【作者】 张燕；

【导师】 王润华；

【作者基本信息】 重庆医科大学 ， 临床检验诊断学， 2011， 博士

【摘要】 研究背景艾滋病流行形势严峻，迫切需要新的安全、有效、可行的生物医学预防措施。艾滋病暴露前预防用药（PrEP）是目前最有前景的HIV生物预防策略，已初步证实其应用于人体的安全性和有效性。我国MSM人群因其规模大，存在大量多性伴和无保护的性行为，是艾滋病新发感染的重要人群和艾滋病传播的桥梁人群，直接影响我国艾滋病的流行程度。因此，MSM人群将是我国PrEP推广的潜在重点人群。了解我国MSM人群对PrEP的知晓和使用意愿及其相关因素，对即将获得进一步临床试验证实的PrEP策略在我国的实施和推广具有重要意义。研究目的（1）了解我国西部MSM人群对PrEP的知晓、使用经历和使用意愿，初步评价PrEP在我国西部MSM人群中实施和推广的可行性；（2）从社会人口学、健康心理学、行为学的角度探索和分析我国MSM人群PrEP使用意愿的相关因素，构建PrEP使用意愿动机模型，探讨PrEP使用意愿形成机制，为制定PrEP的实施和推广策略、促进和保持MSM人群中PrEP的正确和规范使用提出建议。研究方法（1）文献研究和理论研究：通过文献研究的方法系统了解目前PrEP国内国际研究现状，制定研究框架，完成研究设计；通过对健康心理学认知理论的比较研究，结合PrEP相关文献研究提出PrEP使用意愿动机模型假说；（2）调查方法：选择重庆主城区、四川南充、广西南宁和广西柳州四个调查现场，采用滚雪球法、网络招募法，以及通过志愿者的非政府组织招募研究对象，运用定量问卷调查和个人深入访谈相结合的方法收集资料；（3）资料录入和分析软件：采用epidata3.0软件录入，SAS9.1软件和smartPLS软件分析定量数据；MAXqda2007软件整理和分析定性资料。（4）资料分析方法：采用统计描述和统计推断的方法分析定量调查数据，并利用基于PLS的结构方程模型方法验证和求解PrEP使用意愿动机模型，定性访谈资料采用类属分析与情境分析相结合的方法进行分析。主要结论（1）MSM人群对PrEP的知晓率较低，PrEP的实施和推广，需要MSM人群对PrEP的充分知晓和正确理解；低年龄组、学生和城市户口的MSM对PrEP的知晓相对较高；网络、同志工作组、电视和朋友是MSM人群获取PrEP信息的主要途径。少数MSM已开始使用药物预防艾滋病，但目前尚无证据显示有人真正使用过PrEP。（2）安全性和有效性是MSM人群接受PrEP的前提，MSM人群对PrEP药物有较高的安全性和有效性要求。如果证明PrEP的安全性和有效性，MSM人群PrEP的使用意愿较高，PrEP在MSM人群中的实施和推广具有初步可行性。（3）低文化程度、中低收入的MSM人群更愿意使用PrEP，学生、机关企事业单位职员更不愿意使用PrEP；艾滋病知识知晓程度越高越有可能使用PrEP；偶尔或从不在互联网上寻找性伴、曾出现过性病症状、做过HIV免费咨询的MSM人群更愿意使用PrEP；降低需方承担的PrEP费用，开发和选择服用周期更长的PrEP药物，是PrEP使用的促进因素，胶囊制剂是大多数人更接受的药物剂型；疾控中心是MSM人群最愿意获得PrEP药物的机构，网络、电视和MSM人群的志愿者组织是MSM人群认为最容易和最期望的获得PrEP信息的渠道。（4）心理动机因素是影响PrEP使用意愿的内在的和最直接的因素。理论研究和实证研究的结果显示，以保护动机理论为基础的PrEP使用意愿动机模型能够从心理动机因素方面对PrEP使用意愿进行较好的解释和预测，适用于对PrEP使用意愿的分析。威胁感知、反应效益和自我效能正向作用于PrEP使用意愿，反应代价负向作用于PrEP使用意愿。按对PrEP使用意愿影响的大小排序依次为：反应代价、反应效益、自我效能和威胁感知。（5）结构方程模型因其可以同时处理潜变量的测量和潜变量之间的结构关系，可同时处理多个因变量，并允许自变量含有测量误差，在PrEP使用意愿动机模型的求解中具有优势，经过模型的拟合和预测检验，Q2大于0，使用意愿Blindfolding共同因子为0.677，Blindfolding冗余为0.148，模型具有一定预测能力，结构方程模型比较适用于求解PrEP使用意愿动机模型。（6）PrEP使用意愿心理动机因素、其他相关因素以及PrEP使用意愿之间关系分析：不同社会人口学特征的MSM人群，主要由于对PrEP的反应代价不同，以至对PrEP的使用意愿存在差异；艾滋病知识知晓主要通过作用于心理动机因素中的威胁感知，间接作用于PrEP的使用意愿；艾滋病相关行为与PrEP使用意愿通过他们共同的原因变量威胁感知而存在关联；PrEP药物因素和PrEP实施模式因素通过作用于心理动机因素中的三个应对评估变量而影响使用意愿。因此，可以通过对PrEP使用意愿其他相关因素的干预，如艾滋病知识知晓、PrEP药物因素、PrEP实施模式等，降低反应代价，增强反应效益和自我效能，以促进MSM人群对PrEP的使用。同时，可以在PrEP推广过程中，辅以咨询和心理指导，以直接作用于PrEP的心理动机因素，促进PrEP的使用和坚持。建议和设想（1）建议采用“政府主导、CDC管理，医院参与，志愿者组织配合，费用分担”的推广模式；（2）充分利用网络、媒体、MSM志愿者组织等各种渠道，正确宣传和客观报道、传播PrEP知识；（3）继续加强艾滋病相关知识宣传教育，更加全面的宣传艾滋病知识，更加透明化艾滋病流行信息，减少社会大众对HIV感染者的歧视，引导大众更加客观的看待MSM和HIV感染者；（4）采取有力措施预防可能引起的性行为去抑制现象；（5）继续进行PrEP的药物研究，优化服药方案，在PrEP的实施和推广中，建立PrEP监测评价体系，进一步监测评价PrEP的效益，完善PrEP的实施推广模式。更多还原

【Abstract】 Background：The situation of HIV/AIDS epidemic is serious. Anew safe, effective and feasible biomedical prophylaxis measure is urgentlyneeded. The HIV/AIDS pre-exposure prophylaxis (PrEP) is now the mostpromising biomedical prophylaxis for HIV. It has been initially provedthat it is safe and effective for the human being. Because of the big scale,multi sex partners and unprotected sexual behaviors, the MSM is the majorpopulation for new cases of HIV infection as well as the bridge populationfor HIV spreading, who directly impact the extent of HIV spreading inChina. Therefore, MSM will be an important latent population group forPrEP promotion. Knowing the knowledge awareness of PrEP andwillingness to use it among the MSM in China is significantly importantfor the implementation and promotion of PrEP strategy which will soon beproved by clinical trials.Objectives:（1）To know the knowledge awareness, using experience and wiliness to use it among the MSM in Western China in order to initiallyevaluate the feasibility of implementation and promotion of PrEP amongthe MSM in Western China.（2） To explore and analysis factors related to the wilinesssocio-demographically, health psychologically and ethologically in order toestablish the motivation model of willingness to use PrEP and to provideadvices for the establishing of the implementation and promotion strategyand for the correct and standard using of PrEP among MSM.Methods：（1）Literature and theoretic study: The literature study method wasused to know the international and domestic status on PrEP study,establish the study frame and complete the study design. The study on thecognitive theory in health psychology combined with the literature on PrEPwas studied to establish the motivation model of willingness to use PrEP.（2）Investigation methods: Four settings were chosen to do theinvestigation (Chongqing City, Nanchong in Sichuan, Nanning in Guangxiand Liuzhou in Guangxi). Participants were enrolled through thefollowing methods: snow-ball sampling, network enrolling and NGOs.Data were collected through both the method of quantitative questionnairesand in-depth interviews.（3）Data entering and analysis software: Data were entered into theepidata3.0. SAS9.1and smartPLS were used for quantitative data analysis. MAXqda2007were used to collect and analysis qualitativematerials.（4）Data analysis: Quantitative data were analyzed through statisticaldescription and inference. The motivation model was formulated on thebasis of the model of PLS equation of structure. Qualitative materialswere analyzed through both the generic analysis and scenario analysis.Conclusions:（1）The knowledge awareness on PrEP was relatively low amongMSM. It is needed for the MSM to fully know and exactly understand thePrEP for the PrEP implementation and promotion. The MSM of low-age,students and urban residents had relatively high knowledge awareness onPrEP. The newwork, MSM workshops, TV and friends were main waysfor MSM to get PrEP information. A few MSM have already started touse medicines to prevent HIV/AIDS. However, there is still no evidenceto show that there is someone who has exactly used PrEP.（2）Safety and effectiveness are the premise for MSM to accept PrEP.The MSM have relatively high command for the safety and effectiveness.If the two properties of PrEP were proved, the MSM would more willing touse it. There is initiative feasibility for the implementation and promotionof PrEP among MSM.（3）The MSM with low educational degree and low-middle incomewere more likely to use PrEP while students and officials in government/institutes/enterprises were less likely to use it. the higher theknowledge awareness on HIV/AIDS the stronger the willingness to usePrEP. The MSM who occasionally or never found sex partners on the net,ever had STD symptoms and went for free HIV/AIDS consultation weremore likely to use PrEP. Lowering the PrEP costs paid by buyers anddeveloping/selecting medicines with longer oral taking intermittent areprecipitating factors for PrEP taking. Most participants were likely tochoose capsule as the form of the medicine. Participants were mostwilling to get PrEP in CDC. The network, TV and MSM workshops werethe easiest and most expected ways to get PrEP information for the MSM.（4）The psychological factor is the inner and direct factor impactingthe willingness to use PrEP. The theoretical and empirical study show thatthe motivation model of willingness to use PrEP based on protectivemotivation theory can explain and predict the willingness from the aspectof psychological motivation, which is fit to the analysis of willingness touse PrEP. The threat perception, response efficacy and self-efficacypositively influence the willingness while response costs negativelyinfluences it.（5）The structural equation model can deal with the structuralrelationship between the measure of latent variables and latent variablesand deal with more than one dependent variables allowing measure error ofindependent variables, which has advantages in formula of motivation model of using PrEP. The results of least squares fitting and predictivetest are as the following: Q2>0, Blindfolding communality ofwillingness=0.667, Blindfolding redundancy=0.148. The model has certainpredictive function and relatively suitable for the formula of the motivationmodel of willingness to use PrEP.（6）Analysis on the relationship among the willingness relatedfactors, psychological motivation factors and the willingness: MSM withdifferent socio-demographical characteristics have different response costsfor PrEP, so there are differences among their willingness. Theknowledge awareness on HIV/AIDS mainly impacts on the threatperception in the psychological motivation factors and thus indirectlyimpacts on the willingness. The HIV/AIDS related behaviors andwillingness to use PrEP are reacted through their common reason variable(threat perception). The medicine factor and implementation model factorimpact the willingness through acting on the three coping appraisalvariables in psychological motivation factors. Therefore, interventionscould be carried out on the other relevant factors of willingness, such asknowledge awareness, medicine factors, implementation model et al, tolower the response costs and strengthen the response efficacy andself-efficacy and thus promote the using of PrEP among MSM.Meanwhile, during the promotion process of PrEP, consultation andpsychological could be used to directly impact the psychological motivation factors and thus promote the using and continuity of PrEP.Suggestions and assumptions:（1）The promotion model of “government leading, CDC managing,hospitals joining, volunteers organizing and coordinating, cost sharing” issuggested.（2）Various publicizing ways, such as the network, media, MSMNGOs and so on, should be used for exact and objective report of thePrEP trial and dissemination of PrEP relevant knowledge.（3）The health education on HIV/AIDS prevention should beenhanced, the publicizing of HIV/AIDS knowledge should be moreextensive and the epidemic of HIV/AIDS information should be moretransparent to reduce the discrimination of common people for HIVinfection and to guide common people to treat MSM and HIV infectedpeople more objectively.（4） Strong measures should be carried out to prevent thephenomenon of sexual behavior disinhibition.（5）The study on PrEP should be continued to optimize themedication scheme. During the implementation and promotion of PrEP, themonitoring and evaluating system of PrEP should be set up to furthermonitoring and evaluation of the efficiency of PrEP and further perfect theimplementation and promotion model of PrEP..更多还原