[教育]有關(guān)檢測的咨詢：重復(fù)檢測msm的新方法-powerpointpresenta

1、Counseling Associated with Testing: A New Approach for Repeat Testing MSM有關(guān)檢測的咨詢：重復(fù)檢測 MSM 的新方法,James W. Dilley, MDJames W. Dilley 醫(yī)學(xué)博士、Professor of Clinical Psychiatry臨床精神醫(yī)學(xué)教授、Vice-Chair, UCSF Dept. of PsychiatryUC

2、SF（舊金山加州大學(xué)）精神醫(yī)學(xué)學(xué)院副院長Chief of Psychiatry, SF General Hospital and Executive Director, UCSF AIDS Health Project兼 UCSF 艾滋病衛(wèi)生項目精神醫(yī)學(xué)專家，舊金山總醫(yī)院院長兼主任,Acknowledgements致謝,William Woods, 博士, James Sabatino, Barb Adler,Richard Br

3、and, PhD, Willi McFarland, 醫(yī)學(xué)博士 (UCSF/SF DPH)Men attending AHP’s VCT sites 所有參加 AHP（層次咨詢）和 VCT （自愿咨詢檢測）的男性Bill and Melinda Gates Foundation Bill and Melinda Gates 基金會,Goals for today今天的目標(biāo),Provide background on

4、 counseling assoc’d w/testing and review our two published studies on “repeat tester” intervention, PCC 提供有關(guān)檢測咨詢的背景，并回顧我們已發(fā)表的兩項關(guān)于“重復(fù)檢測”干預(yù)的研究，PCCDiscuss other individual prevention interventions 討論其他個人預(yù)防干預(yù)方法,

5、Background on Repeat Testers重復(fù)檢測的背景,Despite years of intense AIDS prevention messages, roughly 900 men who have sex with men (MSM) acquire HIV infection each year in San Francisco 盡管多年來大力宣傳預(yù)防艾滋病，每年在舊金山仍大約有 900 名

6、與同性發(fā)生性關(guān)系的男性 (MSM) 感染 HIV A group at particularly high risk is MSM who repeatedly test for HIV MSM 是高危險人群，應(yīng)重復(fù)做 HIV 檢測 In London, MSM who tested 3 or more times reported more UAI than MSM testing fewer times (Reita

7、g, 2000). 在倫敦，報告表明那些參加三次或是更多次檢測的 MSM 比參加檢測次數(shù)較少的 MSM 進(jìn)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 o

8、f MSM with 1 or 2 previous tests (Dilley, 1993). For some, repeated HIV neg tests conveyed the “wrong” msg re: the client’s behavior. 在舊金山，相對于僅參加一兩次預(yù)先檢測的 MSM ，平均參加 3 次或更多次事先檢測的 MSM 進(jìn)行 UAI 概率更大，而艾滋病毒的感染率是前者 3 倍（D

9、illey ，1993 年）。對一些人來說，HIV 陰性的重復(fù)試驗轉(zhuǎn)達(dá)了患者行為的“錯誤”信息。New prevention intervention s are clearly needed for this group 對于這樣的人群來說新的預(yù)防措施顯然是必要的,“The Stories We Tell Ourselves”: A New Approach我們的研究告訴自己：一個新方法,?Adapted fr

10、om Australian psychologist Ron Gold’s work focusing on “self-justifications” & “on-line” vs. “off-line” thinking 改編自澳大利亞心理學(xué)家 Ron Gold 的著重于“自我辯解” 、“在線”與“離線”思想的著作 ? 1994- Sydney/Melbourne: 300+ MSM from bars/bathh

11、ouses 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/墨爾本：300 多名在酒吧/浴室活動的 MSM 近期關(guān)于 UAI 的狀況：利用性

12、愛日志和完成自我辯解調(diào)查問卷以及查閱安全性行為的海報進(jìn)行為期 16 周的書面干預(yù)? Outcome: Both groups “slipped” following intervention, but SJ questionnaire group was less likely to do so subsequently 結(jié)果：在干預(yù)后兩組均有“下滑”，但是自我辯解問卷調(diào)查組不太可能以后也這樣做,Study 1: Obj

13、ectives研究項目1 ：目標(biāo) 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 描述重復(fù)尋求艾

14、滋病毒檢測的 MSM 在上次未采取保護(hù)措施肛交高危行為時的想法范圍和頻率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 futur

15、e high risk activity 評估某一著重于參與高危性行為的人員想法、態(tài)度或信念的單一咨詢干預(yù)對將來減少高危性行為是否有效,,Methods: Participants方法：參與者,MSM (N=255) were screened and recruited for a counseling intervention trial when scheduling an anonymous HIV antibod

16、y test 在安排匿名 HIV 檢測時共有男同性戀者 (N=255) 進(jìn)行了咨詢干預(yù)試驗篩選和招募Eligibility criteria were men who: 合乎標(biāo)準(zhǔn)的男子有：Had unprotected anal sex with a man who was HIV+ or of unknown serostatus in the last year 在過去的一年里與 HIV 陽性或未知血清狀態(tài)

17、的男性發(fā)生過未采取保護(hù)措施的肛交Had previously tested HIV-negative 曾經(jīng)檢測出 HIV 陰性Did not inject drugs 沒有注射毒品,Study Design研究設(shè)計,Randomized, controlled, longitudinal counseling intervention trial 隨機(jī)法，對照法，縱向咨詢干預(yù)試驗法Conducted in a

18、n anonymous testing site in San Francisco 在舊金山匿名檢測地點進(jìn)行Primary outcome: # episodes of UAI with partner whose serostatus was unknown or known to be positive in previous 90 days 主要結(jié)果：擁有血清狀態(tài)不明或在過去的 90 天內(nèi)呈陽性的性伴侶的 U

19、AI 狀況,Study Design研究設(shè)計,Randomized to four groups:隨機(jī)分為四組：A1: Standard counseling, no diaryA1：標(biāo)準(zhǔn)咨詢，無日志A2: Standard counseling, diaryA2：標(biāo)準(zhǔn)咨詢，有日志B1: Intervention counseling, no diaryB1: 干預(yù)咨詢，無日志B2: Int

20、ervention counseling, diary B2：干預(yù)咨詢，有日志,Self-justification counseling questionnaire自我辯解調(diào)查問卷,Adapted from Gold et al. (1991) 改編自 Gold 等。（1991 年）Asked to rank how strongly each of 102 potential items

21、featured into their thoughts at the moment just preceding the act 要求他們在行動前為當(dāng)時腦中出現(xiàn)的 102 種潛在欲望的強(qiáng)烈性進(jìn)行排序,Self-Justification Items自我辯解名錄,“I want to have unprotected sex because it feels good.” “我想要未采取保護(hù)措施的性愛，因為那樣感覺很好

22、?！薄癢e take chances every day--after all, it’s even taking a chance crossing the road. Taking a risk is a part of life.” “畢竟我們每天都在冒險，甚至過馬路時都有危險。冒險是生活的一部分”“I didn’t want to fuck without a condom but I was so horny

23、 I couldn’t think properly” “我并不是不愿戴避孕套做愛，但當(dāng)時太沖動了，根本不能正常思考”,“At the time I decided to fuck without a condom, I told myself…”當(dāng)時我決定不用保險套做愛，我對自己說……,S-J’s can…..自我辯解能夠……,Make an idea that generally seems like a bad id

24、ea seem like a good one 使一些通?？磥聿辉趺锤呙鞯闹饕饪雌饋硐袷呛弥饕釬unctions as an excuse 作為借口Make an activity at least temporarily, “guilt free” 使某種行為變得“不愧疚” - 至少暫時是這樣Make a problem someone else’s responsibility 將問題責(zé)任推卸到

25、別人身上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 在某種情況下假裝比擁有很多信息，雖然實際上沒有這么多；或者忽略某種當(dāng)時你不想知道的信息,Additional sessi

26、on; post risk-assessment, pre disclosure其他會談：事后危險評估、事前披露1 hour with licensed therapist執(zhí)業(yè)臨床醫(yī)生 1 小時治療begun by participant’s “telling his story”; focus on details, mood, sexual decision-making以參與者的“自述”開始；著重于細(xì)節(jié)、情緒、性行為決定

27、過程discussion of participant’s responses to self-justification questionnaire討論參與者對自我辯解問卷調(diào)查的回答,Intervention Group: Cognitive Focused Counseling干預(yù)組：著重于認(rèn)知的咨詢,Standard: “Client-Centered Counseling”標(biāo)準(zhǔn)：“以患者為中心的咨詢”Preve

28、ntion Counseling method CDC: 1993CDC 預(yù)防咨詢法：1993,An interactive, risk reduction counseling approach with HIV testing that helps the client to 互動式危險降低咨詢法，附帶 HIV 檢測，幫助患者：take a GENERAL personal inventory of risks and th

29、e context and situations in which personal risk occur, and列出總體個人危險清單及發(fā)生個人危險的背景和情況，并且 commit to small, achievable behavior change steps that will reduce personal HIV risk.致力于較小且切實可行的行為改變，這些改變能夠降低個人 HIV 危險。support cli

30、ent in RR steps already made.支持已采取 RR 措施患者。,Demographics人口統(tǒng)計資料,N=12476% white, 11% Latino, 7% API76% 白人，11% 拉丁美洲人，7% APImedian 6 previous tests以前做過 6 次檢測（中值）Average age: 33.2平均年齡：33.2,N=12473% white, 11% Latino

31、, 6% API76% 白人，11% 拉丁美洲人，7% APImedian 6 previous tests以前做過 6 次檢測（中值）Average age: 33.7平均年齡：33.7,Controls對照組,Counseling Intervention咨詢干預(yù)組,,Participants – Risk Behavior參與者 – 危險行為,median 5 anal sex partners in last

32、12 months最近 12個 月與 5 人進(jìn)行肛交（中值）Median 2 unprotected anal sex acts in last 90 days最近 90 天內(nèi)有 2 次未采取保護(hù)措施的肛交（中值）47.6% history of STD47.6% 有性病史,Controls對照組,Counseling Intervention咨詢干預(yù)組,,median 5 anal sex partners in las

33、t 12 months最近 12個 月內(nèi)與 5 人進(jìn)行肛交（中值）Median 2 unprotected anal sex acts in last 90 days最近 90 天內(nèi)有 2 次未采取保護(hù)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)

34、 with non-primary partners of HIV-positive or unknown serostatus in the preceding 90 days by study arm.圖2. 前面 90 天內(nèi)與 HIV 呈陽性或血清狀態(tài)未知的非固定性伴進(jìn)行未采取保護(hù)措施肛交 (UAI) 行為的平均減少次數(shù)（按研究組）。,*,*Significantly fewer episodes compared to A1,

35、 Wilcoxon rank sum test, p < 0.05. *與 A1 相比，次數(shù)顯著減少，Wilcoxon 秩和檢測，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 J

36、W、Woods J、Sabatino J 等。“改變男同性戀者的性行為，重復(fù)檢測 HIV“ JAIDS 2002; 30:177-186.,Conclusions結(jié)論,A 90-day sexual diary, self-justification counseling or both, significantly reduced UAI with non-primary partners of unknown or HIV+ st

37、atus at 6 and 12 months when added to standard counseling and testing將 90 天的性愛日志、自我辯解咨詢，或兩者都添加到標(biāo)準(zhǔn)咨詢和檢測時，在 6 個月 和 12 個月時間內(nèi)，與血清狀態(tài)未知或 HIV 呈陽性的非固定性伴侶進(jìn)行未采取保護(hù)措施肛交的次數(shù)顯著減少The mean reduction in episodes of UAI (partner) was als

38、o significantly reduced among the intervention conditions with the greatest reduction in self-justification only group.在干預(yù)情形中，未采取保護(hù)措施肛交行為的平均減少次數(shù)也顯著減少，且最大減少量出現(xiàn)在僅出現(xiàn)在自我辯解組中。,Conclusions (continued)結(jié)論（續(xù)）,Standard client-

39、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標(biāo)準(zhǔn)的以患者為中心的咨詢從基線到 6 個月之間，與非固定性伴進(jìn)行的未采取保護(hù)措施肛交次數(shù)沒有出現(xiàn)明顯的下降，此數(shù)

40、字返回到基線The diary condition was half as effective as self-justification counseling only日志情形的效果只有自我辯解咨詢的一半,Conclusions (continued)結(jié)論（續(xù)）,This self-justification counseling has a strong, practical appeal此自辯解咨詢有一種強(qiáng)烈的實際需求S

41、ingle session一次性會談“Low cost”“低成本”Applicable for a high risk population voluntarily accessing a service適合自愿接受服務(wù)的高危人群But, is it realistic? 但是，這現(xiàn)實嗎？,Study 2: 研究項目 2：Can this approach be adapted for the “Real Wo

42、rld” of counseling and testing?這種方法能適用于“真實世界”的咨詢和檢測嗎？,Collaborators協(xié)同研究者,William J. Woods, PhD*William J. Woods，博士*Lisa Loeb, MPHLisa Loeb，公共衛(wèi)生碩士Kimberly Nelson, BAKimberly Nelson，學(xué)士Nicolas Sheon, PhD*Nicolas Sh

43、eon，博士*Joseph Mullan, PhDJoseph Mullan，博士Barbara Adler, LMFTBarbara Adler，婚姻治療師Sanny Chen, MHS^Sanny Chen，信息處理系統(tǒng)^Willi McFarland, MD, PhD*^Willi McFarland，醫(yī)學(xué)博士*^,** University of California, San Francisco

44、 Center for AIDS Prevention Studies** 加利福利亞大學(xué)，舊金山艾滋病預(yù)防研究中心^ San Francisco Dept. of Public Health^ 舊金山公共衛(wèi)生部,Objective目標(biāo)Oct 2002-Sept 20042002 年 10 月 — 2004 年 9 月,To assess whether a single counseling intervention

45、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 評估當(dāng)輔助顧問在進(jìn)行單獨咨詢干預(yù)時，此單獨的

46、著重于參與者在高危性行為下的想法、態(tài)度或者信念的咨詢干預(yù)在減少未來高?；顒臃矫媸欠裼行educed SJQ length 減少自我辯解問卷的長度Incorporated counseling session into standard 2 session approach 將咨詢會談并入標(biāo)準(zhǔn) 2 會談方法,,Methods: Participants方法：參與者,HIV- MSM (N=336) were r

47、ecruited when scheduling an anonymous HIV antibody test HIV-MSM (N=336) 從一次匿名的 HIV 抗體檢測中招募Eligibility criteria: 資格標(biāo)準(zhǔn)：Had unprotected anal sex with a man who was HIV+ or of unknown serostatus in the last year w

48、ho was not a “boyfriend or regular partner” 在過去一年中與一位攜帶 HIV 陽性或者血清狀態(tài)未知的非男友或固定性伴侶的男性進(jìn)行過不采取保護(hù)措施的肛交Had previously tested HIV-negative 之前檢測出 HIV 陰性Did not inject drugs 未注射毒品,Study Design研究設(shè)計,Randomized, controlle

49、d, counseling intervention trial隨機(jī)、對照、咨詢干預(yù)試驗Personalized Cognitive Counseling (PCC) vs. Usual Counseling (UC--Client Centered)個人化認(rèn)知咨詢 (PCC) 與普通咨詢（UC — 以患者為中心）Conducted in an anonymous testing site in San Francisco 在

50、舊金山的匿名檢測點進(jìn)行Primary outcome: change from baseline in # episodes of UAI with any non-primary partner of non-concordant serostatus in preceding 90 days主要結(jié)果：在之前 90 天內(nèi)，與任何血清狀態(tài)不一致的非固定性伴侶進(jìn)行的未采取保護(hù)措施肛交次數(shù)基線出現(xiàn)變化 Assessed at 6

51、and 12 months在第 6 個月和第 12 個月進(jìn)行評估,RED2 DemographicsRED2 人口統(tǒng)計資料,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 次檢測（中值＝8）Average age: 35.5平均年齡：35.5,N=1

52、4768% 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 次檢測（中值＝7）Average age: 35.5平均年齡：35.5,Control對照組,Counseling Intervention咨詢干預(yù)組,,No significant differences,

53、 p<0.05無顯著差異，p<0.05,RED2 Risk BehaviorRED2 危險行為,Mean 5 anal sex partners in last 90 days最近 90 天內(nèi)平均與 5 人進(jìn)行肛交Mean 4.8 unprotected anal sex acts in last 90 days最近 90 天內(nèi)平均有 4.8 次未采取保護(hù)措施的肛交72.2% history of STD72.

54、2% 有性病史,Control對照組,Counseling Intervention咨詢干預(yù)組,,Mean 5 anal sex partners in last 90 days最近 90 天內(nèi)平均與 5 人進(jìn)行肛交Mean 4.2 unprotected anal sex acts in last 90 days最近 90 天內(nèi)平均有 4.2 次未采取保護(hù)措施的肛交62.2% history of STD62.2% 有性

55、病史,No significant differences, p<0.05無顯著差異，p<0.05,RED2 - Desire to change behavior RED2 – 對行為改變的愿望,Control對照組,Counseling Intervention咨詢干預(yù)組,,No significant differences, p<0.05無顯著差異，p<0.05,Extreme: 26%

56、非常愿意：Considerable29%相當(dāng)愿意Moderately25%一般Sightly 3%不太愿意None18%不愿意,Extreme22%非常愿意：Considerable32%相當(dāng)愿意Moderately21%一般Slightly 2%不太愿意None24%不愿意,Attitudes Towards Risk: “Given my beha

57、vior, I could get infected….”對危險的態(tài)度：“我的行為會導(dǎo)致感染……”,Control對照組Strongly agree 31%強(qiáng)烈同意Somewhat49%有一點同意Somewhat disagree 17%有一點反對Strongly disagree 3%強(qiáng)烈反對,Intervention干預(yù)組Strongl

58、y agree 29%強(qiáng)烈同意Somewhat49%有一點同意Somewhat disagree 18%有一點反對Strongly disagree 3%強(qiáng)烈反對,p<.05, no significant differencep<0.05，無顯著差異,Intervention干預(yù),Conducted during th

59、e “pre-test” assessment在“事前檢測”評估期間進(jìn)行Introduction: “Bring to mind a specificepisode” 介紹：“使某人想起某次特殊性行為”Complete SJQ (33 items) 完成自我辯解問卷調(diào)查（33項）Detailed “re-telling” -- prior to, during, and after 詳細(xì)的“重新講述”

60、— 之前、期間和之后Discussion of identified SJ’s 討論已確定的自我辯解Identify different strategies 確定不同的策略Referrals as needed 根據(jù)需要進(jìn)行轉(zhuǎn)介,Figure 2. Mean episodes of unprotected anal intercourse with a non-primary partner of unk

61、nown 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.圖 2. 之前 90 天內(nèi)舊金山與同性發(fā)生性關(guān)系的男性與 HIV 血清狀態(tài)未知或已知血清狀況不一致的非固

62、定性伴侶進(jìn)行未采取保護(hù)措施的肛交的平均次數(shù)，干涉與對照咨詢比較，2002 年至 2004 年,Dilley JW et al: JAIDS 2007 44(5):569-77.Dilley JW 等：JAIDS 2007 44(5):569-77.,Satisfaction滿意度,Standardized survey mailed to all P’s, returned by 75% (no difference by grou

63、p)將標(biāo)準(zhǔn)化調(diào)查郵寄給所有參與者，返回 75%（組間無差異）Control P’s were more likely to對照組參與者更可能agree that “the problems that led me to take an HIV test remained unchanged” (26% vs. 9%, p=0.001)同意“讓我參加 HIV 檢測的問題仍然沒有改變”（26% 對 9%，p=0.001）Inte

64、rvention P’s were more likely to:干預(yù)組參與者更可能：rate the quality of service as “Excellent” (69% vs. 54%, p=0.022) 將服務(wù)質(zhì)量評為“優(yōu)秀”（69% 對 54%，p=0.022）rate their counselor’s competence as “high”(58% vs. 39%, p=0.005) 將其顧

65、問的能力評為“高”（58% 對 39%，p=0.005）,Conclusions結(jié)論,Both interventions were effecting in reducing high risk sexual behavior兩種干預(yù)對減少高危性行為都有效P’s who received intervention counseling reported change more swiftly and reported high

66、er satisfaction with their counseling experience接受干預(yù)咨詢的參與者表明改變得更快，并且對他們接受的咨詢經(jīng)歷更滿意,How does it work?如何工作？,,,Forming a link between off-line/on-linethinking : when occurs again, better able tocontrol在離線思考和在線思考之間建立一

67、種聯(lián)系：什么時候再次發(fā)生，最好能夠控制2. Personalizing risk thru re-telling and experiencing the affective component of possible negative outcome--contemplating consequences通過重新講述和體驗可能的有負(fù)面結(jié)果的情感成分-自己考慮后果，將危險個人化3. Learning something new a

68、bout one’s internal process; feeling more in control了解某人內(nèi)心歷程新事物；感覺更多事物受到控制,Other Individual Approaches其他個別方法,Informational videos with HIV negative (“Safe City”) and HIV positive (“Video Doctor”)附帶 HIV 陰性（“安全城市”）和 HIV