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1、Individual, Contextual and Structural Factors that Drive the HIV Epidemic Among Men Who Have Sex with Men促使与同性发生性关系的男性中艾滋病流行的个体、环境与结构因素,Ron Stall University of Pittsburgh Pittsburgh USA美国匹兹堡,Presentation Goals演讲目的,To address three main questions: 解决三个主要问题： Is HIV prevention efficacious? 艾滋病病毒预防措施是否有
2、效？ Are HIV prevention efforts working among American MSM?美国与 同性发生性关系的男性是否采取了艾滋病预防措施？ How can HIV prevention efforts be made more effective?艾滋病病毒预防措施如何才能变得更有效？ Focus on MSM, but with application to other marginalized populations重点放在与 同性发生性关系的男性，但也需应用至其他边缘人群,Is HIV Prevention Efficacious Among MSM?艾滋病
3、预防措施对与同性发生性关系的男性是否有效？,2 recent meta-analyses of published RCT trials近期针对公开的 RCT 试验进行过 2 次元分析 Herbst (2005) review reported a: Herbst (2005) 评论表明： 23% decrease in UAIUAI 下降 23 15% decrease in numbers of sex partners性伴侣数量减少 15 61% increase in protected AI保护性 AI 增加 61 Herbst, J. et al., JAIDS 2005 39(2
4、):228-241. Johnson, W., et al, AIDS: E prevalence rates thus measures burden of HIV disease in a cohort60 岁以下人员无人因感染艾滋病病毒死亡；因此使用发病率衡量某个群体艾滋病比例 Identical non-HIV mortality rates to other men in the US population非艾滋病病毒感染死亡率与其他美国男性相同 *MMWR (2001) HIV incidence among young MSM 7 US Cities, 1994-2000. *M
5、MWR (2001) 7 座美国城市年轻的与同性发生性关系的男性的艾滋病发病率 , 1994-2000.,CDC (2005). HIV prevalence, unrecognized infection, and HIV testing among men who have sex with men Five U.S. cities, June 2004-April 2005. MMWR, 54, 597-601. CDC (2005). 与男性发生性关系的男性中的艾滋病患病率、未确诊是否感染，以及艾滋病检测 美国五个城市，2004 年 6 月到 2005 年 4 月。MMWR, 54,
6、597-601。,Are HIV prevention efforts working among MSM in the United States?艾滋病病毒预防措施对于美国与同性发生性关系的男性是否有效？,Not as well as anyone would like.并非对任何人都有效。,How can HIV prevention efforts among MSM be made more effective?如何让与同性发生性关系的男性艾滋病病毒预防措施变得更有效？,Ongoing Challenges to Prevention Efforts Among MSM针对与同性发生
7、性关系的男性的艾滋病预防措施的持续挑战,Information: What is risk?信息：存在哪些危险？ positional strategies, negotiated safety, poz/poz sex, undetectable viral loads, PREP/PEP?定位策略、协商的安全、poz/poz 性行为、不可检测的病毒载量、PREP/PEP,Ongoing Challenges to Prevention Efforts Among MSM针对与同性发生性关系的男性的艾滋病预防措施的持续挑战,Information: Which information mat
8、ters?信息：有哪些重要信息？ Skill sets and knowledge of own goals in sex vs. memorization of risk calculus技能设定与自己的性目标知识 vs 危险演算记录,Ongoing Challenges to Prevention Efforts Among MSM针对与同性发生性关系的男性的艾滋病预防措施的持续挑战,What are the motivations for safe sex?安全性行为的动机是什么？ Who bears the responsibility for safety? How does saf
9、ety work in a world without disclosure?谁承担安全责任？如何在不披露实情的情况下开展安全工作？,Ongoing Challenges to Prevention Efforts Among MSM针对与同性发生性关系的男性的艾滋病预防措施的持续挑战,Context: Do other health issues affect risk?背景：其他健康问题是否会影响感染危险？ Syndemic effects on increasing risk艾滋病综合流行现象对于日益增加的危险的影响,Intertwining Epidemics among Urban
10、MSM (Significant OR estimates, controlling for age, education, race, income, HIV status and sexual risk)城市里与同性发生性关系的男性交叉感染（重大优势率估值以及年龄、教育、种族、收入、艾滋病病毒感染状况与性交危险控制),Intertwining Epidemics Predict HIV Prevalence and High Risk Sexual Behavior交叉感染流行病预测艾滋病感染率和高危性行为,All associations have ps 0.001. All p val
11、ues are two-tailed.所有群体的 p 0.001，p 值均为双尾。,From Stall et al., 2003资料得自 Stall et al., 2003,Ongoing Challenges to Prevention Efforts Among MSM针对与同性发生性关系的男性的艾滋病预防措施的持续挑战,Context: Addressing Violence and Stigma背景：解决暴力与耻辱 Violence and stigma among youth create syndemic interconnections between psychosocia
12、l conditions and HIV among minority communities青年人之间盛行的暴力与耻辱感导致少数社区中社会心理状况与艾滋病毒感染的艾滋病综合流行现象的交互影响,Ongoing Challenges to Prevention Efforts Among MSM针对与同性发生性关系的男性的艾滋病预防措施的持续挑战,Context: Community Viral Load 背景：社区病毒载量 Proportion of a population that is HIV seropositive but not accessing treatment艾滋病病毒血清
13、状态呈阳性但未接受治疗的人口比例 Untreated HIV seropositive people have higher viral loads and are more efficient transmitters of HIV infection未接受治疗的艾滋病病毒血清状态呈阳性的病毒载量更高，并能更迅速地传播艾滋病病毒 Increased efficacy of social network approaches to finding unknown positives增强的社交网络方法效能易于发现未知的艾滋病病毒阳性患者,HIV Prevalence and Incidence
14、Black MSM 与同性发生性关系的黑人男性艾滋病感染率与发病率,Initial dx of HIV among MSM ages 13-24 与同性发生性关系的男性艾滋病初值1324 岁 Black 16% ; Latino 13%; White 9% (MMWR, 1/14/00) 黑人 16；拉丁美洲人13；白人 9 (MMWR, 1/14/00) Impact 影响 Ages 15-221522 岁 HIV Prevalence: Black 14%, Latino 7%, White 3% (MMWR, 6/1/01)艾滋病感染率：黑人 14；拉丁美洲人 7；白人 3 (MMWR,
15、 6/1/01) HIV Incidence: Black 4%, Latino 1.8%, White 2.4%. (MMWR, 6/1/01)艾滋病发病率：黑人 4；拉丁美洲人 1.8%；白人 2.4% (MMWR, 6/1/01) Ages 23-292329 岁 HIV Prevalence: Black 32%, Latino 13%, White 7% (MMWR, 6/1/01)艾滋病感染率： 黑人 32%；拉丁美洲人 13%；白人 7% (MMWR, 6/1/01) HIV Incidence: Black 14.7%, Latino 3.5%, White 2.5%. (MM
16、WR, 6/1/01)艾滋病发病率：黑人 14.7 ；拉丁美洲人 3.5 %；白人 2.5 % (MMWR, 6/1/01),Risk for HIV Among AA MSM与同性发生性关系的 AA 男性艾滋病感染危险,Risk behavior = HIV infection 危险行为 艾滋病感染,Research Paradox研究悖论,Samuel et al., 1987,“established risk factors for HIV infection in homosexual/ bisexual men do not explain the differences in HIV seroprevalence or seroconversion rates between blacks and whites.”“同性恋/双性恋男性感染艾滋病确定的危险因素不能解释黑人与白人艾滋病毒血清患病率或血清转化率之间差异。”,Non-gay ID/ Disclosure非同性恋编号/
