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James W. Dilley, MD James W. Dilley 医学博士、 Professor of Clinical Psychiatry 临床精神医学教授、

Expanding VCT among MSM in China: Opportunities for Innovation? 在中国 MSM 中推广自愿咨询检测 (VCT) ：是创新机遇吗？. James W. Dilley, MD James W. Dilley 医学博士、 Professor of Clinical Psychiatry 临床精神医学教授、 Vice-Chair, UCSF Dept. of Psychiatry UCSF （旧金山加州大学）精神医学学院副院长

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James W. Dilley, MD James W. Dilley 医学博士、 Professor of Clinical Psychiatry 临床精神医学教授、

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  1. Expanding VCT among MSM in China:Opportunities for Innovation?在中国 MSM 中推广自愿咨询检测 (VCT)：是创新机遇吗？ James W. Dilley, MD James W. Dilley 医学博士、 Professor of Clinical Psychiatry 临床精神医学教授、 Vice-Chair, UCSF Dept. of Psychiatry UCSF（旧金山加州大学）精神医学学院副院长 Chief of Psychiatry, SF General Hospital and Executive Director, UCSF AIDS Health Project 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

  2. Acknowledgements致谢 • Willi McFarland, MD, PhD Willi McFarland 医学博士 • Mary Kamb, MD, CDC Mary Kamb 医学博士，疾病控制中心 • Bill and Melinda Gates Foundation Bill and Melinda Gates 基金会

  3. Goals for today:今天的目标： • Briefly review our HIV C & T program in SF--are there any applicable lessons? 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？ • Briefly review some outcome data on counseling associated w/testing 简要回顾一些有关检测的咨询效果数据 • Propose some topics for further discussion 为进一步讨论提议若干主题

  4. Background背景 • began ATS in 1985 in community health clinics; served over 250K people for HIV since 1985 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 • Began w/group “pre-test counseling” (video w/Q & A) and individual post-test results focused on RR counseling 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: multiple changes including indiv pre/post counseling; addition of other services including mobile testing; confidential testing; partner notification/”Letting Them Know”; on-site STD screening/tx services; formal linkage to care service; Hepatitis A/B vaccines;RNA testing 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 • Telephone appointments and Marketing 电话约诊和营销

  5. Early HIV Testing Ad in Gay Press, 1986 Gay Press（同性恋杂志）上的早期 HIV 检测广告， 1986 年

  6. Location, Location, Location! 位置，位置，位置！ Tenderloin 田德隆区 Castro 卡斯特罗 • AIDS cases: ~30,000 • 艾滋病病例：约 30,000 • Living with HIV: ~18,000 • HIV 携带者：约 18,000 • New infections: ~8-900 per year • 新感染者：每年约 8-900 • HAART: ~75% • MSM: ~90%

  7. Mobile, Community Based HIV Testing 基于社区的 HIV 流动检测

  8. Individual tents; Individual Counseling... 单独帐篷；单独咨询…

  9. Example of “added value” Service: Linkage to Care“增值” 服务示例：与护理联接 • In 1999, began specialized short-term case management for all individuals who test HIV-positive through our HIV Counseling and Testing Program (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。 • Clients are offered up to 4 counseling sessions as they navigate the process of living with a new HIV diagnosis. Each session focuses on client needs and targets appropriate follow up referrals. 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。

  10. Acceptance of Services服务接受 • 84% of those offered Linkage accepted the service. • A. 向其提供了联接方式的84% 的患者接受了服务。 • Main reasons for declining • B. 拒绝接受服务的主要原因 • Alreadyreceivingservices: 39% • 已接受服务： 39% • • Wanted to see own MD first 28% • 希望首先见到自己就诊的医师 28% • Feelingtoooverwhelmed: 18% • 感觉压力太大： 18% • Declined to give reason 9% • 拒绝透露原因 9%

  11. Referral to Primary Medical Care初级医疗护理转介 • Almost all (96%) clients were given an immediate referral to HIV-specific primary medical care services. • 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%) of these clients reported successfully following through on the referral*. • 其中大多数 (71%) 患者表示转介成功*。 • The most common medical referrals were to: • 最常见的医疗转介如下： • Private physicians or plans • 私人医生或计划 • Public Health clinics • 公共卫生诊所 • Alternative health care providers • 其他可选健康护理提供方 *A “successful” referral has been made when the client has contact with the referred organization or agency. * 患者若与转介组织或机构取得联系，转介即“成功”。

  12. Referral to Support Services支持服务转介 • Typical Support Service Referrals: • 典型支持服务转介： • ethnic/cultural identity based support groups for positives; • 基于族群/文化认同的阳性患者支持群体 • individual psychotherapy or substance abuse services. • 私人精神治疗或药物滥用服务 Most (72%) of our clients were given a Support Referral, 59% of these were successful. 大多数 (72%) 患者获得了支持转介服务，其中 59% 转介成功。 *A “successful” referral has been made when the client has contact with the referred organization or agency. * 患者若与转介组织或机构取得联系，转介即“成功”。

  13. Is Counseling Associated with Testing Important?将咨询与检测相关联，这很重要吗？

  14. Reduction in Unprotected Intercourse with Known HIV- 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 Total Reduction in Unprotected Intercourse 未采取保护措施的性行为减少总量 Percent Reduction 减少比率 Knowledge of HIV infection is Prevention: Among those w/HIV对感染 HIV 的知识即预防：HIV 携带者 -53% -68% Marks G. JAIDS. 2005; 39 (4): 446-453 i

  15. Does Counseling Assoc’d w/Testing Change High Risk Behavior?与检测相关的咨询是否会改变高危性行为？ • 2 review articles of 1980s, early 1990s assessing effectiveness of HIV counseling 20 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 (24 studies) Higgins, 1991, JAMA（24 项研究） • Weinhardt, 1991, AJPH (27 studies through 1995) Weinhardt, 1991, AJPH（1995 年进行了 27 项研究） • Counseling approaches were generally informational approaches done with testing (VCT-like) OR intensive interventions in high risk populations 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 • Designs were usually non-controlled (or before-and-after). 通常设计为非对照咨询（或前后对照）。

  16. C & T effectiveness studies咨询与检测效果研究 • Early evidence was variable: 早期症状具有多样性： • Higgins (‘91): meta-analysis of 24 studies: Higgins (‘91)：对 24 项研究进行荟萃分析 • “All longitudinal studies of homosexual men reported reductions in risky behavior among both tested and untested men, and a few reported greater decreases among seropositive men than among seronegative men and those untested or unaware of their serostatus.” “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-analysis of 27 studies Weinhardt (‘99)：对 27 项研究进行荟萃分析 • “HIV C & T appears to provide an effective means of secondary prevention for HIV positive individuals,…. [though it] is not an effective primary prevention strategy for uninfected participants” “HIV 咨询与检测项目似乎提供了一个有效的 HIV 阳性个体辅助预防方法……（尽管）这对未感染人群并非有效的主要预防策略”

  17. Many Controlled Trials Since:大量对照试验： HIV CT among most well-studied of the HIV prevention interventions 大多数进行了充分研究的 HIV 预防干预方法均采用 HIV 对照试验方法 • 1991 – 2005, ~ 20 controlled trials evaluated various CT approaches in high-risk persons with status unknown partners 1991 至 2005 年间，约 20 项针对有未知血清状态性伴侣的高危人群对照试验评估了各种对照试验方法 • Of these, at least 9 were conducted in STI patients 其中，至少有 9 例为 STI 患者 • All involved offering (n=5) or requiring (n=4) an HIV test 所有受试者都进行 (n=5) 或必须进行 (n=4) 一次 HIV 检测

  18. Controlled Trials (N=9) of HIV/STI Prevention Counseling/Testing in STI Patients (cont)在 STI 患者中进行的 HIV/STI 预防咨询/检测的对照试验 (N=9)（续） • Interventions ranged in complexity: 根据复杂程度进行干预等级划分： • Brief Interactive RR Counseling -- 2 session pre-test/post-test interventions (e.g. Client Centered Counseling, MI) 简短的互动 RR 咨询 — 两次会谈的检测前/后干预（例如，以患者为中心的咨询，MI） • Enhanced– multiple sessions (range, 3 to 7) based on behavioral science theories 强化 — 多次会谈（3 到 7 次），基于行为科学理论 • Skills Building – single session 技能培养 — 一次会谈 • Comparison groups varied 不同的群体比较 • Information alone or typical services (n = 6) 仅提供信息或典型服务 (n=6) • Interactive RR counseling (e.g., CCC) (n = 3) RR 互动咨询（例如：CCC） (n=3)

  19. Efficacy of HIV/STD Prevention Counseling among STI patients HIV/STD 预防咨询对 STI 患者的效果 6/8 U.S. studies evaluating STI outcomes found STI reductions with prevention counseling 6/8 美国评估 STI 效果的研究发现预防咨询使 STI 有所减少 1 0.8 0.6 0.4 0.2 0 Shain RESPECT O’Donnell Boyer TAKE Cohen Cohen et al 等 et al 等 et al 等 et al 等 et al 等 et al 等 et al 等 1999 1998 1997 1997 1992 1991, 2 studies 2 项研究 1998 N 617 5878 964 2004 393 551 192 GRP IND GRP DEM IND DEM DEM

  20. Effectiveness of PCCPCC 的效果 • Shown effective in two RCTs (PCC vs. “client-centered counseling”) conducted between 1998 and 2005 1998 年和 2005 年的两次 RCT（随机对照试验）（PCC 对比“以患者为中心的咨询”）证明 PCC 有效 • Each conducted in SF’s largest HIV anonymous testing site 两者都是在旧金山最大的 HIV 匿名检测地进行 • Participants: (N=248 and 336) 参与人数：（N=248 和 336） • diverse group of MSM who had hx of UAI in past yr w/another man whose serostatus was unknown or known to be +; 不同的 MSM 群体，且在过去一年里曾与血清状态未知或已知为 HIV 阳性的患者发生过未采取保护措施的性关系 • tested at least once before; no IDU in past year 以前至少检测过一次；过去一年内没有 IDU • Primary outcome: # episodes of UAI with partner whose serostatus was unknown or known to be positive in previous 90 days 主要结果：之前 90 天与血清状态未知或已知为阳性的性伴侣发生未采取保护措施的性关系的次数减少 • Control groups in both studies showed a decrease in high risk behavior at 6 mos; also at 12 mos in the second study 两项研究内的对照组表明 6 个月内高危行为在减少，第二项研究的 12 个月内亦减少。 Dilley JW et al; JAIDS 2002 30:177-186. Dilley JW et al: JAIDS 2007 44(5):569-77.

  21. Motivation for use of VCT in Shenyang (2006-7)?在沈阳推广使用 VCT(2006-7)？ • Cross-sectional survey of 2676 VCT clients 对 2676 名 VCT 患者进行交叉调查 • 41% were 20-30 yrs; 73% males (only 2.8% were MSM) 41% 在 20-30 岁之间；73% 为男性（只有 2.8% 为男同性恋者） • Primary information source TV/newspaper 信息首要来源为电视和报纸 • Primary barrier: fear of result; Primary incentive: recent information re: HIV 最大的障碍：对检测结果的恐惧；最大的动机：最近对 HIV 的了解。 • Among MSM: 64% reported one partner in past year; 45% reported “never” using condoms MSM 中：64% 在过去一年有一个性伴侣；45% 的人从不用避孕套 • Rec: Increasing understanding of HIV; improve/expand informational sources 记录：对 HIV 了解的人越来越多；信息来源的改进或扩展 Zhou L, et al. Survey of motivation for use of VCT services for HIV in a high risk are of Shenyang, China BMC Health Services research 2009,9:23 (avail from www.biomedcentral.com/1472-6963/9/23) Zhou L, et al. 对于中国沈阳高危险 HIV 的 VCT 服务推广使用 BMC Health Services research 2009,9:23 (avail from www.biomedcentral.com/1472-6963/9/23)

  22. Opportunities for Innovation创新机遇 • “Pre-test” Possibilities “检测前”的可能性 • Policy Related: 相关政策 • What can local and federal governments do to “de-stigmatize” HIV testing and homosexuality? 地方和联邦政府该怎么做来对 HIV 检测和同性恋行为去标签化？ • Develop and fund a National AIDS Plan? 出台全国艾滋病计划并投入资金？ • Continually engage/involve members of the MSM community in planning and marketing 在计划和营销上持续使 MSM 社区成员参与/跟进 • Provide counseling to HIV negative MSM? 向 HIV 阴性的 MSM 提供咨询？ • Outreach Related: 相关外展活动： • increase community level interventions, eg, social marketing and use of media of all types (include internet ads, etc.) 加大社区干预力度，例如，社会营销和使用各种媒体（包括互联网广告等） • Enhance peer outreach training support? Use MSM as peers as much as possible. Popular Opinion Leader Model? Review messages given? Project Inform type program? 增强同伴外展培训支持？尽可能将 MSM 作为同伴。公众意见领袖模范？回顾提供的信息？项目通知类型计划？

  23. Opportunities for Innovation (cont’d)创新机遇（续） • Health Care Service Innovations/”Incentivize” Testing 健康护理服务革新/鼓励检测 • VCT sites: VCT 场所： • enhance convenience? (Location, location, location…?) 增强便利性？（位置，位置，位置…？） • Enhance hrs of operation? 延长经营时间？ • Add other services, eg., Linkage? STI screening/treatment? Others important to local MSM? 增加其他服务，例如：联接服务？STI 检查/治疗？其他对当地 MSM 重要的服务？ • Provide “mobile testing?” (esp in PSEs and bathhouses) 提供“流动检测？”（特别在 PSE 和公共浴室） • Add “opt-out” HIV testing in other clinical service sites serving MSM? 在其他服务 MSM 的诊所服务点增加“选择性退出” HIV 检测 • OTHER structural intervention possibilities? 增加其他结构性干预的可能性？

  24. Association Between HIV Testing Rates and Elimination of Written Consent in San Francisco旧金山 HIV 检测率和检查同意书免除之间的关联 • Consent mechanism streamlined in San Francisco DPH Care System 旧金山 DPH 护理制度的同意机制精简 • In May 2006: 2006 年 5 月： • HIV antibody test added to routine lab requisition HIV 抗体检测增加到常规化验申请书中 • Clinicians required to document in chart that patient consent was obtained 需要在已取得的患者同意书计划中记录临床医生 • Patient signature not required 不要求患者签名 Zetola et al. JAMA 2007 Mar; 297 (10): 1061-1062

  25. Association Between HIV Testing Rates and Elimination of Written Consent in San Francisco旧金山 HIV 检测率和检查同意书免除之间的关联 • Results: 结果： • Monthly rate of HIV testing increased from 13.5 tests /1000 visits in 6/06 to 17.9 in 12/06 HIV 每月检测率从 2006 年 6 月的每 1000 个访问者获得 13.5 次检测上升到了 2006 年 12 月的 17.9 次检测 • Mean number positive HIV tests/ month increased from 20.6 to 30.6 每月 HIV 阳性检测数量平均患者人数从 20.6 上升到了 30.6 • Conclusion: 结论： • Administrative policy change simplifying consent was followed by a substantial increase in HIV testing and increased positivity rate 实施简化同意的行政政策后，HIV 检测率和检测阳性率显著提高 Zetola et al. JAMA 2007 Mar; 297 (10): 1061-1062

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