基于社区的HIV抗体普遍检测和强化随访的效果研究及艾滋病阳性的老年人群特征分析

发布时间：2018-04-10 05:09

  本文选题：HIV普遍检测　切入点：居民健康体检　出处：《浙江大学》2014年博士论文

【摘要】：第一部分结合居民健康体检的社区艾滋病抗体普遍检测研究 背景： 是否艾滋病普遍检测的争议已经持续了25年之久,2012年美国预防服务工作组(USPSTF)发布指南性文件,强烈建议在所有成人中开展普遍HIV抗体检测。暗娼等桥梁人群的作用,使中国艾滋病从高危、重点人群向普通人群扩散,由于潜伏期长、无症状,使艾滋病的主动发现更为困难,当前疫情监测体系难以完全触及普通人群,急需探索普通人群的全民HIV抗体筛查策略,及早发现传染病、及时控制传染源、减少传播和降低感染率。 目的： 探索结合浙江省现行的居民健康体检工程的HIV抗体普遍筛查策略,发现潜在阳性人群,及时掌握区域人群艾滋病感染率、分布及其相关风险因素,为摸清艾滋病流行率打下基础。 方法： 2010年6月到2012年5月,采用分层多阶段整群抽样策略,结合健康体检,完成社区居民HIV抗体普遍检测,并收集人口学、抗体检测结果。用SPSS18.0进行数据清洗和分析,一般信息用描述性分析,参照2000年中国人口标准结构标化感染率,不同感染率之间比较用卡方检验,相关影响因素用Logistic回归分析。结果： 在1113030纳入检测人群中,确诊HIV阳性310例,感染率为3.45/10000,其中男性为5.62/10000,女性为1.17/10000,相对于男性人群,女性人群的艾滋病感染风险相对较低(ARR,0.16,p0.001)。不同年龄层的艾滋病感染率也具有显著差异,25-34岁年龄层感染率最高为9.30/10000,相比对15岁人群,其他年龄组人群的艾滋病感染风险均较高(ARR范围从2.49-25.69),尤其是25-34与35-44年龄组人群高(ARR,25.69,p0.001和ARR18.48,p0.001),在老年人群中发现55-64岁和65岁以上年龄组人群的艾滋病感染率分别为2.04/10000和0.78/10000。在中等GDP地区,25-44岁,男性人群感染率高。310例阳性人群中203为既往诊断阳性病例,107例为本次普遍检测新诊断出病例,本次普遍检测贡献率达34.52%。相比于本地户籍阳性人群,非本地户籍具有具有如下特点：平均年龄小10岁、未婚比例高、文化程度低等。结论： 1)本研究通过在浙江省居民健康体检基础上增加HIV抗体检测,成功的在大规模人群(111万)完成HIV抗体普遍检测； 2)基于分层多阶段整群抽样策略,在111万人群中,诊断阳性310例,艾滋病感染率为3.45/10000,尚属低流行区,同时率的分布将为后续疫情监测、干预研究提供基础资料； 3)诊断的310例阳性中,107例(34.52%)为新诊断病例,普遍检测有助于发现潜在阳性人群。 第二部分基于社区的艾滋病强化随访效果研究 背景： 高效抗逆转录病毒治疗(HAART)对减少艾滋病病人死亡和提高病人生活质量发挥了极其重要的作用,但较差的服药依从性使HAART的疗效大打折扣。因此,开展有效病人管理探索,以期较好的完成病人随访管理指标,加强接受抗病毒治疗病人的服药督促、社会心理支持,提高治疗效果,有利于降低病死率。 目的： 本研究旨在建立基于社区的抗病毒治疗随访干预措施,评估不同随访管理模式下接受HAART患者的用药依从性情况、随访指标体系和治疗效果。了解HAART人群依从性状况和相关影响因素,从而在降低病死率方面进行探索。 方法： 2012年3月到2013年6月,强化随访组建立的社区-疾控-专科医院的“三位一体”阳性随访管理措施,常规随访组以当前的“疾控”随访为主要模式。评估12个月后依从性变化、随访管理指标变化以及治疗效果。采用SPSS18.0进行数据分析,运用描述统计、卡方检验、Logistic回归、t检验等统计方法。 结果： 在强化随访组和常规随访组各纳入165例和84例,强化随访组的依从性从83.03%提高到91.52%,常规随访组依从性从82.14%提高到83.33%,两者有显著性差异(χ2=3.733,P=0.045),综合比较前后依从性变化情况,发现强化随访组变好比例为16.36%,常规随访组为7.14%,有统计学差异性(χ2=4.117,P=0.042)。对HAART人群中的关键指标分析发现,相比于常规随访组,强化随访组在坚持治疗比例、完成7次随访比例、CD4检测比例、病毒载量检测比例等主要指标的完成情况均优于常规随访组。在免疫学指标观察中,强化随访组和常规随访组CD4+T细胞计数均显著上升(t=-3.028,P=0.003；t=-2.327,P=0.022)；强化随访组活化系统表达(CD8+CD38+)比例37.38±8.68下降到34.40±11.53,具有显著性差异(t=1.987,P=0.048)；强化随访组IL7-CD127系统(CD4+CD127+)比例从23.22±7.11上升到27.69±11.72,具有显著性差异(t=-3.237,P=0.001)；常规随访组均没有显著性差异。 结论： 1)经12个月随访,强化随访组依从性的改善显著优于常规随访组(χ2=4.117,P=0.042)； 2)相比于常规随访组,强化随访组坚持治疗比例、完成7次随访比例、CD4检测比例、病毒载量检测比例等主要指标的完成情况均优于常规随访组； 3)经过12个月的治疗,两组研究对象的CD4+T细胞数均能显著提高,然而强化随访组在免疫活化和IL7-CD127系统的免疫恢复情况显著优于常规随访组。 第三部分艾滋病阳性的老年人群流行病学与病死率分析 背景： 随着人口老龄化的到来,预期寿命的提高和生活质量的改善,使得该人群性活跃程度出现了极大的变化,中国老年人感染病例快速增长的趋势,但这个人群的流行、发病、死亡特点仍不清楚。 目的： 系统回顾分析老年艾滋病感染者病人流行特征,比较死亡原因及病死率,掌握浙江省老年感染人群特征,为针对性防治提供依据。 方法： 根据浙江省疫情分布和流行病学因素,收集2000年1月1日-2012年12月30日报告的1115例艾滋病阳性病例,其中196例为老年(≥50岁),应用SPSS18.0进行数据分析,采用卡方检验、生存分析方法。 结果： 发现≥50岁组占整个艾滋病阳性的比例成逐年上升的趋势,特别是在2000年后,从0上升到2012年的22.45%,性传播为主,占82.65%。相对与50岁组,50岁组诊断时CD4数值显著低(291.64vs.363.63p0.05).更多的人发现即处于发病状态(51.02%vs.34.06%p0.05)。生存分析估计≥50岁组存活时间为11.54±0.49年；50岁组为13.85±0.46年,两组之间Log Rank (Mantel-Cox)检验卡方值为3.83,两者有显著差异性(P0.05)。 结论： 1)老年病例发现数逐年上升,性传播为主,老年群体艾滋病问题不容忽视； 2)老年阳性人群估计生存时间为11.54±0.49年,不能及时早期诊断和本身的基础疾病,可能是该人群估计存活时间短、病死率高的主要原因； 3)加强对老年人探索主动筛查策略或扩大监测体系的年龄谱,以便及时发现老年病人,及时治疗,降低老年艾滋病人病死率。
[Abstract]:Study on the universal detection of community AIDS antibody in the first part in combination with residents ' health examination

Background :

It is highly recommended that universal HIV antibody detection be carried out in all adults . It is highly recommended that universal HIV antibody detection be carried out in all adults . It is highly recommended that HIV antibody detection be carried out in all adults . As the latent period is long and asymptomatic , the active discovery of AIDS is more difficult . The current epidemic situation monitoring system is difficult to reach the general population . It is urgent to explore the universal HIV antibody screening strategy of the general population . It is urgent to detect infectious diseases in time , control the source of infection in time , reduce the transmission and reduce the infection rate .

Purpose :

To explore the universal screening strategy of HIV antibody in the current residents ' health check - up project in Zhejiang Province , find out the potential positive population , grasp the HIV infection rate , distribution and relevant risk factors of the regional population in time , and lay the foundation for finding out the prevalence rate of AIDS .

Method :

From June 2010 to May 2012 , a stratified multi - stage cluster sampling strategy was adopted to carry out general detection of HIV antibodies in community residents and to collect population and antibody detection results .

Among the 1113030 patients , 310 HIV - positive patients were diagnosed , with an infection rate of 3.45 / 10000 , with a male of 5.62 / 10000 and a female 1.17 / 10000 , with a relatively low risk of HIV infection in the female population compared to the male population ( ARR , 0.16 , p0.001 ) . Among the elderly population , the prevalence of HIV infection was 2.04 / 10000 and 0.78 / 10000 . Among the elderly population , the prevalence of HIV infection was 2.04 / 10000 and 0.78 / 10000 respectively . Among the elderly population , the prevalence of HIV infection was 2.04 / 10000 and 0.78 / 10000 respectively .

1 ) HIV antibody test was carried out on the basis of health examination of residents in Zhejiang Province , and the universal detection of HIV antibody was completed in large - scale population ( 111 million ) .


2 ) Based on stratified multi - stage cluster sampling strategy , among 111 000 people , 310 cases were diagnosed positive , the infection rate of AIDS was 3.45 / 10000 , still belonged to low epidemic area , and the distribution of the rate will provide basic information for follow - up epidemic monitoring and intervention study ;


3 ) Of the 310 positive cases , 107 cases ( 34.52 % ) were newly diagnosed cases .

The Second Part Based on Community - based AIDS Intensive Follow - up Effect

Background :

High - efficiency anti - retroviral therapy ( HAART ) plays a very important role in reducing the death of patients with AIDS and improving the quality of life of patients . However , the poor drug compliance makes HAART ' s curative effect very low . Therefore , effective patient management exploration is carried out with a view to better completing the patient ' s follow - up management index , strengthening the administration supervision and social psychological support of patients receiving anti - virus treatment , improving the treatment effect , and being beneficial to reducing the mortality rate .

Purpose :

The purpose of this study was to establish a community - based follow - up intervention to evaluate the compliance of patients with HAART in different follow - up management modes , follow - up index system and treatment effect .

Method :

From March 2012 to June 2013 , the " three - in - one " follow - up management of the community - disease control - specialist hospital established in the follow - up group was strengthened . The routine follow - up group was followed up as the main mode with the current " disease control " follow - up . The data were analyzed by SPSS 18.0 , and the statistical methods such as descriptive statistics , chi - square test , Logistic regression , t - test were applied .

Results :

In the intensive follow - up group and routine follow - up group , 165 cases and 84 cases were included , the compliance of the intensive follow - up group was increased from 83.03 % to 91.52 % , and the compliance of routine follow - up group increased from 82.14 % to 83.33 % . According to the analysis of key indexes in HAART population , compared with the routine follow - up group , the completion of the main indexes such as the proportion of follow - up , the proportion of CD4 , the proportion of CD4 and the proportion of viral load were better than those of the conventional follow - up group . In the observation of immunology , the number of CD4 + T cells in the intensive follow - up group and the conventional follow - up group increased significantly ( t = - 3.028 , P = 0.003 ;
t=-2.327,P=0.022)锛，

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