【作者】 张莹；

【导师】 羊海涛； 闫红静；

【作者基本信息】 东南大学 ， 公共卫生（专业学位）， 2022， 硕士

【摘要】 研究背景当前我国HIV传播途径主要为性传播,其中以男男同性性行为人群(Men who have sex with men,MSM)为主。江苏省每年报告的HIV新发感染病例中,MSM占比由2007年的0.91%上升到2021年的55.07%,2019年南京市新报告的艾滋病病例中一半以上为MSM人群。尽管使用安全套和HIV定期检测可以有效降低HIV的传播,但全国MSM人群哨点监测显示该人群的安全套使用率仅为50%左右,最近一年的HIV检测率也低于暗娼等高危人群。针对MSM人群的安全套使用促进和HIV早检测、早发现等行为干预措施未能达到控制HIV流行的预期,因此迫切需要引入新的预防手段以控制艾滋病流行。暴露前预防(pre-exposure prophylaxis,PrEP)是被世界卫生组织推荐的一项极具前景的HIV生物学干预手段,国外真实世界研究证明PrEP可有效降低MSM、跨性别女性及单阳家庭人群HIV感染风险达90%以上,从而显著减轻国家艾滋病公共卫生疾病负担。MSM作为江苏省乃至全国艾滋病防治的重点人群,亦是PrEP推广的潜在重点人群。MSM的PrEP使用意愿及其最终使用情况决定着PrEP策略在我国推广实施的可行性及控制艾滋病流行的效果。本研究先期通过横断面调查,了解南京市MSM人群的PrEP使用意愿、服药依从倾向及其影响因素;其后通过社会网络分析,挖掘南京市MSM人群人际交流的内在联系和社会网络空间特征,并筛选出处于网络中心位置的、高度性活跃的“关键”MSM作为深入访谈的候选对象;最后通过定性研究,对“关键”MSM以及医务人员、疾病预防控制中心(CDC)工作人员、MSM社会组织志愿者骨干、MSM娱乐场所业主和Blued医学官等PrEP利益相关者(stakeholders)进行个人深入访谈,从MSM和PrEP利益相关者视角了解对在中国广泛实施PrEP的认知和建议,探索促进和阻碍MSM人群使用PrEP的影响因素以及建议与对策,为制定我国MSM人群PrEP预防策略提供科学依据。研究目的1.了解南京市MSM人群社会人口学特征、性行为特征、心理健康状况、PrEP的使用意愿和服药依从倾向及其影响因素;2.探索南京市MSM人群人际交流的内在联系和社会网络空间特征,以及处于网络中心位置的、高度性活跃的“关键”MSM的特征,以期为PrEP精准干预、资源配置提供依据;3.从MSM个人角度和PrEP服务利益相关者角度探讨PrEP使用的促进与阻碍因素,探索促进PrEP实施的有效对策,为制定我国MSM人群PrEP干预策略提供建设性的意见。研究方法1.开展横断面调查。在南京市通过时间场所抽样调查和互联网途径招募MSM人群进行问卷调查、HIV和梅毒抗体快速检测,了解南京市MSM人群社会人口学特征、性行为特征、心理健康状况、PrEP的使用意愿和服药依从倾向及其影响因素。2.进行社会网络分析。利用问卷调查中研究对象寻找性伴的空间数据,使用UCINET 6.0软件和Net Draw 2.0软件分别进行社会网络中心性分析和可视化分析,了解MSM人群社会空间网络分布特征、不同空间的危险性,以及处于网络中心位置的、高度性活跃的“关键”MSM的特征。3.开展定性研究。对MSM和PrEP利益相关者进行个人深入访谈,访谈围绕PrEP认知情况、广泛实施PrEP的促进和阻碍因素、PrEP服务的建议等方面。利用Nvivo 11定性研究分析软件将访谈内容Word文本导入并进行逐行或逐段编码,最后进行归纳总结,并用举例法表达具体结果。研究结果1.共有311人参与问卷调查,有效问卷309份,有效应答率99.4%。研究对象年龄中位数为27岁(四分位数间距(IQR)为23-34岁),最小为18岁,最大为65岁;48.9%(151/309)文化程度为本科及以上;月收入以5000元以下为主,占比58.9%(151/309);79.0%(244/309)处于单身状态;68.9%(213/309)自我认同为同性恋;第一次肛交年龄中位数为20岁(IQR:19-24岁),最小发生在10岁,最大发生在52岁。在过去6个月,分别有31.7%(98/309)和26.2%(81/309)的MSM在做“1”和做“0”时发生过无保护性行为。新发现HIV抗体阳性者9名(2.9%),梅毒抗体阳性者32名(10.4%)。自我恐同和社区恐同得分中位数分别为20分(IQR:16～24)和27分(IQR:22～30),分别有85.8%(265/309)和87.4%(270/309)的MSM存在较高的自我恐同和社区恐同;HIV预期耻辱感中位数得分为20分((IQR:17～23),有92.6%(286/309)的MSM HIV预期耻辱感较高;有59.2%(183/309)的研究对象听说过PrEP,75.7%(234/309)的调查对象愿意使用PrEP,55.3%(171/309)的调查对象有着较高的服药依从倾向。听说过PrEP(OR=2.366,95%CI:1.232-4.545)和HIV预期耻辱感(OR=4.173,95%CI:1.367-12.74)是PrEP使用意愿的显著影响因素。本科及以上(OR=1.854,95%CI:1.126-3.051)、社区恐同(OR=0.444,95%CI:0.202-0.978)和HIV预期耻辱感(OR=3.804,95%CI:1.282-11.289)是PrEP服药依从倾向的显著影响因素。2.共收集309份有效问卷,其中有300名(97.1%)MSM提到了至少一个寻找性伴的空间。MSM选择最多的前三个寻找性伴的空间依次为Blued(81.0%)、微信(34.3%)和星达吧(34.0%)。HIV感染排名前三的高危险空间为泰格酒吧(8.3%)、碧波池浴室(8.0%)、探探(7.4%);梅毒感染排名前三的高危险空间为神策门公园(29.2%)、九点半酒吧(19.4%)和菊花台公园(15.4%);高无保护性行为风险的空间是神策门公园(58.3%);知道PrEP和愿意使用PrEP比例最高的空间均为Aloha(77.1%、85.7%),高服药依从倾向比例最高的空间为泰格酒吧(63.9%)。处于网络中心位置的、高度性活跃的MSM第一次肛交年龄在18岁以下(P=0.001)、过去6个月,做“1”(P=0.003)和做“0”(P=0.006)时发生肛交性行为的性伴数>1个、在性行为前或期间饮酒(P=0.011)以及使用Rush等物质(P<0.001)的比例均高于非高度性活跃者。3.共访谈21人,其中MSM 15名,利益相关者6名。有13名MSM访谈对象(包括2名正在服药者)听过PrEP,但大多数(66.7%,10/15)仅是听过暴露前预防或PrEP这个名词,对具体相关知识了解甚少,其中1名错把PEP当做PrEP;听过暴露前预防的访谈对象知晓途径为网络(66.7%%,8/12)、社会组织(33.3%,4/12)以及朋友告知(8.3%,1/12)。大多数MSM访谈对象认为MSM人群在使用PrEP后会增加不使用安全套等危险性行为,但若正确告知仍需使用安全套后,风险补偿问题可能会有所缓解。12名MSM访谈对象表示会主动向朋友推荐PrEP。在开具药物处方和药物获取途径方面,大多数MSM都提到了CDC(86.7%,13/15),部分MSM提到医院(40.0%,6/15)、药店(33.3%,5/15)、社会组织(线上与线下)(33.3%,5/15)和社区卫生服务中心(26.7,4/15)。所有访谈对象(N=21)认为主要阻碍PrEP策略在中国广泛实施的因素为较高的药物价格(76.2%,16/21)、传统认知(66.7%,14/21)、歧视和隐私性(47.6%,10/21),对在中国广泛实施的促进因素或建议主要为加强宣传(100.0%,21/21)和推进药物降价(71.4,15/21)。研究结论1.南京市HIV阴性或感染状态未知的MSM人群中,PrEP使用意愿度较高,但服药依从倾向较低,特别是在受教育程度较低的MSM中。在启动PrEP和服用药物的全过程中,要关注MSM社会心理问题,降低其对PrEP使用与服药依从性的负面影响,以达到PrEP干预策略的最大效益。2.南京市MSM人群通过多种寻找性伴的空间组成了一个庞大的社交网络。MSM人群主要基于网络寻找性伴。网络型MSM的PrEP知晓率和使用意愿相对较高,而场所型的MSM感染HIV和梅毒的风险相对较高,但PrEP知晓率和使用意愿相对较低。处于网络中心位置、高度性活跃的MSM存在较高的感染和直接或间接传播HIV的风险。3.大多数知晓PrEP的MSM对PrEP具体知识并不十分清楚,且得到的PrEP信息多是以盈利为目的的商业推销,权威机构应发布正确的PrEP信息,消除MSM人群对PrEP的负面印象和误解。广泛实施PrEP的主要阻碍因素包括较高的药物价格、负面传统认知、隐私性和歧视。对我省乃至我国扩大PrEP实施的促进因素或建议有宣传正确的PrEP、控制药物价格、加强政府主导,完善PrEP相关政策和指南、完善用药前的体检和用药后的随访管理,同时将心理健康服务纳入PrEP服务体系,制定针对性的具体PrEP实施措施。更多还原

【Abstract】 Background Sexual transmission is the main route of HIV transmission in China,and men who have sex with men(MSM)are the majority of the population infected with HIV.Among the new HIV infections reported annually in Jiangsu province,the proportion of HIV transmission through MSM increased from 0.91% in 2007 to 55.07%in 2021,and more than half of the new HIV cases reported in Nanjing in 2019 were also transmitted through MSM.Although condom use and regular HIV testing can effectively reduce HIV transmission,national MSM sentinel monitoring showed that the rate of condom use among MSM was only about 50%,and the rate of HIV testing in the last year was lower than that of high-risk groups such as commercial sex workers.Behavioral interventions such as condom use promotion,early HIV testing and early HIV detection for MSM population have failed to achieve the expectation of control the HIV epidemic.Therefore,new prevention methods are urgently needed to introduce to control the Acquired Immune Deficiency Syndrome(AIDS)epidemic.Pre-exposure prophylaxis(PrEP),recommended by the World Health Organization as a promising biological intervention for HIV.Foreign real-world studies have proved that PrEP can effectively reduce the risk of HIV infection in MSM,transgender women and families with single-positive HIV by more than 90%,thus significantly reducing the national burden of AIDS public health disease.MSM is the critical population of AIDS prevention and control in Jiangsu Province and even the whole country,and also is a potential key population for the PrEP promotion.Their willingness to use PrEP and final utilization determines the feasibility of the promotion and implementation of PrEP strategy in China and the effectiveness of AIDS epidemic control.In this study,a cross-sectional questionnaire survey was conducted to understand the willingness to use and the intention to adhere to PrEP among MSM in Nanjing and its associated factors.Then,the interconnectedness of interpersonal communication and the characteristics of social network space of MSM population were explored through social network analysis.Meanwhile,highly sex active and “key”MSM in the center of the network were selected as candidates for in-depth personal interview.Finally,through qualitative research,in-depth personal interviews were conducted with “key” MSM and PrEP stakeholders,including doctors,CDC staff,the cadre of MSM social organization,and the boss of entertainment venues.We will understand their cognition and suggestions on the widespread implementation of PrEP in China from the perspective of both MSM and PrEP stakeholders.Moreover,explore the potential impacts that facilitate and impede the use of PrEP among MSM,as well as suggestions and countermeasures,which provides scientific basis for the formulation of PrEP prevention strategies for MSM in China.Objective1.Investigate the sociodemographic characteristics,sexual behavior characteristics,psychologies,willingness to use,and intention to adhere PrEP among MSM in Nanjing and its influencing factors.2.Investigate the interconnectedness of interpersonal communication and the characteristics of social network space of MSM population,as well as the characteristics of highly sex active and "key" MSM at the center of the network to provide a basis for precise intervention and resource allocation of PrEP.3.Investigate the facilitators and barriers to using PrEP from the perspective of both MSM and PrEP stakeholders and explore effective strategies to promote PrEP implementation to provide constructive suggestions for the formulation of PrEP strategies for MSM in China.Methods1.Cross-sectional surveys is conducted.MSM in Nanjing are recruited through time and place sampling and online to conduct questionnaire survey,rapid HIV and syphilis antibodies testing.Questionnaire investigated the sociodemographic characteristics,sexual behavior characteristics,psychologies,willingness to use and intention to adhere PrEP among MSMas well as its influencing factors.2.Social network analysis is performed.UCINET 6.0 software and Net Draw 2.0 software are used to conduct the social network centrality analysis and visual analysis with the spatial data of MSM seeking sexual partners of surveyed individuals.Furthermore,to understand the distribution characteristics of MSM social-spatial network,the risk of different spaces,and "key" MSM characteristics at the center of the network.3.Qualitative study is conducted.In-depth personal interviews are conducted on MSM and stakeholders.The content of the interview is focused on PrEP cognition,facilitators and barriers to the widespread implementation,and recommendations for PrEP services.Nvivo 11 qualitative research and analysis software is used to import Word text of interview content and encode it line by line or paragraph by paragraph.Finally,a summary is given and specific results are expressed with examples.Results1.311 MSM participated in the questionnaire survey,and 309 are effective questionnaires;the effective response rate is 99.4%.The median age of all subjects is 27 years old(interquartile range: 23-34);the youngest is 18 years,and the maximum is 65 years;48.9%(151/309)MSM are bachelor or above;the monthly income is mainly less than 5,000 yuan,accounting for 58.9%(151/309);79.0%(244/309)MSM are in the single state and 68.9%(213/309)self-identity are homosexual.The median age of the first anal sex is20 years old(interquartile range: 19-24);the youngest is 10 years,and the maximum is 52 years.In the past6 months,31.7%(98/309)and 26.2%(81/309)MSM have had unprotected anal intercourse when had insertive and receptive anal sex,respectively.9(2.9%)are the new HIV positive cases and 32(10.4%)are syphilis antibody positive.The median of self-homophobia and community homophobia are 20 points(IQR:16 ～ 24)and 27 points(IQR:22 ～ 30),respectively.85.8%(265/309)and 87.4%(270/309)of MSM have high self-homophobia and community homophobia.The median of anticipated HIV stigma is 20(IQR:17 ～ 23),and 92.6%(286/309)of MSM have high anticipated HIV stigma.There are 59.2%(183/309)of MSM had heard of PrEP,75.7%(234/309)of MSM are willing to use PrEP,and 55.3%(171/309)have a high intention to adhere to PrEP.Heard of PrEP(OR = 2.366,95% CI: 1.232-4.545)and anticipated HIV stigma(OR= 4.173,95% CI: 1.367-12.74)are significantly associated with willingness to use PrEP.Bachelor degree or above(OR=1.854,95%CI: 1.126-3.051),high community homophobia(OR=0.444,95%CI: 0.202-0.978),and anticipated HIV stigma(OR=3.804,95%CI: 1.282-11.289)were significantly associated with high intention to adhere to PrEP.2.With 309 valid questionnaires,300(97%)MSM mention at least one space for seeking sexual partners.MSM chose Blued(81.0%),We Chat(34.3%),and Xingda bar(34.0%)as the top three places for seeking sexual partners.The top three of the HIV infectious risk spaces are Taige Bar(8.3%),Bibochi Bathroom(8.0%),and Tan Tan(7.4%).The top three places of risk for syphilis infection are Shencemen Park(29.2%),Half-past nine Bar(19.4%),and Juhuatai Park(15.4%).The highest proportion of non-condom sex is Shenzhimen Park(58.3%).Aloha(77.1%)is the most aware of PrEP and the most willing to use PrEP(85.7%),while Taige Bar(63.9%)has the highest percentage of high intention to adhere to PrEP.The proportion of highly sexually active MSM in the center of the network who had their first anal intercourse under the age of 18 is significantly higher than that of non-highly active MSM(P=0.001).In the past six months,the proportion of highly sexually active MSM who had insertive anal sex with more than one partner(P=0.003),receptive anal sex with more than one partner(P=0.006),alcohol consumption before or during sex(P=0.011)and use of substance such as Rush(P<0.001)are also significantly higher than that of nonhighly active MSM.3.21 people are interviewed,including 15 MSMs and 6 stakeholders.13 MSM(including 2 PrEP user)have heard of PrEP,but most(66.7%,10/15)are just to heard of PrEP,very little known about specific knowledge.Internet(66.7%%,8/12),social organizations(33.3%,4/12),and friends(8.3%,1/12)are main way for MSM who heard about PrEP.Most MSM think that MSM would increase high-risk behavior after using PrEP,but the risk compensation problem may be mitigated if the condom use is informed correctly.12 MSM say they would actively recommend PrEP to friends.In terms of issuing drug prescriptions and drug acquisitions,most of the MSM mention CDC(86.7%,13/15),some MSM refer to hospital(40.0%,6/15),pharmacies(33.3%,5/15),social organization(online and offline)(33.3%,5/15)and the Community Health Service Center(26.7,4/15).All interviewees(n = 21)believe that the main barriers to widely implemented in China are priced(76.2%,16/21)traditional cognition(66.7%,14/21),discrimination,and privacy(47.6%,10/21).The recommendations widely implemented in China mainly are propaganda(100.0%,21/21)and drug price reduction(71.4,15/21).Conclusion1.MSM with HIV negative or unknown infection status in Nanjing show a high willingness to use PrEP but a low intention to adhere to PrEP,especially for MSM with low education levels.Meanwhile,attention should be paid to the psychosocial problems of MSM during the whole process of PrEP initiation and medication taking to reduce its negative impact on PrEP use and medication compliance,so as to achieve the maximum benefits of PrEP intervention strategies.2.The MSM in Nanjing consist of an extensive social network through various spaces,and they mainly seek sex partners by virtual space.The MSM in virtual places are more aware of and willing to use PrEP,while MSM in real space have a high risk of HIV and syphilis infection,but a relatively low awareness and willingness to use PrEP.MSM who are at the center of the network and highly active have a high risk of direct or indirectly transmitting HIV.3.Most of the MSMs who heard of PrEP are not clear about PrEP,and most of the PrEP information is commercially available,so the authority should release the correct PrEP information to eliminate the negative impression and misunderstanding on PrEP among MSM.Barriers to widespread PrEP implementation include high drug prices,traditional perceptions,privacy and discrimination.The facilitators and recommendations for widespread implementation of PrEP in our province and even in China include correct publicity,drug price control,government leadership,improvement of PrEP related policies and guidelines,improvement of pre-medication physical examination and post-medication follow-up management,integration of psychological services into the PrEP service system,and development of specific PrEP implementation measures.更多还原