【作者】 韩琳；

【导师】 乌正赉； 吕繁；

【作者基本信息】 中国协和医科大学 ， 护理学， 2009， 博士

【摘要】 背景和意义随着我国艾滋病传播模式的转变,性接触已逐渐成为HIV/AIDS的主要传播途径。女性性工作者群体中HIV感染率逐年增高,也使一般人群的感染风险增加。由于安全套的使用受男性知识及意愿的较大影响,在一定程度上限制了其预防作用。因此,研究开发新的既能预防HIV/STI传播、又便于女性使用的措施很有必要。女用安全套及阴道外用杀微生物剂均为女性主导HIV/STI预防措施,研究我国FSWs对其的可接受性将为这两种措施的推广和应用提供理论依据,并具有一定的现实意义。目的通过对我国部分地区FSWs对女用安全套和杀微生物剂可接受性的调查,探讨该高危群体对女性主导HIV/STI预防措施的可接受性及其影响因素。方法本研究采用横断面调查,选择云南德宏、四川乐山、辽宁沈阳三个HIV疫情水平不同的地区,运用定量和定性两种方法收集资料。问卷调查采用方便抽样方法,抽取符合纳入及排除标准的FSWs,用自行设计的问卷调查FSWs的危险性行为,用可接受性量表测量女性主导预防措施的可接受性,数据录入EpiData 3.1软件进行管理,采用SPSS 13.0软件进行统计分析。个人访谈和焦点小组讨论采用目的抽样和滚雪球抽样方法,选取合适的样本,深入了解FSWs对使用杀微生物剂和女用安全套的态度及其影响因素,并用定性分析软件NVIVO 8.0进行编码和分析。结果1.问卷调查共收到合格问卷968份,包括德宏329份,乐山291份,沈阳348份。调查对象中439名(45.4%)来自中档性服务场所,529名(54.6%)来自低档场所;平均年龄28岁;分属于14个民族,其中汉族791名(82.1%):425名(43.9%)单身,24.7%已婚,20.5%离婚或分居、9.4%同居、1.5%丧偶。调查对象有72.0%受过初中及以上教育,208名(21.8%)为小学文化程度,仅59名(6.2%)为文盲;平均月收入约为3200元;111名(11.5%)为外省移民。定性研究共招募访谈对象72人,其中德宏29人、乐山20人、辽宁23人。31人参加个人访谈,41人分6组参加焦点小组讨论。2.调查对象首次从事性交易的年龄平均为25岁,461人(47.6%)目前有主要性伴(指调查对象的丈夫、男朋友或情人),133人(13.7%)有其他性伴(指除主要性伴及金钱交易性伴外的其他性伙伴)。近一个月调查对象的性伴数平均27人,阴道性行为平均32次,503人(52.1%)在阴道性行为中能坚持使用安全套。调查对象与“客人”(指存在金钱交易的性伴)发生阴道性行为的次数明显高于与其他两类性伴的次数(x~2=402.41,P=0.000)。FSWs与性伴发生阴道性行为时,不同性伴的安全套使用率和坚持每次使用安全套的比例各异。FSWs主动要求“客人”使用安全套的比例最高(95.6%),其次为其他性伴(78.9%)与主要性伴(62.1%)。不能坚持使用安全套的首要原因是性伴不喜欢。访谈对象常用的避孕和预防措施是使用安全套。多数FSWs表示能够坚持要求对方使用安全套,不坚持使用安全套的情况和原因主要是同一天发生多次性行为时、熟悉的“客人”或主要性伴、“客人”处于醉酒状态、性伴在性行为过程中私下摘套、为增加收入、使用时感觉不舒服、安全套质量较差、容易影响性伴心理、影响性伴性快感等。3.调查对象中127人自报(13.1%)有性病史,604人(62.5%)做过HIV检测,4人(0.7%)自报HIV抗体阳性,593人(61.5%)有妊娠史,其中442人(74.5%)有流产史。419人(43.3%)使用过阴道润滑剂,481人(50.2%)在阴道里放置过药片、丸、栓剂等治疗感染,850人(88.1%)做过阴道灌洗。近一半调查对象(475人)表示非常担心得性病,近60%调查对象(550人)表示非常担心感染HIV。访谈对象最常用的避孕方法是安全套、口服避孕药、宫内节育器;常用的预防措施为安全套、口服消炎药、慎重选择性伴侣、定期体检、阴道灌洗等。4.调查对象中有189人(19.5%)听说过女用安全套,其中22人(2.3%)使用过女用安全套。女用安全套可接受性平均得分为2.52(满分4分)。单因素分析显示,不同地区、性服务场所档次、性服务场所性质以及收入、婚姻状况、教育水平不同的FSWs,其女用安全套的可接受性得分存在显著性差异(P＜0.01)。调查对象越担心感染HIV/STI,其女用安全套可接受性得分越高,有统计学显著性(x~2=9.69,P=0.008;x~2=6.06,P=0.048)。有妊娠史的调查对象对女用安全套的可接受性得分高于无妊娠史者(Z=-2.38,P=0.017)。Logistic回归分析显示,女用安全套的可接受性与调查地区、是否曾被性伴拒绝使用安全套、“患性病是否与自己有关”以及“患性病是否与性伴有关”的得分关联。大多数访谈对象认为男性不会接受女用安全套。她们认为女用安全套的缺点包括置入方式不佳、外观不雅、内环质地较硬、使用时会发出响声、影响性快感等;优点是可以自己隐蔽置入、保护面积比男用安全套大、便于男性射精等。5.外用杀微生物剂的可接受性得分平均为2.88(满分4分)。不同地区、性服务场所档次、性服务场所性质以及年龄、教育水平、是否主动要求使用安全套、是否被拒绝使用安全套、是否做过HIV检测、妊娠史、阴道药物使用史不同的FSWs,其杀微生物剂的可接受性得分存在显著性差异(P＜0.05)。调查对象越担心感染HIV/STI,其杀微生物剂可接受性得分越高,有统计学显著性(x~2=39.95,P=0.000;x~=32.16,P=0.000)。调查对象与不同类别性伴使用(x~2=47.39,P=0.000)和隐蔽使用(x~2=102.86,P=0.000)杀微生物剂的意愿存在显著性差异。Logistic回归分析显示,杀微生物剂的可接受性与阴道外用药物史、是否曾经被性伴拒绝使用安全套、“患性病是否与自己行为有关”以及担心感染HIV关联。访谈对象对杀微生物剂的态度普遍积极,她们认为男性对杀微生物剂的接受程度可能较高。影响可接受性的因素包括杀微生物剂的产品性质(剂型、置入方式、颜色与气味、包装)、功能特点(效果、起效时间、作用持续时间、副作用)、价格、从众心理等。结论所调查的FSWs最常采用的HIV/STI预防措施是安全套,但坚持使用安全套的比例和安全套使用率仍较低,不能坚持使用的主要原因是男性不愿意或拒绝使用。女性主导HIV/STI预防措施为弥补上述不足提供了可能。FSWs对于女性主导预防措施特别是杀微生物剂的态度普遍较积极,说明女用安全套和杀微生物剂有可能作为安全套的补充,满足女性在HIV/STI预防中的特殊需求。根据本研究结果及文献综述,女性主导的HIV/STI预防措施可接受性主要受产品、使用者及社会文化环境因素的影响。在其推广和应用中,须重视这些因素,以更有效地发挥女性的自主作用。更多还原

【Abstract】 Background and significanceWith the changing of HIV transmission mode,sexual contact has become the most common mode of HIV transmission and the main driver of the epidemic in China.HIV antibody positive rate among FSWs increased year after year,which might increase the risk of HIV transmission to general population.Prevention strategy and measures are sought to adapt to characteristics of HIV epidemic in China.Condom use is affected by knowledge and willingness of men,therefore its protection against HIV is limited in certain degrees.Research and development on HIV prevention methods easier for women to use are needed.Studies on acceptability of women-initiated HIV/STI prevention methods including microbicides and female condom among FSWs will establish important theoretical and practical basis for the future promotion of their use for HIV prevention.ObjectivesTo explore acceptability of women-initiated HIV/STI prevention methods including microbicides and female condom and its related factors among FSWs in three areas of China.MethodsA cross-sectional study was conducted with both quantitative and qualitative methods to collect data in Dehong,Yunnan province,Leshan,Sichuan province and Shenyang,Liaoning province.In the survey,FSWs in accordance with inclusion and exclusion criteria were recruited with convenience sampling.Their risk behaviors and the acceptability scores were measured by self-designed questionnaire and scales;EpiData version 3.1 software was used for data input and management and SPSS version 13.0 software was used for data analysis.In in-depth interviews and group focus discussions, FSWs were recruited by purposive and snowball sampling to gain comprehensive understanding of their acceptability and its related factors;and NVIVO version 8.0 software was used for coding and analysis of qualitative data.Results1.A total of 968 FSWs completed the questionnaires,including 329 in Dehong, 291 in Leshan and 348 in Shenyang.Among the participants,45.4 percent(439) were from medium class sex establishments and 54.6 percent(529) from low class ones. Average age of the participants was 28 years,and they were from 14 ethnics,82.1 percent(791) of whom were Han Chinese.Nearly half of them(43.9%) were single,24.7 percent married,20.5 percent divorced or separated,9.4 percent cohabited,and only 1.5 percent widowed.Majority(72.0%) of them had junior high school education or above, 208(21.8%) had primary school education and only 59(6.2%) never went to school. Their average income during the last month before the survey was about 3200 RMB yuan. Among all the participants,11.5 percent migrated from other provinces.Totally,72 FSWs were recruited in qualitative study,including 29 from Dehong,20 from Leshan and 23 from Shenyang.Thirty-one FSWs participated in in-depth interviews and 41 participated in six group focus discussions.2.Their average age at initiating commercial sex work was 25 years.Totally, 461(47.6%) participants reported to have a primary sexual partner currently,while 133(13.7%) had other sexual partners.In average,each FSW had 27 sexual partners and 32 vaginal sexual encounters,and 503 participants(52.1%) used condom consistently in the past 30 days.Vaginal sexual encounters with paying partners were significantly higher than those with primary and other partners(X~2=402.41,P=0.000).There was statistically significant difference in condom use rate and percentage of consistent condom use among varied types of sexual partners.The percentage of participants who had ever asked their paying,other and primary partners to use condoms was 95.6 percent, 78.9 percent and 62.1 percent,respectively.The main reason for inconsistent condom use with three types of partners was that men do not like using condom.Condom was the most commonly used contraception and HIV prevention methods by the participants. Majority of them reported they could insist on condom use,and the reason why condom was not used in sexual encounter included uncomfortableness of FSWs,poor quality of condom,and less sexual pleasure of their partners.3.Totally,127 of(13.1%) FSWs had ever been diagnosed with an STD;604 (62.5%) had ever had a HIV test;and four(0.7%) were HIV antibody positive.Among 593(61.5%) FSWs who had ever been pregnant,442(74.5%) of them had aborted at least once.A total of 419(43.3%) participants reported experiences with vaginal lubrication,481(50.2%) reported experiences with vaginal pills/suppositories,850(88. 1%) douched their vagina after sex.Nearly half(475) of the FSWs were very worried about contracting STI,and nearly 60 percent(550) were very worried about contracting HIV,with statistically significant difference among study sites(P＜0.001).Score of women’s STI internal locus of control averaged 2.88(with full score of four),that of STI locus of control by their partners averaged 2.58,and that of STI locus of control by chance averaged 1.91.The most frequently used contraception methods by interviewees included condom,oral contraceptive pills and IUD.Besides condom,the most frequently used HIV prevention methods included oral anti-inflammation pills,careful choice of partners,physical examinations,vaginal douching,and so on.4.Among the participants,189(19.5%) had ever heard of female condom,of which 22(2.3%) had ever used it.Mean score of female condom acceptability was 2.52 (with full score of four).Univariate analysis indicated that the score of acceptability varied by the study sites,class and features of sex establishments,income,marital status and education level of the participants.Women who worried more about contracting HIV or STI had a higher acceptability score than those worried a little or not at all(x~2=9.69, P=0.008 and x~2=6.06,P=0.048,respectively).Women who had ever been pregnant had higher acceptability score than those had not(Z=-2.38,P=0.017).Logistic regression analysis showed that female condom acceptability in FSWs were associated with the study sites,their experience of being refused to use condom,STI internal locus of control, and STI locus of control by their partners.Majority of interviewees believed that their partners would not accept female condom use.Disadvantages of female condom included inconvenience in its placement,poor appearance,uncomfortableness of its hard inner ring,embarrassment by noise during sex,less sexual pleasure,and so on.Its advantages included women’s initiative use without knowledge of their partners,more protection area of the vagina than condom,convenience for ejaculation,and so on.5.Mean score of microbicides acceptability for all FSWs surveyed was 2.88(with full score of four).Microbicides acceptability score of FSWs varied by the study sites, class and features of sex establishments,age and education level of FSWs,their experience of asking partners for condom use and being refused by partners,history of HIV test,pregnancy,abortion and vaginal product use(P＜0.05).Women who very worried about contracting HIV or STI had a significantly higher score than those worried a little or not at all(x~2=39.95,P=0.000 and x~2=32.16,P=0.000,respectively).There was statistically significant difference in participants’ willingness to use microbicides (x~2=47.39,P=0.000) and covert use of it(x~2=102.86,P=0.000) among varied types of partners.Logistic regression analysis indicated that microbicides acceptability in FSWs were associated with their experiences of vaginal product use and being refused to use condom by their partners,their STI internal locus of control and worrying about contracting HIV.Interviewees had generally positive response to microbicides use;and they also believed that their partners had a higher acceptability to microbicides.Factors related to their microbicides acceptability included characteristics(forms,placement methods,color and odor,package and storage),function(effectiveness,time of action initiation and persistence,and side effects),price of the products and FSWs’ mentality to follow the majority.ConclusionsCondom is the most frequently used prevention method during sexual encounters with FSWs’ partners.However,percentage of the participants who use condoms in every sexual encounters and condom use rate are still very low.Main reasons why condom is not used consistently include unwillingness and refusal by their partners.The participants have generally positive response to women-initiated HIV/STI prevention methods, especially microbicides,indicating female condom and microbicides may act as supplements to condom and further,satisfy women’s special needs in HIV/STI prevention.Factors related to the acceptability of women-initiated HIV/AIDS prevention methods include characteristics,function and price of the products,FSWs’ individual characteristics,and socio-cultural environmental factors,which should be emphasized to bring women’s initiation into effects during future promotion and application of these methods in order to make sense to HIV/STI prevention.更多还原