=0.001)和注射吸毒的平均年龄(t=-3.168,P=0.002)、吸毒时间(χ2=11.636,P=0.003)、注射吸毒(χ2=11.981,P=0.001)、最近一个月注射过毒品(χ2=10.142,P=0.001)、与别人共用过针具(χ2=63.878,P=0.000)及在戒毒所里戒过毒(χ2=15.968,P=0.000)方面差异有统计学意义,病例组在注射吸毒、最近一个月注射过毒品、与别人共用过针具和在戒毒所里戒过毒的人数比例均高于对照组。(4)对研究对象艾滋病性病相关高危行为与HIV感染的关系分析发现,在有关艾滋病性病相关高危行为的调查中发现,两组研究对象在最近六个月发生过性行为(χ2=16.620,P=0.000)、最近六个月发生性行为的频次(χ2=14.782,P=0.001)、最近一次性行为使用安全套(z2=34.173,P=0.000)和吸毒后发生性行为中使用安全套(z2=11.211,P=0.001)方面差异有统计学意义,HIV感染者中在最近六个月发生过性行为和性行为的频次两方面的比例低于非感染者,而在最近一次性行为和吸毒后发生性行为中使用安全套中的比例则高于非感染者；对其固定性伴分析显示两组研究对象在固定性伴(χ2=13.504,P=0.000)、最近一年发生性行为的频次(χ2=40.585,P=0.000)、最近一次与配偶发生性行为中使用安全套(χ2=34.608,P=0.000)、最近一年与配偶发生性行为中使用安全套(χ2=26.057,P=0.000)和固定性伴吸毒(χ2=29.481,P=0.000)方面差异有统计学意义,病例组在固定性伴、最近一年发生性行为的频次两方面的比例低于非感染者,而在最近一次和最近一年与配偶发生性行为中使用安全套及固定性伴同为吸毒者中的比例则高于非感染者；对性病相关症状与HIV感染的关系进行分析发现,两组人群出现性病相关症状的比例差异有统计学意义(χ2=5.338,P=0.021),病例组出现性病相关症状的比例高于对照组。(5)对研究对象包皮环切术的认知及实施手术情况与HIV感染的关系进行分析,发现两组在听说过包皮环切手术方面差异无统计学意义,而在做过包皮环切手术方面差异有统计学意义(χ2=10.796,P=0.001),对照组实施手术的人数明显高于病例组。(6)将单因素分析中P<0.10的变量纳入多因素Logistic模型进行分析。发现平均月收入(OR=3.668,95%CI=2.077～6.478)、与别人共用针具(OR=9.257,95%CI=3.434～24.953、吸毒后发生性行为使用安全套的频次(OR=0.573,95%CI=0.380～0.864)、固定性伴同为吸毒者(OR=3.622,95%CI=1.117～11.748)和实施过包皮环切手术(OR=0.023,95%CI=0.002～0.312)与HIV感染相关。结论(1)社会人口学特征和艾滋病知识知晓情况对吸毒人群的HIV感染均有影响。(2)包皮环切术可能是HIV感染的影响因素,需进一步扩大样本进行研究。第三部分三种包皮环切推广模式的成本-效果评价目的对已开发的包皮环切推广模式的经济效率进行测量和评价,筛选出有效宣传材料和适宜的宣传方式最佳组合,达到以最低的投入,提高男性包皮环切率的目的,充分发挥在艾滋病疫情严重地区通过重点成年男性包皮环切减少其HIV性途径感染的作用。方法在一般描述性统计分析的基础上,应用数据包络分析模型(DEA),以推广模式为单位,测算三种推广模式在不同人群中推广的技术效率和规模效率。结果本次研究共招募符合纳入标准的外出务工者1670人,吸毒者1218人,高发区普通人群1640人,将各人群随机分为3组,分别用三种干预模式对其进行包皮环切预防艾滋病的干预。(1)不同干预模式在同种人群推广的成本-效果分析显示,外来务工者中,模式三改变研究对象手术接受意愿所需的成本最低,在手术率改变方面则优先选择模式一；吸毒者中,无论是要改变其手术意愿还是要提高其手术率,所需成本最低的均是模式三；普通人群中,改变其手术接受意愿效果最好的是模式二,手术率提高最高的是模式一。(2)同种干预模式在不同人群中推广的成本-效果分析结果显示,在手术意愿改变方面,模式一和模式三均为在外出务工者中每改变一个人手术意愿所需的成本最低,模式二对普通人群的干预效果较好；在实施手术方面,模式一和模式二均为在感染高发区的普通人群每使一个人做手术所需的成本最低,而模式三对吸毒人群的干预效果较好,对于外来务工者无论是哪种干预模式,其手术实施方面的干预效果均不理想。(3)基于DEA的三种包皮环切干预模式在不同人群中推广的效率值分析结果显示,外来务工者使用模式三和感染高发区普通人群使用模式二的综合评价效果最优；对投入、产出指标的投影分析发现,外来务工者使用的模式一投入过剩比例最高,为23.84%,而吸毒人群使用的模式一和模式二存在的差距比例最大。结论采用DEA模型综合评价三种包皮模式在不同人群中推广的成本-效益,结果表明外来务工者使用模式三和感染高发区普通人群使用模式二的综合评价效果最优。更多还原

【Abstract】 Section one:Investigation of risk behaviours among male drug addicts in GuangxiObjective To investigate the risk behaviours and HIV relative epidemiological factors among drug addicts in AIDS serious epidemic area in Guangxi, providing the basic data for intervention strategies. Methods Drug addicts in HIV high-prevalence areas were surveyed through asking face to face by the qualified trained investigators, the contents of questionnaire included social demographic characteristics of subjects, AIDS knowledge and risk behaviours. Results 511 drug addicts in HIV high-prevalence areas were investigated. (1) The history of drug taking was analyzed, and it was founded that the median age of starting drug use and injecting drug use was 21 and 24. Univariate analysis showed that, there were statistical differences in ages and marital status. Of 511 drug addicts,482 persons were injecting drug users (IDUs). Among IDUs,41.3% reported sharing needle with others. There was significant difference in the average of income (x2=22.064,P=0.000), the ratio of low income was more higer than high income. (2) The age at sexual debut of the subjects was analyzed, and it was found that the median age at sexual debut was 18. Univariate analysis showed that, there were statistical differences in ages (J=51813.5, P=0.000) and the average income (x2=8.427, P=0.015).274 persons were regular sex partners in 504 persons being sexually experienced. Univariate analysis showed that, there were statistical differences in marital status (x2=362.730, P=0.000), education level(x2=12.279,P=0.002), career (x2=16.221, P=0.000) and the average income(x2=22.064, P=0.000), the ratio of regular sex partners in married, after high school education, waiting for employment and the average income exceed￥1000 was more higher than others. Logistic regression analysis found the ratio of there was the regular sex partners in cohabitant (OR=0.014,95%CI=0.004～0.057) and married (OR=0.003,95%CI=0.001～0.011) were higer than divorcee, while the ratio of there was the regular sex partners in the under Y 500 (OR=2.858, 95%CI=1.562～5.228) were less than exceed￥500 in the average income. (3) Univariate analysis showed that, having sex but never used condoms were statistical differences in drug-abusing (x2=100.925,P=0.000), ages (x2=16.001, P=0.000) and the average income (x2=9.525, P=0.009), the ratio of never used condoms was high with after drug-abusing, old age and high income. The relationship between social demographic characteristics of subjects and casual sex partners:univariate analysis showed that, there were significant differences in ages (x2=13.004,P=0.002) and marital status (x2=9.808, P=0.020), the ratio of casual sex partners in aged 21-30 and unmarried was higher than others. Logistic regression analysis found the ratio of casual sex partners in those aged 31-40 (OR=0.314,95%CI=0.132～0.748) and 41-56 (OR=0.495, 95%CI=0.267～9.918) were less than those aged 21-30, while in divorcee (OR=0.495,95%CIi=0.267～9.918) was higer than other marital status. (4) The overall HIV prevalence among 511 drug addicts was 36.6%. (5) Used condoms were significant difference in different sexual relation (P=0.000), the rate of never used condoms in married was 47.8%, and used condoms everyone in causual sex partners and commercial sex partners was 46.3% and 72.5%. Univariate analysis showed that, never used condoms was statistical differences in HIV-infecting (x2=10.334, P=0.001). Conclusions (1) The age in the starting drug use, injecting drug use and sexual debut was young among the male drug addicts in Guangxi. (2) The social demographic characteristics of subjects were the factors of behaviours. (3) The subjects had unsafe sex and needle sharing, which were all of high AIDS risk. The risk behaviours of unsafe sex had changed after infectin HIV.Section two:Factors associated with HIV infection among male drug addicts in Guangxi:a case-control studyObjective To study HIV infective factors and investigate the relation between the male circumcision and HIV infection among drug addicts, for taking appropriate intervention measure to reduce new HIV infections. Methods Male drug addicts in HIV high-prevalence areas using case-control methodology were surveyed through asking face to face by the qualified trained investigators, the contents of questionnaire included social demographic characteristics of subjects, AIDS knowledge and attitudes, drug-abusing, risk behaviours changing after drug-abusing, STDs and whether to operate circumcision, subjects who infect HIV were classified as the group of case, subjects who were HIV-negative as the group of control. With HIV and HIV-negative as binary dependent variable, various factors were analyzed by univariate and multivariate Logistic regression. Results 187 HIV carrier and 318 HIV-negative people in HIV high-prevalence areas were investigated. (1) The relationship between social demographic characteristics of subjects and HIV infection:univariate analysis showed that the case group and the control group were significant differences in marital status (χ2=14.316, P=0.003), education level (χ2=19.681, P=0.000), career (χ2=21.830, P=0.000) and the average income (χ2=63.272, P=0.000), the ratio of unmarried or divorcee, before middle school, waiting for employment and the average income under￥500 in case group was more higher than control group. (2) The relationship between the AIDS knowledge of the drug addicts and HIV infection was analyzed, and it was founded that there was significantly difference between the case and control group, the proportion in case group whose AIDS knowledge score≥average score was higher than control group (χ2=3.870, P=0.049). (3) The relationship between drug-abusing and HIV infection was analyzed, and it was founded that there were significantly differences in the average ages of starting drug use (t=-3.464, P=0.001) and injecting drug use (t=-3.168,P=0.002), drug-abusing life (χ2=11.636, P=0.003), injecting drug use (χ2=11.981, P=0.001), injecting drug use in recent month (χ2=10.142, P=0.001), sharing needle (χ2=63.878, P=0.000) and having rehabilitation in drug rehabilitation center (χ2=15.968, P=0.000). (4) The relationship between risk behaviours and HIV infection was analyzed, and it was founded that the proportion who had sexual behaviours in recent six months (χ2=16.620, P=0.000), the frequence of sexual behaviours in recent six months (χ2=14.782,P=0.001) of case group were less than control group, but in using condoms in recent sexual behaviours (χ2=34.173,P=0.000) and after drug-abusing (χ2=11.211, P=0.001) of case group were higher than control group. Univariate analysis showed that there were differences in the regular sex partners (χ2=13.504, P=0.000) and the frequence of sexual behaviours in recent year (χ2=40.585,P=0.000), the proportions of case group were less than control group, while in using condoms with the regular sex partners in recent one (x2=34.608, P=0.000) and year (x2=26.057, P=0.000), and the regular sex partners drug-abusing (x2=29.481, P=0.000), the proportions of case group were higher than control group. The relationship between STD of the subjects and HIV infection was analyzed, and it was founded that there is difference in two groups (x2=5.338, P=0.021). (5) The relationship between the cognition on circumcision of the drug addicts and their circumcised surgery was analyzed, and it was founded that there was not significant difference in the cognition on circumcision in two groups, but in their circumcised surgery there was significant difference, the ratio of the control case was more than the case group(x2=10.796, P=0.001). (6)Variables which P was less than 0.10 in univariate analysis were analyzed by multivariate Logistic regression model. It was found that the average income (OR=3.668,95%CI=2.077～6.478), sharing needle (OR=9.257,95%CI=3.434～24.953) and the frequence of using condoms after drug-abusing (OR=0.573,95%CI=0.380～0.864) were risk factors, while the regular partners being the drug addicts (OR=3.622,95%CI=1.117～11.748) and circumcised surgery (OR=0.023,95%CI=0.002～0.312) were protective factors. Conclusions (1) The social demographic characteristics of subjects and their AIDS knowledge were the factors on HIV infection. (3) Male circumcision might prevent HIV infections.Section three:Cost-benefit analysis of three modes and effectiveness to promote male circumcisionObjective To analyze the cost-benefit of three modes of male circumcision and select the best suitable combination of these materials that can increase effectively the circumcision rate of vulnerable adult male in the AIDS serious epidemic area, give full play to circumcision that can reduce HIV infection by sexual behaviour in the adult male in AIDS serious epidemic area. Methods Basing the descriptive statistics, the technical efficiency and scale efficiency to three modes of male circumcision in the different kind of persons were evaluated with a DEA model with nondiscretionary inputs. Results 1670 migrant workers,1218 drug addicts and 1640 general people in HIV high-prevalence area met the inclusion criteria were recruited and randomly divided into three groups, and were respectively intervened with three modes of male circumcision proteceted against HIV prevention. (1) Promoted the different modes of male circumcision in the same kind of persons was analyzed, and it was founded that in migrant workers the cost of Mode 3 to change the willingness to accept surgery circumcised was the lowest, while the cost of Mode 1 to change the ratio of the surgery was the lowest. In drug addicts the cost of Mode 3 to change the willingness and the ratio of the surgery were both the loweset. In general people in HIV high-prevalence area the cost of Mode 2 to change the willingness was the lowest, while Mode 1 to change the ratio of the surgery was the lowest. (2) Promoted the same mode of male circumcision in the different kinds of persons was analyzed, and it was founded that the cost of Mode 1 and Mode 3 which change the willingness to accept surgery in migrant workers were lowest, while the best effectiveness of the invention was Mode 2. The cost of Mode 1 and Mode 2 which change the ratio of the surgery in HIV high-prevalence area were lowest, while the best effectiveness of the invention was Mode 3. (3) Promoted three modes of male circumcision with a DEA model in the different kinds of persons were analyzed, and it was founded that the effectiveness of Mode 3 in migrant workers and Mode 2 in general people in HIV high-prevalence area were best. DEA input and output projection analysis showed that three modes of male circumcision was actual surplus, especially in Mode 1 in migrant workers surplus as high as 23.84%, and the gap between input and output of Mode 1 and Mode 2 in drug addicts were largest. Conclusions To analyze the cost-benefit of three modes of male circumcision with a DEA model, the effectiveness of Mode 3 in migrant workers and Mode 2 in general people in HIV high-prevalence area were best.更多还原