中推广自愿咨询检测

ExpandingVCTamongMSMinChina:OpportunitiesforInnovation?在中国MSM中推广自愿咨询检测(VCT)：是创新机遇吗？JamesW.Dilley,MDJamesW.Dilley医学博士、ProfessorofClinicalPsychiatry临床精神医学教授、Vice-Chair,UCSFDept.ofPsychiatryUCSF（旧金山加州大学）精神医学学院副院长ChiefofPsychiatry,SFGeneralHospitalandExecutiveDirector,UCSFAIDSHealthProject兼UCSF艾滋病卫生项目精神医学专家，旧金山总医院院长兼主任Acknowledgements致谢•WilliMcFarland,MD,PhDWilliMcFarland医学博士•MaryKamb,MD,CDCMaryKamb医学博士，疾病控制中心•BillandMelindaGatesFoundationBillandMelindaGates基金会Goalsfortoday:今天的目标：•BrieflyreviewourHIVC&TprograminSF--arethereanyapplicablelessons?简要回顾旧金山的HIV咨询与检测项目—是否可以从中吸取适用的经验教训？•Brieflyreviewsomeoutcomedataoncounselingassociatedw/testing简要回顾一些有关检测的咨询效果数据•Proposesometopicsforfurtherdiscussion为进一步讨论提议若干主题Background背景•beganATSin1985incommunityhealthclinics;servedover250KpeopleforHIVsince1985年，率先开始在社区卫生诊所使用ATS（收集追踪系统）；自成立以来，为超过25万人次提供了艾滋病服务•Beganw/group“pre-testcounseling”(videow/Q&A)andindividualpost-testresultsfocusedonRRcounseling最早提供群体“检测前咨询”（视频问答）和着重于RR咨询的个体检测后结果服务•Since:multiplechangesincludingindivpre/postcounseling;additionofotherservicesincludingmobiletesting;confidentialtesting;partnernotification/”LettingThemKnow”;on-siteSTDscreening/txservices;formallinkagetocareservice;HepatitisA/Bvaccines;RNAtesting起始：包括个人检测前后咨询在内的许多变化；包括流动检测在内新增的其他服务；保密检测；性伴侣通知/“让伴侣知晓”；性病现场检查服务；护理服务官方联接；甲肝/乙肝疫苗；RNA（核糖核酸）检测•TelephoneappointmentsandMarketing电话约诊和营销EarlyHIVTestingAdinGayPress,1986GayPress（同性恋杂志）上的早期HIV检测广告，1986年•AIDScases:~30,000艾滋病病例：约30,000•LivingwithHIV:~18,000HIV携带者：约18,000•Newinfections:~8-900peryear新感染者：每年约8-900•HAART:~75%•MSM:~90%Tenderloin田德隆区Castro卡斯特罗Location,Location,Location!位置，位置，位置！Mobile,CommunityBasedHIVTesting基于社区的HIV流动检测Individualtents;IndividualCounseling...单独帐篷；单独咨询…Exampleof“addedvalue”Service:LinkagetoCare“增值”服务示例：与护理联接•In1999,beganspecializedshort-termcasemanagementforallindividualswhotestHIV-positivethroughourHIVCounselingandTestingProgram(HCAT).1999年开始通过HIV咨询与检测项目(HCAT)致力于对所有HIV检测呈阳性的患者进行短期病例管理。•Clientsareofferedupto4counselingsessionsastheynavigatetheprocessoflivingwithanewHIVdiagnosis.Eachsessionfocusesonclientneedsandtargetsappropriatefollowupreferrals.向患者提供4次咨询会谈服务，此项服务帮助指导新HIV携带者如何就诊。每次会谈均以患者需求为重点，旨在为患者提供适当的复诊转介服务。AcceptanceofServices服务接受B.MainreasonsfordecliningB.拒绝接受服务的主要原因A.84%ofthoseofferedLinkageacceptedtheservice.A.向其提供了联接方式的84%的患者接受了服务。•Alreadyreceivingservices:39%已接受服务：39%•WantedtoseeownMDfirst28%希望首先见到自己就诊的医师28%•Feelingtoooverwhelmed:18%感觉压力太大：18%•Declinedtogivereason9%拒绝透露原因9%2555055050100150200250300Accept接受Decline拒绝Unknown未知ReferraltoPrimaryMedicalCare初级医疗护理转介Almostall(96%)clientsweregivenanimmediatereferraltoHIV-specificprimarymedicalcareservices.几乎所有(96%)的患者在第一时间被推荐接受专门针对HIV的初级医疗护理服务。Most(71%)oftheseclientsreportedsuccessfullyfollowingthroughonthereferral*.其中大多数(71%)患者表示转介成功*。Themostcommonmedicalreferralswereto:最常见的医疗转介如下：•Privatephysiciansorplans私人医生或计划•PublicHealthclinics公共卫生诊所•Alternativehealthcareproviders其他可选健康护理提供方*A“successful”referralhasbeenmadewhentheclienthascontactwiththereferredorganizationoragency.*患者若与转介组织或机构取得联系，转介即“成功”。18117412304080120160200TotalClients总客户数ReferralMade做出转介ReferralSuccessful*成功转介ReferraltoSupportServices支持服务转介Most(72%)ofourclientsweregivenaSupportReferral,59%oftheseweresuccessful.大多数(72%)患者获得了支持转介服务，其中59%转介成功。TypicalSupportServiceReferrals:典型支持服务转介：•ethnic/culturalidentitybasedsupportgroupsforpositives;基于族群/文化认同的阳性患者支持群体•individualpsychotherapyorsubstanceabuseservices.私人精神治疗或药物滥用服务1811307704080120160200TotalClients总客户数ReferralMade做出转介ReferralSuccessful*成功转介*A“successful”referralhasbeenmadewhentheclienthascontactwiththereferredorganizationoragency.*患者若与转介组织或机构取得联系，转介即“成功”。IsCounselingAssociatedwithTestingImportant?将咨询与检测相关联，这很重要吗？KnowledgeofHIVinfectionisPrevention:Amongthosew/HIV对感染HIV的知识即预防：HIV携带者-68%-53%-100-80-60-40-200TotalReductioninUnprotectedIntercourse未采取保护措施的性行为减少总量ReductioninUnprotectedIntercoursewithKnownHIV-Partner已知性伴侣为HIV携带者而未采取保护措施的性行为减少量PercentReduction减少比率MarksG.JAIDS.2005;39(4):446-453iDoesCounselingAssoc’dw/TestingChangeHighRiskBehavior?与检测相关的咨询是否会改变高危性行为？•2reviewarticlesof1980s,early1990sassessingeffectivenessofHIVcounseling20世纪80年代和20世纪90年代初的两篇评论文章评估了HIV咨询的效果–Higgins,1991,JAMA(24studies)Higgins,1991,JAMA（24项研究）–Weinhardt,1991,AJPH(27studiesthrough1995)Weinhardt,1991,AJPH（1995年进行了27项研究）•Counselingapproachesweregenerallyinformationalapproachesdonewithtesting(VCT-like)ORintensiveinterventionsinhighriskpopulations咨询通常采用检测信息咨询（类似VCT）的方法或者对高危人群的深度干预•Designswereusuallynon-controlled(orbefore-and-after).通常设计为非对照咨询（或前后对照）。C&Teffectivenessstudies咨询与检测效果研究•Earlyevidencewasvariable:早期症状具有多样性：–Higgins(‘91):meta-analysisof24studies:Higgins(‘91)：对24项研究进行荟萃分析•“Alllongitudinalstudiesofhomosexualmenreportedreductionsinriskybehavioramongbothtestedanduntestedmen,andafewreportedgreaterdecreasesamongseropositivementhanamongseronegativemenandthoseuntestedorunawareoftheirserostatus.”“所有对男同性恋者的纵向研究表明，高危行为在已检测与未检测男性中都有所减少，而少数研究表明，相对于血清状态为阴性但未做检测或不知道自己血清状态的男性，血清状态为阳性的男性高危性行为次数减少量更大。”–Weinhardt(‘99):meta-analysisof27studiesWeinhardt(‘99)：对27项研究进行荟萃分析•