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1、Overview概述,In the absence of an effective vaccine,behavioral interventions remain the primary tool in the global fight against HIV and most STDs在缺乏有效免疫疫苗的情况下，行为干预仍是全球对抗艾滋病病毒和大多数性病的主要手段。The plan for my talk:演讲计划：Where we are?现状如何？Effective interventions for HIV+MSM针对 HIV+MSM（感染爱滋病病毒的与同性发生性关系的男性）的有效行为
2、干预Where do we need to go?目标何在？Contextual issues to consider需考虑的环境脉络问题Understanding what HIV+MSM want了解 HIV+MSM 的需求,Where are we?现状如何？,Interventions ready for replication可重复进行的行为干预Healthy Relationships group-level健康的性关系 群体Interventions with promise附带承诺的行为干预Positive Choices individual+group积极正面的选择 个体+
3、群体PLUS(Positive Living through Understanding and Support)individual-levelPLUS（充满理解与支持的积极的生活）个体,CLEARResults清晰结果,At 15-months post-baseline,HIV+youth in the intervention condition used condoms for 73%of sexual acts with HIV-negative partners;youth in the control condition used condoms for 32%of sexua
4、l acts with HIV-negative partners.以 15 个月期限为基准，在行为干预条件下，感染爱滋病病毒的青年与未感染爱滋病病毒的性伴侣性交时使用保险套的比率为 73；在行为控制条件下，感染爱滋病病毒的青年与未感染爱滋病病毒的性伴侣性交时使用保险套的比率为 32。The number of HIV-negative partners decreased from 4.0 to 1.4 in the intervention condition,versus from 4.3 to 2.5 in the control condition.在行为干预条件下，未感染爱滋病病毒
5、的性伴侣的数字从 4.0 降至 1.4；在行为控制条件下，未感染爱滋病病毒的性伴侣的数字从 4.3 降至 2.5。,Healthy Relationships健康的性关系,Healthy Relationships is a five-session,small-group intervention for HIV+men(including MSM)and women.健康的性关系指对感染爱滋病病毒的男性（包括与同性发生性关系的男性）与女性分五个阶段进行小组行为干预。Based on Social Cognitive Theory and focuses on developing skil
6、ls and building self-efficacy and positive expectations about new behaviors through modeling behaviors and practicing new skills.依据社会认知理论并通过行为塑造与新技能实践，注重培养技能，建立对于新行为的自我效能感与积极的期望。,Healthy Relationships健康的性关系,Groups of 5 to 12 HIV+participants of the same gender and sexual orientation meet in a room t
7、hat allows privacy for discussion5 至 12 组性别与性取向相同的感染爱滋病病毒的参与者在一个房间开展小组讨论，这可让参与者的隐私得到全面保护The group sessions are facilitated by a licensed counselor and a peer,who may be HIV-positive.小组会谈会配备一名执证顾问与一名同伴，这个同伴可能是爱滋病病毒感染者。Sample size was 332(233 men)样本大小为 332（其中 233 名男性）Control condition was a health-mai
8、ntenance support group(attention control)控制条件为健康维护支持组（注意力控制）Eligibility did not require sexual risk性交危险并非资格审定的必备要素,Healthy RelationshipsCore Elements健康的性关系 核心要素,Defining stress and reinforcing coping skills across three life areasdisclosing to family and friends,disclosing to sexual partners,and bui
9、lding healthier and safer relationships.定义压力，强化三大生活领域的适应能力 向亲朋好友披露实情，向性伴侣披露实情，以及建立更健康、更安全的性关系。Using modeling,role-play,and feedback to teach and practice skills related to coping with stress.通过模仿、角色扮演与反馈来教授并实际运用处理压力的技能。Teaching decision-making skills about disclosure of HIV status.教授披露爱滋病病毒实情的决策技能。,
10、Healthy RelationshipsCore Elements健康的性关系 核心要素,Providing personal feedback reports to motivate change of risky behaviors and continuance of protective behaviors.提供个人反馈报告，激励改变危险行为，持续采取保护行为。Using movie clips to set up scenarios about disclosure and risk reduction to stimulate discussions and role-plays
11、.利用电影剪辑的方法编制实情披露与危险降低的剧情，鼓励进行讨论与角色扮演。,Healthy RelationshipsResults健康的性关系 结果,At 6 months post-intervention,participants in the intervention condition reported行为干预执行 6 个月后，参与者讲述：significantly less unprotected intercourse,more protected intercourse,and fewer sexual contacts.未采取保护措施的性交次数大幅降低，采取保护措施的性交次数
12、大幅上升，性接触次数更少。greater refusal of unsafe sex更明确拒绝不安全的性行为greater self-efficacy for suggesting condom use with new partners.与新性伴侣性交时建议使用保险套的更大的自我效能感greater intentions to consider the pros and cons of HIV status disclosure to partners.更加有意地考虑向性伴侣披露艾滋病实情的赞成和反对的理由greater intentions to engage in safer sex w
13、ith partners who did not know their HIV status.更加有意地与不知道自己爱滋病病毒实情的性伴侣进行更安全的性行为,Healthy RelationshipsConcerns健康的性关系 问题,Major focus of intervention involves use of video clips may be difficult to find appropriate segments for use in China行为干预的重点在于使用视频剪辑 可能很难在中国找到合适的使用群体Requires an HIV+peer group facil
14、itator brings up concerns about confidentiality需要一名感染爱滋病病毒的同伴组推进者 产生保密性问题,Positive Choices积极正面的选择,Positive Choices is a mixed-delivery intervention targeting HIV+MSM with alcohol-related problems.积极正面的选择指针对酗酒的感染爱滋病病毒的与同性发生性关系的男性进行混合行为干预。2 individual sessions2 次个体会谈4 group sessions4 次群体会谈2 individual
15、 sessions2 次个体会谈Focused on both reducing HIV sexual risk practices and reducing alcohol use.致力于减少存在感染艾滋病危险的性行为，并减少饮酒。Based on Motivational Interviewing and the Stages of Change model.基于激发性面谈与变化阶段模型进行实施。,Positive Choices积极正面的选择,Individual sessions delivered by trained Motivational Interviewing(MI)the
16、rapists;group sessions delivered by trained HIV+peer group counselors.由经过培训的激发性面谈(MI)治疗专家主持个人会谈；由经过培训的感染爱滋病病毒的同伴组顾问主持分组会谈。Sessions delivered in community settings in New York City.会谈地点设在纽约市的选定社区。Study included 253 HIV+MSM with alcohol problems.研究包括 253 名酗酒的感染爱滋病病毒的与同性发生性关系的男性。Eligibility did not req
17、uire sexual risk.性交危险并非资格审定的必备要素。Control condition was referral to community resources.控制条件依据社区资源而定。,Positive ChoicesCore Elements积极正面的选择 核心要素,Provides individualized feedback on alcohol use and sexual risk practices.提供针对饮酒与性交危险的个体化反馈意见。Explores decisional balance and stage of change for alcohol use
18、 and safer sex.探索饮酒与安全性行为的决策均衡与变化阶段。Works toward development of goal change plans for both behaviors.致力于为此两种行为制定目标变更计划。Group sessions emphasize condom use and HIV status disclosure.分组会谈着重强调使用保险套和披露爱滋病病毒实情。Group sessions are“sandwiched”between individual sessions in order to permit processing of grou
19、p sessions on an individual level.分组会谈在个体会谈之间进行，以便能在个体水平上开展分组会谈。,Positive ChoicesResults积极正面的选择 结果,Participants in the comparison group,at 3 months post-intervention,had a higher number of days in which unsafe sex was combined with drinking.行为干预执行 3 个月后，对比组参与者在饮酒的情况下做出不安全性行为的天数更多。,Positive ChoicesCo
20、ncerns积极正面的选择 问题,Did not have an effect,overall,on sexual risk.对于性交危险基本无效。Many were already using harm reduction and serosorting.许多人都已开始采取减少伤害与血清分类的行为。Intervention tested without an attention control.测试行为干预效果无需进行注意力控制。Requires skilled individual therapists and peer-group leaders.需要技能熟练的个体治疗专家与同伴组领导。
21、Other targeted outcome HIV disclosure-was NOT improved.其它针对性成果 爱滋病病毒实情披露 未获改善。Has been adapted for HIV+youth both in United States and in Thailand.针对美国与泰国感染爱滋病病毒的青年已做出调整。,PLUS,PLUS is an 8 session individual-level intervention targeting heavy drinking HIV+men and women.PLUS 指分 8 个阶段针对重度酗酒的感染爱滋病病毒之男女
22、进行个体行为干预。Focused on both increasing HIV medication adherence and reducing alcohol use.着重促进感染者坚持服用抗艾滋病药物并减少饮酒。Based on Motivational Interviewing and Cognitive Behavioral Therapy.依据激发性面谈与认知行为治疗方法开展。,PLUS,Individual sessions delivered by trained therapists.个人会谈由经过培训的治疗专家主持进行。Sessions delivered in commu
23、nity settings in New York City.会谈地点设在纽约市的选定社区。Study included 143 HIV+men and women with alcohol problems(54%MSM).研究包括 143 名酗酒的感染爱滋病病毒的男女（与同性发生性关系的男性比例为 54%）。Control condition was health education regarding alcohol use and adherence(attention control).控制条件为关于饮酒与酗酒的健康教育（注意力控制）。,PLUSCore ElementsPLUS 核
24、心要素,Provides individualized feedback on alcohol use and HIV medication adherence.提供饮酒与抗艾滋病药物使用的个体化反馈意见。Explores decisional balance and self-efficacy for both behaviors.探索此两种行为的决策均衡与自我效能感。Works toward development of goal change plans for both behaviors.致力于为此两种行为制定目标变更计划。Therapists conduct functional
25、analysis of skills deficits for both behaviors and then choose relevant modules to address these deficits(intervention individually tailored).治疗专家针对此两种行为进行技能缺乏功能分析，然后选择相关模型，解决技能缺乏问题（行为干预量身定做）。,PLUSResultsPLUS 结果,PLUSResultsPLUS 结果,PLUSConcernsPLUS 问题,Effect was not significant at 6 months,suggesting
26、 need for booster sessions.6 个月后效果不明显，则需召开推进会谈。Requires skilled individual therapists.需要技能熟练的个体治疗专家。Did not specifically address sexual risk behaviors,but did decrease viral load.未特别解决性交危险行为，但确实减少了病毒载量。Has been adapted and currently being tested to reduce methamphetamine use,reduce unprotected sex,a
27、nd increase medication adherence among HIV+MSM who use methamphetamine.已经过调整并于近期进行过测试，减少使用甲基苯丙胺（俗称“冰毒”），较少未采取保护措施的性行为，促进使用甲基苯丙胺的感染爱滋病病毒之与同性发生性关系的男性坚持服用药物。,Where do we need to go?目标何在？,There are other considerations,involving contextual and other factors that exert considerable influence on safer sex
28、 practices among HIV+MSM.还需考虑其它因素，包括对感染爱滋病病毒的与同性发生性关系的男性之间更安全的性行为影响重大的环境脉络与其它因素。Serosorting血清分类Perceived Responsibility已知责任Sexual Compulsivity强迫性性行为,Serosorting血清分类,Serosorting involves sexual partner selection on the basis of the HIV status(or assumed HIV status)of the partner.血清分类涉及依据性伴侣的爱滋病病毒感染状况
29、（或猜想的爱滋病病毒状况）选择性伴侣。HIV+MSM are more likely to seek out other HIV+MSM as sexual partners.感染爱滋病病毒的与同性发生性关系的男性更有可能选择其他感染爱滋病病毒的与同性发生性关系的男性作为性伴侣。HIV-negative MSM are more likely to report unsafe sex with other MSM believed to be HIV-negative.未感染爱滋病病毒的与同性发生性关系的男性更有可能向其他确信其未感染爱滋病病毒的与同性发生性关系的男性讲述不安全的性行为。,Se
30、rosorting血清分类,Serosorting is a form of harm reduction HIV+MSM are using this approach to limit the risk of HIV transmission.血清分类可减少伤害 感染爱滋病病毒的与同性发生性关系的男性使用此方法限制爱滋病病毒传播的危险。BUT it assumes MSM are但它假定与同性发生性关系的男性：Accurate about their own HIV status十分清楚自己的爱滋病病毒感染状况Honest about their own HIV status对自己的爱滋病
31、病毒感染状况坦诚相待Communicate effectively to their partners与性伴侣进行有效的沟通One study of HIV+MSM found that 42%reported sex without disclosing their status一项针对感染爱滋病病毒的与同性发生性关系的男性的研究表明，42 的受访者称其与他人性交时没有披露自己的爱滋病病毒感染状况,Perceived Responsibility已知责任,In a study of 250 HIV+MSM in New York City and San Francisco,72%of se
32、xual narratives included discussion of responsibility.针对纽约与旧金山 250 名感染爱滋病病毒的与同性发生性关系的男性的研究显示，72 的性话题涉及责任探讨。3 major themes:3 大主题：Personal responsibility 63%个人责任 63Partner responsibility 12%性伴侣的责任 12Shared responsibility 24%共同的责任 24,Personal Responsibility个人责任,If you dont have safer sex,you are at ris
33、k of endangering the persons life to the point of death.And its like murder.I am a responsible person and I have chosen this for myself and those I am in contact with.如果你不采取更安全的性行为，那么你就是在置他人于死地。这等同于谋杀我是负责任的人，我将这视为对自己以及自己接触之人的责任。,I have to think within myself,this person may not know whats good or no
34、t good for them.They may not know the reasons,or they may not care,but that doesnt mean that I cant care for them.我必须考虑，这人可能不知道什么对自己有利，什么对自己不利。他们可能不知道原因，或者他们根本不在乎，但这并不意味着我无需为他们着想。,Well,you have a responsibility to not make people like you HIV+.Its an awesome responsibility.We cant procreate as gay p
35、eople,but we can keep those already here living.and we cant do that if were giving everybody a disease thats going to kill them.你有责任不让他人感染爱滋病病毒。这是一种责任我们不能生育后代，但我们可以防止他人受到感染如果会导致他人感染致命的爱滋病病毒，我们就不能和其发生任何性行为。,Partner Responsibility性伴侣的责任,One time I had the philosophy of,“Well,Im dying anyhow.I might as
36、 well live it up.”And I left the responsibility in my partners hands-the person that I was with-in their hands.Well,if they really dont care,then its not up to me to take care of them.我曾经的人生哲学是“不管怎样，我都快死了。我也可以快乐地生活”。因此，我将责任交到伴侣的手里，交到与我发生性关系之人的手里。如果他们真的不在乎，那么我也无需关照他们。,But everybody is responsible for
37、 their own bodies and lives and the risks that they put themselves under.Everybody has different opinions of whats safe and whats not safe.每个人都必须对其身体、生活以及所冒危险负责。每个人对于什么是安全的与什么是不安全的问题有自己不同的看法。,And I told him that I was HIV+,but he still didnt want to use a condom.So,like thats you,thats on you.I mean
38、,I told you.I did my part.You know?So we had unprotected sex.我告诉他我感染了爱滋病病毒，但他仍不想使用保险套。因此，与你的情况类似，那取决于你。我的意思是，我告诉你了，我尽到了自己的责任。你知道吗？因此我们在未采取保护措施的情况下发生了性关系。,Shared Responsibility共同的责任,Whatever happens between the two of you,you both allow that to happen.Each person has to take individual responsibility
39、 as to how far theyll go,or what theyll do,with either a safe or an unsafe practice.无论你们之间发生什么，那都是你们允许其发生的。每个人都必须对其所做的安全或不安全的性行为担负个人责任，无论其要走多远或做什么。,I dont insist on it condom use in the baths,for example,where I assume everybody is taking responsibility for themselves,their own risk,their own level
40、of risk that theyll accept.例如，我不会坚持在浴室性交时使用保险套，我认为每个人都必须对其行为负责，对其所冒危险负责，对其可接受的危险水平负责。,Sexual Compulsivity强迫性性行为,Rates of sexual compulsivity are higher among MSM than among other groups,and higher among HIV+MSM than among HIV-negative MSM.与同性发生性关系的男性组强迫性性行为的比例高于其它组，感染爱滋病病毒的与同性发生性关系的男性组强迫性性行为的比例高于未感染
41、爱滋病病毒的与同性发生性关系的男性组。MSM with symptoms of sexual compulsivity(SC)engage in more sexual risk than other MSM,even when matched on number of sex partners.拥有强迫性性行为(SC)症状的与同性发生性关系的男性性交时感染艾滋病的危险要比与其它与同性发生性关系的男性高，即使拥有相同数量的性伴侣。#of unprotected anal sex acts with serodiscordant partners was 5.44 among the SC MS
42、M versus 0.88 among the non-SC MSM拥有强迫性性行为症状的与同性发生性关系的男性与 serodiscordant 性伴侣未采取保护措施进行肛交的得分为 5.44，而没有强迫性性行为症状的与同性发生性关系的男性的得分为 0.88。,What Do HIV+MSM Want?感染爱滋病病毒的与同性发生性关系的男性想要什么？,We seldom actually ask HIV+what they want in HIV prevention programs,yet knowing what a population wants is critical for de
43、signing effective programs.我们很少询问感染爱滋病病毒的与同性发生性关系的男性想从艾滋病防治计划中得到什么，但知道人们想要什么对于设计有效的艾滋病防治计划极为关键。We assume we know what they want.假定我们知道他们想要什么。In a study of 206 HIV+MSM in New York City and San Francisco,few actually expressed interest in what we might traditionally include in an HIV prevention intervention.针对 206 名纽约与旧金山感染爱滋病病毒的与同性发生性关系的男性的研究显示，实际上很少有人称其对于艾滋病防治干预计划内容感兴趣。,Discussion讨论,
