有关检测工作咨询：重复检测工作MSM新方式

1、有关检测工作咨询：重复检测工作MSM新方式Acknowledgements致谢William Woods, 博士, James Sabatino, Barb Adler,Richard Brand, PhD, Willi McFarland, 医学博士 (UCSF/SF DPH)Men attending AHPs VCT sites 所有参加 AHP（层次咨询）和 VCT （自愿咨询检测）的男性Bill and Melinda Gates Foundation Bill and Melinda Gates 基金会Goals for today今天的目标Provide background o

2、n counseling assocd w/testing and review our two published studies on “repeat tester” intervention, PCC 提供有关检测咨询的背景，并回顾我们已发表的两项关于“重复检测”干预的研究，PCCDiscuss other individual prevention interventions 讨论其他个人预防干预方法Background on Repeat Testers重复检测的背景Despite years of intense AIDS prevention messages, roughly

3、900 men who have sex with men (MSM) acquire HIV infection each year in San Francisco 尽管多年来大力宣传预防艾滋病，每年在旧金山仍大约有 900 名与同性发生性关系的男性 (MSM) 感染 HIV A group at particularly high risk is MSM who repeatedly test for HIV MSM 是高危险人群，应重复做 HIV 检测 In London, MSM who tested 3 or more times reported more UAI than MS

4、M testing fewer times (Reitag, 2000). 在伦敦，报告表明那些参加三次或是更多次检测的 MSM 比参加检测次数较少的 MSM 进行 UAI 概率更大（Reitag，2000 年） In San Francisco, MSM with an average of 3 or more prior tests had higher rates of UAI and an incidence of HIV nearly 3 times that of MSM with 1 or 2 previous tests (Dilley, 1993). For some, re

5、peated HIV neg tests conveyed the “wrong” msg re: the clients behavior. 在旧金山，相对于仅参加一两次预先检测的 MSM ，平均参加 3 次或更多次事先检测的 MSM 进行 UAI 概率更大，而艾滋病毒的感染率是前者 3 倍（Dilley ，1993 年）。对一些人来说，HIV 阴性的重复试验转达了患者行为的“错误”信息。New prevention intervention s are clearly needed for this group 对于这样的人群来说新的预防措施显然是必要的“The Stories We Te

6、ll Ourselves”: A New Approach我们的研究告诉自己：一个新方法Adapted from Australian psychologist Ron Golds work focusing on “self-justifications” & “on-line” vs. “off-line” thinking 改编自澳大利亚心理学家 Ron Gold 的着重于“自我辩解” 、“在线”与“离线”思想的著作 1994- Sydney/Melbourne: 300+ MSM from bars/bathhouses w/ recent episode of UAI-Randomi

7、zed to: 16 wk paper & pencil intervention using a sex diary and completing SJ questionnaire vs. viewing safe sex posters 1994 年 - 悉尼/墨尔本：300 多名在酒吧/浴室活动的 MSM 近期关于 UAI 的状况：利用性爱日志和完成自我辩解调查问卷以及查阅安全性行为的海报进行为期 16 周的书面干预 Outcome: Both groups “slipped” following intervention, but SJ questionnaire group was

8、less likely to do so subsequently 结果：在干预后两组均有“下滑”，但是自我辩解问卷调查组不太可能以后也这样做Study 1: Objectives研究项目1 ：目标 May 1997 - January 2000 1997 年 5 月至 2000 年 1 月To describe the range and frequency of thoughts at the moment of last high-risk unprotected anal sex among MSM repeatedly seeking HIV testing 描述重复寻求艾滋病毒检测

9、的 MSM 在上次未采取保护措施肛交高危行为时的想法范围和频率To assess whether a single counseling intervention focusing on the thoughts, attitudes or beliefs of the participants at the time of high risk behavior is effective in reducing future high risk activity 评估某一着重于参与高危性行为的人员想法、态度或信念的单一咨询干预对将来减少高危性行为是否有效Methods: Participant

10、s方法：参与者MSM (N=255) were screened and recruited for a counseling intervention trial when scheduling an anonymous HIV antibody test 在安排匿名 HIV 检测时共有男同性恋者 (N=255) 进行了咨询干预试验筛选和招募Eligibility criteria were men who: 合乎标准的男子有：Had unprotected anal sex with a man who was HIV+ or of unknown serostatus in the la

11、st year 在过去的一年里与 HIV 阳性或未知血清状态的男性发生过未采取保护措施的肛交Had previously tested HIV-negative 曾经检测出 HIV 阴性Did not inject drugs 没有注射毒品Study Design研究设计Randomized, controlled, longitudinal counseling intervention trial 随机法，对照法，纵向咨询干预试验法Conducted in an anonymous testing site in San Francisco 在旧金山匿名检测地点进行Primary outc

12、ome: # episodes of UAI with partner whose serostatus was unknown or known to be positive in previous 90 days 主要结果：拥有血清状态不明或在过去的 90 天内呈阳性的性伴侣的 UAI 状况Study Design研究设计Randomized to four groups:随机分为四组：A1: Standard counseling, no diaryA1：标准咨询，无日志A2: Standard counseling, diaryA2：标准咨询，有日志B1: Intervention c

13、ounseling, no diaryB1: 干预咨询，无日志B2: Intervention counseling, diary B2：干预咨询，有日志Self-justification counseling questionnaire自我辩解调查问卷Adapted from Gold et al. (1991) 改编自 Gold 等。（1991 年）Asked to rank how strongly each of 102 potential items featured into their thoughts at the moment just preceding the act

14、要求他们在行动前为当时脑中出现的 102 种潜在欲望的强烈性进行排序Self-Justification Items自我辩解名录“I want to have unprotected sex because it feels good.” “我想要未采取保护措施的性爱，因为那样感觉很好。”“We take chances every day-after all, its even taking a chance crossing the road. Taking a risk is a part of life.” “毕竟我们每天都在冒险，甚至过马路时都有危险。冒险是生活的一部分”“I did

15、nt want to fuck without a condom but I was so horny I couldnt think properly” “我并不是不愿戴避孕套做爱，但当时太冲动了，根本不能正常思考”“At the time I decided to fuck without a condom, I told myself”当时我决定不用保险套做爱，我对自己说S-Js can.自我辩解能够Make an idea that generally seems like a bad idea seem like a good one 使一些通常看来不怎么高明的主意看起来像是好主意F

16、unctions as an excuse 作为借口Make an activity at least temporarily, “guilt free” 使某种行为变得“不愧疚” - 至少暂时是这样Make a problem someone elses responsibility 将问题责任推卸到别人身上Allow one to pretend to have more information re: a situation than you actually do; OR ignore information you dont want to think about at the mo

17、ment 在某种情况下假装比拥有很多信息，虽然实际上没有这么多；或者忽略某种当时你不想知道的信息Additional session; post risk-assessment, pre disclosure其他会谈：事后危险评估、事前披露1 hour with licensed therapist执业临床医生 1 小时治疗begun by participants “telling his story”; focus on details, mood, sexual decision-making以参与者的“自述”开始；着重于细节、情绪、性行为决定过程discussion of partic

18、ipants responses to self-justification questionnaire讨论参与者对自我辩解问卷调查的回答Intervention Group: Cognitive Focused Counseling干预组：着重于认知的咨询Standard: “Client-Centered Counseling”标准：“以患者为中心的咨询”Prevention Counseling method CDC: 1993CDC 预防咨询法：1993An interactive, risk reduction counseling approach with HIV testing

19、 that helps the client to 互动式危险降低咨询法，附带 HIV 检测，帮助患者：take a GENERAL personal inventory of risks and the context and situations in which personal risk occur, and列出总体个人危险清单及发生个人危险的背景和情况，并且 commit to small, achievable behavior change steps that will reduce personal HIV risk.致力于较小且切实可行的行为改变，这些改变能够降低个人 HI

20、V 危险。support client in RR steps already made.支持已采取 RR 措施患者。Demographics人口统计资料N=12476% white, 11% Latino, 7% API76% 白人，11% 拉丁美洲人，7% APImedian 6 previous tests以前做过 6 次检测（中值）Average age: 33.2平均年龄：33.2N=12473% white, 11% Latino, 6% API76% 白人，11% 拉丁美洲人，7% APImedian 6 previous tests以前做过 6 次检测（中值）Average a

21、ge: 33.7平均年龄：33.7Controls对照组Counseling Intervention咨询干预组Participants Risk Behavior参与者 危险行为median 5 anal sex partners in last 12 months最近 12个 月与 5 人进行肛交（中值）Median 2 unprotected anal sex acts in last 90 days最近 90 天内有 2 次未采取保护措施的肛交（中值）47.6% history of STD47.6% 有性病史Controls对照组Counseling Intervention咨询干预

22、组median 5 anal sex partners in last 12 months最近 12个 月内与 5 人进行肛交（中值）Median 2 unprotected anal sex acts in last 90 days最近 90 天内有 2 次未采取保护措施的肛交（中值）45.2% history of STD45.2% 有性病史Figure 2. Mean reduction in episodes of unprotected anal intercourse (UAI) with non-primary partners of HIV-positive or unknow

23、n serostatus in the preceding 90 days by study arm.图2. 前面 90 天内与 HIV 呈阳性或血清状态未知的非固定性伴进行未采取保护措施肛交 (UAI) 行为的平均减少次数（按研究组）。*Significantly fewer episodes compared to A1, Wilcoxon rank sum test, p 0.05. *与 A1 相比，次数显著减少，Wilcoxon 秩和检测，p 0.05.Dilley JW, Woods J, Sabatino J, et al. Changing sexual behavior am

24、ong gay male repeat testers for HIV. JAIDS 2002; 30:177-186. Dilley JW、Woods J、Sabatino J 等。“改变男同性恋者的性行为，重复检测 HIV“ JAIDS 2002; 30:177-186.A1: Standard counseling, no diary标准咨询，无日志A2: Standard counseling, diary标准咨询，有日志B1: Intervention counseling, no diary干预咨询，无日志B2: Intervention counseling, diary干预咨询

25、，有日志*Conclusions结论A 90-day sexual diary, self-justification counseling or both, significantly reduced UAI with non-primary partners of unknown or HIV+ status at 6 and 12 months when added to standard counseling and testing将 90 天的性爱日志、自我辩解咨询，或两者都添加到标准咨询和检测时，在 6 个月 和 12 个月时间内，与血清状态未知或 HIV 呈阳性的非固定性伴侣进行

26、未采取保护措施肛交的次数显著减少The mean reduction in episodes of UAI (partner) was also significantly reduced among the intervention conditions with the greatest reduction in self-justification only group.在干预情形中，未采取保护措施肛交行为的平均减少次数也显著减少，且最大减少量出现在仅出现在自我辩解组中。Conclusions (continued)结论（续）Standard client-centered counse

27、ling showed a non-significant decline in UAI with non-primary partners from baseline to 6 months; at 12 months, this number had returned to baseline标准的以患者为中心的咨询从基线到 6 个月之间，与非固定性伴进行的未采取保护措施肛交次数没有出现明显的下降，此数字返回到基线The diary condition was half as effective as self-justification counseling only日志情形的效果只有自我

28、辩解咨询的一半Conclusions (continued)结论（续）This self-justification counseling has a strong, practical appeal此自辩解咨询有一种强烈的实际需求Single session一次性会谈“Low cost”“低成本”Applicable for a high risk population voluntarily accessing a service适合自愿接受服务的高危人群But, is it realistic? 但是，这现实吗？Study 2: 研究项目 2：Can this approach be a

29、dapted for the “Real World” of counseling and testing?这种方法能适用于“真实世界”的咨询和检测吗？Collaborators协同研究者William J. Woods, PhD*William J. Woods，博士*Lisa Loeb, MPHLisa Loeb，公共卫生硕士Kimberly Nelson, BAKimberly Nelson，学士Nicolas Sheon, PhD*Nicolas Sheon，博士*Joseph Mullan, PhDJoseph Mullan，博士Barbara Adler, LMFTBarbara

30、Adler，婚姻治疗师Sanny Chen, MHSSanny Chen，信息处理系统Willi McFarland, MD, PhD*Willi McFarland，医学博士* University of California, San Francisco Center for AIDS Prevention Studies* 加利福利亚大学，旧金山艾滋病预防研究中心 San Francisco Dept. of Public Health 旧金山公共卫生部Objective目标Oct 2002-Sept 20042002 年 10 月 2004 年 9 月To assess whether

31、 a single counseling intervention focusing on the thoughts, attitudes or beliefs of participants at the time of high risk behavior is effective in reducing future high risk activity when conducted by paraprofessional counselors 评估当辅助顾问在进行单独咨询干预时，此单独的着重于参与者在高危性行为下的想法、态度或者信念的咨询干预在减少未来高危活动方面是否有效Reduced

32、 SJQ length 减少自我辩解问卷的长度Incorporated counseling session into standard 2 session approach 将咨询会谈并入标准 2 会谈方法 Methods: Participants方法：参与者HIV- MSM (N=336) were recruited when scheduling an anonymous HIV antibody test HIV-MSM (N=336) 从一次匿名的 HIV 抗体检测中招募Eligibility criteria: 资格标准：Had unprotected anal sex wit

33、h a man who was HIV+ or of unknown serostatus in the last year who was not a “boyfriend or regular partner” 在过去一年中与一位携带 HIV 阳性或者血清状态未知的非男友或固定性伴侣的男性进行过不采取保护措施的肛交Had previously tested HIV-negative 之前检测出 HIV 阴性Did not inject drugs 未注射毒品 Study Design研究设计Randomized, controlled, counseling intervention tr

34、ial随机、对照、咨询干预试验Personalized Cognitive Counseling (PCC) vs. Usual Counseling (UC-Client Centered)个人化认知咨询 (PCC) 与普通咨询（UC 以患者为中心）Conducted in an anonymous testing site in San Francisco 在旧金山的匿名检测点进行Primary outcome: change from baseline in # episodes of UAI with any non-primary partner of non-concordant

35、serostatus in preceding 90 days主要结果：在之前 90 天内，与任何血清状态不一致的非固定性伴侣进行的未采取保护措施肛交次数基线出现变化 Assessed at 6 and 12 months在第 6 个月和第 12 个月进行评估 RED2 DemographicsRED2 人口统计资料N=15862% white, 13% Latino, 9% API, 7% AA62% 白人，13% 拉丁美洲人，9% API，7% AAMean 9 previous tests (median=8)平均以前有 9 次检测（中值8）Average age: 35.5平均年龄：3

36、5.5N=14768% white, 11% Latino, 8% API, 8% AA68% 白人，11% 拉丁美洲人，8% API，8% AAMean 9 previous tests (median=7)平均以前有 9 次检测（中值7）Average age: 35.5平均年龄：35.5Control对照组Counseling Intervention咨询干预组No significant differences, p0.05无显著差异，p0.05RED2 Risk BehaviorRED2 危险行为Mean 5 anal sex partners in last 90 days最近 9

37、0 天内平均与 5 人进行肛交Mean 4.8 unprotected anal sex acts in last 90 days最近 90 天内平均有 4.8 次未采取保护措施的肛交72.2% history of STD72.2% 有性病史Control对照组Counseling Intervention咨询干预组Mean 5 anal sex partners in last 90 days最近 90 天内平均与 5 人进行肛交Mean 4.2 unprotected anal sex acts in last 90 days最近 90 天内平均有 4.2 次未采取保护措施的肛交62.2

38、% history of STD62.2% 有性病史No significant differences, p0.05无显著差异，p0.05RED2 - Desire to change behavior RED2 对行为改变的愿望Control对照组 Counseling Intervention咨询干预组No significant differences, p0.05无显著差异，p0.05Extreme: 26%非常愿意：Considerable29%相当愿意Moderately25%一般Sightly 3%不太愿意None18%不愿意Extreme22%非常愿意：Considerabl

39、e32%相当愿意Moderately21%一般Slightly 2%不太愿意None24%不愿意Attitudes Towards Risk: “Given my behavior, I could get infected.”对危险的态度：“我的行为会导致感染”Control对照组Strongly agree 31%强烈同意Somewhat49%有一点同意Somewhat disagree 17%有一点反对Strongly disagree 3%强烈反对Intervention干预组Strongly agree 29%强烈同意Somewhat49%有一点同意Somewhat disagree

40、 18%有一点反对Strongly disagree 3%强烈反对p.05, no significant differencep0.05，无显著差异Intervention干预Conducted during the “pre-test” assessment在“事前检测”评估期间进行Introduction: “Bring to mind a specificepisode” 介绍：“使某人想起某次特殊性行为”Complete SJQ (33 items) 完成自我辩解问卷调查（33项）Detailed “re-telling” - prior to, during, and after

41、详细的“重新讲述” 之前、期间和之后Discussion of identified SJs 讨论已确定的自我辩解Identify different strategies 确定不同的策略Referrals as needed 根据需要进行转介Figure 2. Mean episodes of unprotected anal intercourse with a non-primary partner of unknown HIV serostatus or known discordant serostatus in the preceding 90 days, intervention

42、 vs. control counseling, men who have sex with men, San Francisco, 2002- 2004.图 2. 之前 90 天内旧金山与同性发生性关系的男性与 HIV 血清状态未知或已知血清状况不一致的非固定性伴侣进行未采取保护措施的肛交的平均次数，干涉与对照咨询比较，2002 年至 2004 年P = 0.069P 0.001P 0.001P = 0.181P = 0.151P = 0.756P = 0.029Dilley JW et al: JAIDS 2007 44(5):569-77.Dilley JW 等：JAIDS 2007 4

43、4(5):569-77.Satisfaction满意度Standardized survey mailed to all Ps, returned by 75% (no difference by group)将标准化调查邮寄给所有参与者，返回 75%（组间无差异）Control Ps were more likely to对照组参与者更可能agree that “the problems that led me to take an HIV test remained unchanged” (26% vs. 9%, p=0.001)同意“让我参加 HIV 检测的问题仍然没有改变”（26% 对

44、 9%，p=0.001）Intervention Ps were more likely to:干预组参与者更可能：rate the quality of service as “Excellent” (69% vs. 54%, p=0.022) 将服务质量评为“优秀”（69% 对 54%，p=0.022）rate their counselors competence as “high”(58% vs. 39%, p=0.005) 将其顾问的能力评为“高”（58% 对 39%，p=0.005）Conclusions结论Both interventions were effecting in

45、reducing high risk sexual behavior两种干预对减少高危性行为都有效Ps who received intervention counseling reported change more swiftly and reported higher satisfaction with their counseling experience接受干预咨询的参与者表明改变得更快，并且对他们接受的咨询经历更满意How does it work?如何工作？Forming a link between off-line/on-linethinking : when occurs

46、again, better able tocontrol在离线思考和在线思考之间建立一种联系：什么时候再次发生，最好能够控制2. Personalizing risk thru re-telling and experiencing the affective component of possible negative outcome-contemplating consequences通过重新讲述和体验可能的有负面结果的情感成分-自己考虑后果，将危险个人化3. Learning something new about ones internal process; feeling more

47、in control了解某人内心历程新事物；感觉更多事物受到控制Other Individual Approaches其他个别方法Informational videos with HIV negative (“Safe City”) and HIV positive (“Video Doctor”)附带 HIV 阴性（“安全城市”）和 HIV 阳性信息的视频（“视频医生”）Prevention Case Management预防案例管理Peer Interventions同伴干预Community Promise社区承诺Popular Opinion Leaders公众意见领袖“Safe i

48、n the City”“城市中的安全”23 minute video that can be played in the waiting room可以在休息室中播放 23 分钟的视频requires very little staff time to set up with no disruption to clinic flow只需很少的工作时间来设置，不影响临床工作requires no counseling or small-group facilitation不需要咨询，也不需要小组推进shown to be effective in a controlled trial to red

49、uce sexually transmitted diseases (STDs) among diverse groups of STD clinic patients, including MSM经证明，对于各种各样的性病临床患者（包括 MSM），对照试验对减少性病是有效的。Warner, L. et al, for the Safe in the City Study Group(2008). Effect of a Brief Video Intervention on Incident Infection among Patients Attending Sexually Transm

50、itted Disease Clinics. PLoS Medicine 5(6): e135.Warner, L. 等，城市中的安全研究组(2008)。性病诊所患者意外感染简短视频干预效果。PLoS Medicine 5(6): e135.“Community Promise”“社区承诺”Creating role model stories based on personal accounts from individuals in the target population who have made positive behavior change根据做出了积极行为改变的目标人群中的个体创造榜样故事Recruiting and training peer advocates from the target population to distribute role model stories and prevention materials从目标人群中招募和培训同伴以分发榜样故事和预防材料At the community level, movement toward consistent condom use with main (P .05) and nonmain (P .05) partners, as well a