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Counseling Associated with Testing: A New Approach for Repeat Testing MSM 有关检测的咨询：重复检测 MSM 的新方法

Counseling Associated with Testing: A New Approach for Repeat Testing MSM 有关检测的咨询：重复检测 MSM 的新方法. 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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Counseling Associated with Testing: A New Approach for Repeat Testing MSM 有关检测的咨询：重复检测 MSM 的新方法

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  1. Counseling Associated with Testing: A New Approach for Repeat Testing MSM有关检测的咨询：重复检测 MSM 的新方法 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 • William Woods, 博士, James Sabatino, Barb Adler,Richard Brand, PhD, Willi McFarland, 医学博士 (UCSF/SF DPH) • Men attending AHP’s 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 andMelinda Gates 基金会

  3. Goals for today今天的目标 • Provide background on counseling assoc’d 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，PCC • Discuss other individual prevention interventions 讨论其他个人预防干预方法

  4. Background on Repeat Testers重复检测的背景 • Despite years of intense AIDS prevention messages, roughly 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 MSM 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, repeated HIV neg tests conveyed the “wrong” msg re: the client’s 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

  5. “The Stories We Tell Ourselves”: A New Approach我们的研究告诉自己：一个新方法 • Adapted from Australian psychologist Ron Gold’s 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--Randomized 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 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

  6. Study 1: Objectives研究项目1 ：目标May 1997 - January 20001997 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

  7. Methods: Participants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 last 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

  8. 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 outcome: # 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

  9. Study Design研究设计 Randomized to four groups: 随机分为四组： A1: Standard counseling, no diary A1：标准咨询，无日志 A2: Standard counseling, diary A2：标准咨询，有日志 B1: Intervention counseling, no diary B1:干预咨询，无日志 B2: Intervention counseling, diary B2：干预咨询，有日志

  10. 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 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

  11. Self-Justification Items自我辩解名录 “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…… • “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, it’s 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 didn’t want to fuck without a condom but I was sohorny I couldn’t 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”

  12. S-J’s 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 • Functions 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 else’s 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 don’t want to think about at the moment 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

  13. Intervention Group: Cognitive Focused Counseling干预组：着重于认知的咨询 • 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 participant’s “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 participant’s responses to self-justification questionnaire讨论参与者对自我辩解问卷调查的回答

  14. 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：1993 An interactive, risk reduction counseling approach with HIV testing 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 HIV 危险。 • support client in RR steps already made.支持已采取 RR 措施患者。

  15. N=124 76% white, 11% Latino, 7% API76% 白人，11% 拉丁美洲人，7% API median 6 previous tests以前做过 6 次检测（中值） Average age: 33.2平均年龄：33.2 N=124 73% white, 11% Latino, 6% API76% 白人，11% 拉丁美洲人，7% API median 6 previous tests以前做过 6 次检测（中值） Average age: 33.7平均年龄：33.7 Demographics人口统计资料 Controls对照组 Counseling Intervention咨询干预组

  16. 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 Participants – Risk Behavior参与者 – 危险行为 Controls对照组 Counseling Intervention咨询干预组 • 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

  17. 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，有日志 * * * * Figure 2. Mean reduction in episodes of unprotected anal intercourse (UAI) with non-primary partners of HIV-positive or unknown 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 among 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.

  18. 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。

  19. Conclusions (continued)结论（续） • Standard client-centered counseling 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辩解咨询的一半

  20. 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？

  21. Study 2: 研究项目 2：Can this approach be adapted 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？

  22. Collaborators协同研究者 William J. Woods, PhD* William J. Woods，博士* Lisa Loeb, MPH Lisa Loeb，公共卫生硕士 Kimberly Nelson, BA Kimberly Nelson，学士 Nicolas Sheon, PhD* Nicolas Sheon，博士* Joseph Mullan, PhD Joseph Mullan，博士 Barbara Adler, LMFT Barbara Adler，婚姻治疗师 Sanny Chen, MHS^ Sanny 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

  23. Objective目标Oct 2002-Sept 20042002 年 10 月 — 2004 年 9 月 • To assess whether 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 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

  24. 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 with 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

  25. Study Design研究设计 • Randomized, controlled, counseling intervention trial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 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

  26. N=158 62% white, 13% Latino, 9% API, 7% AA62% 白人，13% 拉丁美洲人，9% API，7% AA Mean 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：35.5 N=147 68% white, 11% Latino, 8% API, 8% AA68% 白人，11% 拉丁美洲人，8% API，8% AA Mean 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：35.5 RED2 DemographicsRED2 人口统计资料 Control对照组 Counseling Intervention咨询干预组 No significant differences, p<0.05无显著差异，p<0.05

  27. Mean 5 anal sex partners in last 90 days最近 90 天内平均与 5 人进行肛交 Mean 4.8 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 RED2 Risk BehaviorRED2 危险行为 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% history of STD62.2% 有性病史 No significant differences, p<0.05无显著差异，p<0.05

  28. RED2 - Desire to change behavior RED2 – 对行为改变的愿望 Control对照组 Counseling Intervention咨询干预组 Extreme: 26% 非常愿意： Considerable 29% 相当愿意 Moderately 25% 一般 Sightly 3% 不太愿意 None 18% 不愿意 Extreme 22% 非常愿意： Considerable 32% 相当愿意 Moderately 21% 一般 Slightly 2% 不太愿意 None 24% 不愿意 No significant differences, p<0.05无显著差异，p<0.05

  29. Control对照组 Strongly agree 31% 强烈同意 Somewhat 49% 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 Somewhat 49% 有一点同意 Somewhat disagree 18% 有一点反对 Strongly disagree 3% 强烈反对 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……” p<.05, no significant differencep<0.05，无显著差异

  30. 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 specific episode”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详细的“重新讲述” — 之前、期间和之后 • Discussion of identified SJ’s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

  31. P = 0.069 P = 0.151 P < 0.001 P < 0.001 P = 0.029 P = 0.181 P = 0.756 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 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 Dilley JW et al: JAIDS 2007 44(5):569-77. Dilley JW 等：JAIDS 2007 44(5):569-77.

  32. Satisfaction满意度 • Standardized survey mailed to all P’s, 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 P’s 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 9%，p=0.001） • Intervention P’s 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 counselor’s 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）

  33. Conclusions结论 • Both interventions were effecting in reducing high risk sexual behavior两种干预对减少高危性行为都有效 • P’s 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

  34. How does it work?如何工作？ Forming a link between off-line/on-line thinking : when occurs again, better able to control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 one’s internal process; feeling more in control了解某人内心历程新事物；感觉更多事物受到控制

  35. 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

  36. “Safe in 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 reduce 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ﾊ(2008). Effect of a Brief Video Intervention on Incident Infection among Patients Attending Sexually Transmitted Disease Clinics. PLoS Medicine 5(6): e135. • Warner, L. 等，城市中的安全研究组ﾊ(2008)。性病诊所患者意外感染简短视频干预效果。PLoS Medicine 5(6): e135.

  37. “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 as increased condom carrying (P < .0001), was greater in intervention than in comparison communities. At the individual level, respondents recently exposed to the intervention were more likely to carry condoms and to have higher stage-of-change scores for condom and bleach use.在社区层面，大力宣传在与固定性伴侣 (P < .05 ) 和非固定性伴 ( P < .05 ) 发生性行为时使用避孕套，以及随身携带避孕套 (P < .0001) 活动的干预效果也优于对照社区。在个人层面，最近接受干预的响应者更可能携带避孕套，并且在使用避孕套和洗液方面有更高的改变阶段得分。 CDC AIDS Community Demonstration Projects Research Group (1999). Community-level HIV Intervention in Five Cities: Final Outcome Data from the AIDS Community Demonstration Projetss, AJPH 89 (3), 336 B 345.

  38. “Popular Opinion Leader”“公众意见领袖” • A cadre of trusted, well-liked men who frequent gay bars are trained to endorse safer sexual behaviors in casual, one-on-one conversations with peers at the bars and other settings. 训练那些信誉较高、受人欢迎，经常出现在同性恋酒吧中的骨干，在酒吧和其他场所中，通过偶然的、平等的、一对一的交谈倡导更安全的性行为。 • Popular opinion leaders wear buttons displaying the project logo, which also is on posters around the bars, as a conversation-starting technique. Each leader agrees to have at least 14 such conversations and to recruit another popular opinion leader.公众意见领袖的衣服上有带计划徽标的钮扣，这种徽标还会出现在酒吧四周的柱子上，作为一种开始交谈的技巧。每名领袖同意至少进行 14 次此类交谈并且招募其他公众意见领袖。 • Outcomes: reduced UAI between 15-29%; increased condom use; decreased number of sex partners结果：未采取保护措施肛交行为减少到 15-29%，避孕套使用率提高，性伴侣数量减少 • Kelly, J. A., et al. (1997). Randomised, controlled, community-level HIV-prevention intervention for sexual-risk behaviour among homosexual men in US cities. Community HIV Prevention Research Collaborative. Lancet, 350(9090), 1500-1505. • Kelly、J. A. 等 (1997). 美国各城市同性恋者危险性行为随机、控制、社区级 HIV 预防干预。HIV 社区干预合作研究。Lancet, 350(9090), 1500-1505.

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