【作者】 许奕华；

【导师】 聂绍发；

【作者基本信息】 华中科技大学 ， 流行病学， 2008， 博士

【摘要】 一、研究目的1、通过了解湖北省在HIV感染者的发现、流调、追踪和管理的现状,对其工作模式中存在的问题进行分析研究,提出相应的政策性建议,为今后进一步制定艾滋病防治工作计划和策略提供科学的依据;2、对湖北省历年来艾滋病流行特点和趋势的全面分析,为预防控制策略的修订提供科学的依据;3、探讨艾滋病患者HAART治疗效果,综合评价在策略指导下所取得的治疗效果,为提高艾滋病患者的疗效和改善预后提供科学依据;4、探讨湖北省随州市有偿献血AIDS患者的病情特征、生存时间分布特征及其影响因素,以及评价防治策略和措施效果;5、探讨HIV感染者/AIDS患者的生存质量及其影响因素,为预防控制策略的修订提供科学的依据;6、对湖北省因受血或使用血液制品感染艾滋病问题展开研究,为因受血或使用血液制品感染的艾滋病人群救助政策制定研究方案提供依据。二、研究方法1、采用社会学方法资料定性分析、焦点小组访谈、专家咨询法等对各地针对艾滋病感染者发现、流调、追踪及管理所采取的现有措施进行评价。2、采用现况研究方法,对湖北省网络直报系统的各市、县1995年至2005年疫情监测、哨点监测资料及2004年、2005年综合监测资料,进行系统分析。3、采用流行病学描述性研究的方法,从五个纬度对随州市181名艾滋病患者治疗后临床症状,病毒载量和免疫功能的改变情况进行描述,用Epidata双人录入数据,SPSS13.0建立数据库,并进行统计学分析。4、采用历史队列研究的方法,收集随州市经有偿献血感染的141例AIDS患者的病情、生存时间及其影响因素信息。用K-M法描述其生存时间,用Cox比例风险模型分析影响因素。5、采用WHOQOL-HIV-BREF及自制的一般情况调查表对湖北省4个地区的166名HIV /AIDS患者进行调查。比较HIV感染者/AIDS患者各领域的生存质量得分和全国常模的差异,采用一般线性回归模型分析生存质量的影响因素。6、应用新闻学方法和卫生管理方法进行艾滋病防治工作模式研究。三、结果1、从湖北省各地第一例艾滋病感染者的发现和确认过程中,了解各地解决对艾滋病感染者的发现、流行病学调查、追踪与管理方面存在的问题及主要困难,并提出了解决这些问题的措施和策略。2、目前湖北省艾滋病感染情况较为严重,特别是04、05年感染人数明显增多。艾滋病的主要传播途径有:有偿供血(44.17%)、性接触(9.91%)、输血(9.47%)。感染者年龄多集中在16~45岁(74.11%)。艾滋病的高危人群的感染率仍然很高,虽然暗娼的感染率有所降低,但是吸毒者感染率仍持续增高。3、对不规则发热、咳嗽、腹泻、淋巴结肿大、体重下降、皮疹、真菌感染有效率分别为81.39%,85%,84.62%,81.89%,82.86%,66.07%,45.45%。用药后CD4+T淋巴细胞计数明显升高,三个月CD4+T淋巴细胞计数平均为276×106cells/ml(65~824×106cells/ml),上升129×106cells/ml。六个月CD4细胞计数平均为294×106cells/ml(102~750×106cells/ml)。用药后六个月与三个月相比较无明显变化。停药者中死亡人数14例,病死率29.79%;未停药者死亡人数3例,病死率2.24%。4、艾滋病主要死亡原因为严重感染、脏器衰竭和HIV脑病。141例患者总死亡率为78.04/1000人月,AIDS相关死亡率为71.43/1000人月。中位生存时间为6.00个月,95%可信区间为5.54～6.46个月。就诊或检出时状态、发病年代、是否经联合抗病毒治疗对生存时间有影响。5、除精神支柱/宗教/个人信仰领域外,HIV感染者/AIDS患者其他领域的得分均低于全国常模。多因素分析显示,性别、职业、文化程度、CD4+T细胞计数、症状数及HAART治疗对PLWHA生存质量的影响有统计学差异。WHOQOL-HIV-BREF各领域及总的Cronbach’s Alpha均大于0.6,准则关联效度的person相关系数为0.735(p<0.01)。6、虽然各地采取了措施后在现阶段解决了大部分感染者及病人眼前的基本问题,而且我国没有统一的救助标准。随着新发现的感染者和病人的增多,纠纷处理协调的工作量很大,在精神和经费支出上造成很大的压力,严重影响各地工艾滋病的防治工作。四、结论1、在进行艾滋病病毒的检测发现、流调、追踪及管理工作,要依法管理和教育,动员群众积极参与,保护广大人群免受感染和维护感染者及病人的合法权益,教育艾滋病病毒感染者改变不良行为,不危害他人。对于易感人群,也要加强宣传教育,使他们在社会上可以方便地获得一定的预防手段。2、湖北省虽未有艾滋病大规模流行的情况发生,但存在的问题仍不容忽视,进行积极有效的艾滋病防治工作已势在必行。3、高效抗逆转录病毒治疗可明显改善艾滋病患者的临床症状,并可有效降低病毒载量,而提高临床依从性是可以降低病死率。4、随州市AIDS患者病情较严重,生存时间较短。HAART能够延长生存时间。今后应针对各地特点,加强该地区AIDS的综合防治防治力度。5、HIV感染者/AIDS患者的生存质量普遍较低。推广APPRT治疗时应引导患者规范治疗。在建立综合关怀服务体系时,应更多地照顾到弱势群体及农村人群。WHOQOL-HIV-BREF信度效度尚可,也比较简明省时,但不适合我国文化背景的条目需要修改。6、为解决湖北省因受血或使用血液制品感染艾滋病问题,提出了近十条符合我国国情的政策性建议。主要创新点:1、本研究首次在湖北省艾滋病防治工作中,针对艾滋病的病毒的检测发现、流调、追踪及安置管理措施,提出了合理的工作模式;2、首次综合评价了湖北省艾滋病患者经HAART疗法治疗后所取得的临床效果,证明了在策略指导下所取得的治疗效果,为提高艾滋病患者的疗效和改善预后提供科学依据。3、本研究首次提出了因受血感染艾滋病人群救助政策,为湖北省顺利解决由该人群救助问题提供了科学依据,并为卫生部指导其他兄弟省市解决类似问题提供了决策建议。更多还原

【Abstract】 Objective1.To understand the status of HIV-infected individuals’finding, epidemiological investigation, tracing and management, and analyze existing problems in the working mode, put forward relevant suggestions, finally provide some scientific evidences for further constituting plans and strategy to prevent and control AIDS.2.To analyze AIDS prevalent characteristics and trend completely in the past years in Hubei province, and then provide scientific evidences to perfect strategy of prevention and control.3.To study the post-treatment clinical effect by highly active anti-retroviral therapy (HAART) in AIDS patients and provide scientific basis for improving the curative effect and prognosis.4.To analyze the pathogenetic condition, survival and related factors of AIDS patients among paid blood donors in Suizhou city of Hubei province, evaluate the effect of strategy and measure for prevention and control.5.To study the life quality of HIV/AIDS patients and its related factors, and provide scientific evidence to perfect strategy of prevention and control.6.To have an investigation to the problem that people were infected by HIV via blood transfusion or using blood goods, and provide some evidences to investigation scheme for instituting salvation policy to AIDS patients who were infected by blood transfusion or using blood goods. Method1.To assess present measures that were adopted in allusion to the finding, epidemiological investigation, tracing and management of patients with AIDS by using qualitative analysis of sociological method, focusing grouping discussion, expert consultation, and so on.2.By adopting cross-sectional study, to have a systematic analysis to point surveillance materials from 1995 to 2005 which were collected by network direct report system in all cities and counties of Hubei province, and comprehensive surveillance materials in 2004 and 2005.3.An epidemiological method was used to describe the post-treatment clinical symptoms of 181 AIDS patients in Suizhou from five aspects, and to evaluate the change of virus load and immune function of 79 AIDS patients. Data was doubly recorded in Epidata and database was set up by using SPSS13.0 to analyze.4.A retrospective cohort study was carried out to determine the pathogenetic condition, survival time and related factors of 141 AIDS patients who were infected through paid blood donation. Kaplan-meier method was used to describe the survival distribution and Cox proportional hazard model was used to analyze the factors associated with the survival.5. A cross-sectional study was carried out to166 HIV/AIDS people in Hubei province. Life quality was measured by WHOQOL-HIV-BREF,the Sociodemographic variables was examined by the self-made questionnaire. Compared life quality scores of HIV/AIDS patients with normal model nationwide, and multiple linear regression was used to examine the influencing factors of life quality.6.To explore work model of AIDS prevention and control by using journalism means and hygiene administration method.Result1.From the process that the first AIDS patient in each place of Hubei province was found and identified, to understand the main problems and difficulties in AIDS patients’finding, epidemiological investigation, tracing and management, and propose measures and strategy to solve the problems.2.At present, the HIV-infected situation is very serious in Hubei province. In particularly, the infected individuals have increased obviously. The main transmission routes of AIDS are paid selling blood(44.17%), sex contact(9.91%), blood transfusion(9.47%). The age of infect patients mainly concentrated between 16 and 45 years (74.11%). The infected rates of AIDS risk population is still in a high level. Although infect rate of prostitutes decreased, it is increasing persistently in injection drug users.3. The effective rate of irregular fever, cough, diarrhea, lymphadenectasis, weight loss, tetter, mycotic infection is 81.39%, 85%, 84.62%, 81.89%, 82.86%,66.07%and 45.45%, respectively. CD4+ T lymphocyte count obviously rose after treatment, its mean was 276×106cells/ml (65~824×106cells/ml ) and added 129×106 cells/ml in three months. The mean was 294×106cells/ml (102~750×106cells/ml ) in six months. The count change of CD4+ T lymphocyte between 3 months and 6 months had no obvious difference. The death cases in patients who discontinued therapy were 14, case fatality rate was 29.79%; and the death in patients who insisted therapy persistently was 3, case fatality ratewas2.24%.4.Serious infection, organ failure and AIDS cerebropathia were the main cause of death. Of the 141 AIDS cases, the total mortality was 78.04/1000 p-m and AIDS related mortality was 71.43/1000 p-m. The median survival time was 6.00 months(95% Confidence Interval: 5.54～6.46 months). The median survival time was related to the clinical stage when they saw the doctor or they were detected HIV positive and the period when they felt ill and received HAART.5.Except for Spirituality/Personal beliefs domain, the scores of the other five domains and overall life quality and general health perceptions were significantly lower than normal model nationwide. Multiplicity showed that sex, career, culture, CD4+ T cell count, symptom count and HAART had a significant difference to the influence of PLWHA life quality. Each field of WHOQOL-HIV-BREF and total Cronbach’s Alpha exceed 0.6. The Pearson coefficient of criterion related validity was 0.735(p<0.01).6.Although most current problems of HIV-infected persons and patients are solved at the moment by some measures in various places, there aren’t uniform helping standard in our country. With the increase of new infected persons and patients, the workload of dealing with dissensions is very heavy. It causes huge pressure in energy and outlay, and influences the work of AIDS prevention and control severely in each place.Conclusion1. While testing and finding out HIV, performing the epidemiological investigation, tracing and management, we should manage and educate the masses according to the law, mobilize the masses to participate actively, protect the population from infecting and stick up for the legal rights of the infected individuals and the patients, educate the patients with HIV to change their bad behavior and not do harm to others. For the susceptible population, we also need to reinforce publicity and education to make them get certain prevention easily.2. Although there was never a large-scale epidemic of AIDS in Hubei province, but the existing problems should not be ignored. So the positive and effective AIDS prevention and treatment are imperative.3. This research shows that HAART can improve the AIDS patients’clinical symptom obviously, and decline virus load, and improving the clinical compliance can reduce the case fatality rate.4. The AIDS patients were seriously ill in Suizhou city, they had a poor life quality, and the survival time was short. HAART is an effective approach to prolong survival of AIDS patients. We should enhance the interventions according to the local epidemic characteristics.5 The life quality of HIV/AIDS patients is significantly low. It is necessary to guide patients to treat regularly in extending HAART. The comprehensive care model should have been established more for the poorest population and peasants. The WHOQOL-HIV -BREF was demonstrated with good reliability and validity, and it is concise and can save time. However, the items which are unfit to our country’s background need modifying.6. To solve the problem that the population was infected HIV by using the blood or blood products in Hubei province, 10 policy proposals according to our national conditions were suggested.Main innovations1. This research put forward a reasonable work mode according to the detection and find of HIV, epidemiological investigation, trace and management for the first time in Hubei province.2. It has a comprehensive assessment of clinical remedial effect of AIDS patients after HAART for the first time, prove the remedial effect under the strategy guide, and provide scientific basis for improving the remedial effect and prognosis of the AIDS patients.3. This research put forward a helping policy firstly for the ones who infected HIV via the blood transmission, provides scientific basis for the salvation of this population, and also suggestion to other provinces on solving familiar problems.更多还原