文章信息
- 凌倩, 李培龙, 汤后林, 唐林, 李东民.
- Ling Qian, Li Peilong, Tang Houlin, Tang Lin, Li Dongmin
- 青少年及青年HIV感染影响因素
- HIV related risk factors among adolescents and young adults
- 中华流行病学杂志, 2021, 42(1): 164-170
- Chinese Journal of Epidemiology, 2021, 42(1): 164-170
- http://dx.doi.org/10.3760/cma.j.cn112338-20200120-00048
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文章历史
收稿日期: 2020-01-20
联合国与WHO将青少年定义为10~19岁人群,将青年定义为15~24岁人群[1-2]。截至2018年底,全球青少年HIV感染者数约为110万~230万;与HIV相关的死亡已成为青少年死亡的8个主要原因之一[3-4]。2018年全球青少年及青年中HIV新发感染者数约30万~74万,其中青少年新发感染者数达5.9万~38万[4]。2018年全球平均每天有5 000例HIV新发感染,而其中约32.0%发生在青年中[5]。青少年及青年阶段是一个人从儿童向成年人转变的关键时期,其生理、心理和行为会发生重大改变,高危行为发生增加[6-7],感染HIV的风险加大。
一、青少年及青年HIV感染现状1.国外感染现状:全球青少年及青年艾滋病疫情分布不均,HIV感染者中超过80.0%分布在撒哈拉以南非洲地区,该地区约有170万青少年为HIV感染者,仅乌干达地区就有17万青少年感染者[8-12];同时,因该地区青少年对自身感染状况的知晓率低,治疗依从性低,导致该人群的HIV感染者数增加[10, 13]。在2015年,HIV相关死亡已成为撒哈拉以南非洲地区青年人群的第2大死因[14],HIV感染情况在该地区较为严重,尤其在校外青少年及青年中其感染率更高。如肯尼亚一般青年人群中的HIV感染率为2.1%,而校外青年的HIV感染率可达4.1%,赞比亚地区校外青少年的HIV感染率为6.4%,乌干达地区该数值为6.7%~10.5%[15-17]。从病例报告看,其他国家的青少年及青年HIV感染者数尚没有该地区多,但新报告病例占比呈上升趋势。美国2010-2016年青少年及青年新报告HIV感染者数较为平稳,但是在全部新报告感染者的占比则逐年增加[18];同时,美国2016年青少年及青年HIV感染者仅为6.03万人,但该人群HIV新报告病例占比超过了20.0%[19],其中亚特兰大市超过了23.0%,华盛顿特区超过了40.0%[20-21]。亚太地区青少年HIV感染者数2005-2014年呈上升趋势,2014年增至22万,其中15~19岁感染者数超过5万[22]。在印度,超过30.0%的HIV感染者为青年,该人群占HIV新发感染的35.0%[23-24]。在缅甸,青年HIV感染率超过1.5%[25]。在泰国,青年HIV感染者在全部HIV感染者占比超过10.0%,同时也是HIV新发感染率最高年龄组别[26-27]。由此,青少年及青年的HIV感染情况应引起重视。此外,非洲以外国家青少年及青年HIV感染相关研究多关注校外和受到商业性剥削的青少年。各国的校外青少年及青年的HIV感染率差异较大(美国达拉斯和玻利维亚Cochabamba均为0.0%,俄罗斯圣彼得堡为37.4%),受商业性剥削的青少年HIV感染率差异也较大(加拿大多伦多为2.0%,印度Kolkata为20.0%)[28]。
2.国内感染现状:近年来,我国青年HIV感染者数呈上升趋势,15~24岁青年新报告HIV感染者数由2010年的9 373例增加至2015年的16 986例,后逐步降至2017年的16 307例,HIV感染新增报告病例中超过40.0%集中在青年;同期青年学生新报告HIV感染数由794例增加至3 236例,后降至3 077例,青年学生报告病例中的HIV感染年均增长率超过30.0%[29-33]。在绍兴市、武汉市、沧州市的HIV感染报告病例中,青年所占HIV感染报告病例的比例均超过20.0%,在武汉市、沧州市中该占比还表现出逐年增加的趋势[34-36]。尽管广西壮族自治区新报告青年HIV感染数逐年下降,但青年学生新报告HIV感染数逐年上升[37]。此外,一项基于重庆市校外青少年MSM调查研究显示,该人群HIV阳性检出超过了20.0%[38]。我国哨点监测发现,全国65个青年学生哨点HIV阳性率由2010年的0.02%(95%CI:0.01%~0.03%)上升至2015年的0.04%(95%CI:0.02%~0.06%)[39]。
二、青少年及青年HIV感染与发现途径分析1.感染途径:国外青少年及青年中的感染途径以同性性传播为主,该人群中超过60.0%的新发感染发生在青年MSM中[40]。我国青少年及青年中的HIV感染超过90.0%归因于性行为,特别是15~24岁青年学生,感染HIV的主要途径是同性性传播[32, 41]。在HIV感染的青年学生中,同性性传播比例由2006年的8.0%上升至2017年的81.8%[33, 42]。我国各地艾滋病疫情报告中,同性性传播途径所占比例正逐年上升[34-37]。同性性传播已成为我国青年学生HIV感染的主要途径,其原因与性观念改变有关[32]。
2.发现途径:包括专题调查、自愿咨询检测以及医院就诊发现3种方式。有研究表明,青少年及青年对自愿咨询检测的接受度较高,经由自愿咨询检测发现的比例为45.5%~73.8%[34, 43-44],进一步扩大咨询检测的覆盖面,有利于早期发现感染者。
三、青少年及青年HIV易感因素1.个体因素:
(1)社会人口学因素:①年龄:我国青少年及青年中HIV感染者多集中在18~22岁,其中年龄≥ 18岁为感染HIV的危险因素[45-46]。国外研究也有类似发现,即相较于14~19岁青少年,20~24岁青年感染HIV的风险更高[47],可能与该年龄段人群处于性活跃时期,高危性行为发生率增加有关[48]。此外,初次发生性行为时年龄过小,则感染HIV/STD的风险增加[49]。②性别:在撒哈拉以南非洲国家与其他国家表现出不同的特点。在撒哈拉以南非洲国家的青少年及青年HIV感染者中有近70.0%为女性,研究认为在此地区女性感染HIV的风险是同年龄段男性的5~14倍[10, 50-51],可能与女性遭受性暴力、经济地位不平等、缺乏教育机会、从事商业性行为等因素有关[51-52],该地区女性的商业性伴与女性的年龄差较大,而与性伴间年龄差距大(≥ 5.5岁)是造成HIV易感的危险因素(HR=1.91,95%CI:1.33~2.74)[50];同时,女性与其商业性伴发生性行为时,很难协商使用安全套,无保护性性行为的发生增加了女性HIV感染的风险[49, 52]。而在其他国家,男性较女性更易感染HIV,原因与男性的性行为发生率更高、更易发生高危性行为有关,具体表现为男性发生性行为时间更早、更有可能具有多性伴、不愿意使用安全套[53-54]。③种族与民族:目前有关种族、民族与青少年及青年HIV感染关系的研究不多。有研究认为黑人青年最易感染HIV,其感染风险是白人青年的20倍,是拉丁裔青年的5倍[55]。我国四川省凉山州、云南省的研究发现,少数民族的青年感染HIV的风险更高,原因与少数民族青少年及青年接受有关艾滋病健康教育机会更少、少数民族青少年及青年的亲属文化程度更低、发生性行为及具有不良行为的比例更高等因素有关[45, 56-58]。此外,种族可对青少年及青年HIV检测行为产生影响[59],而早检测有利于更早了解自身的感染状态,可避免HIV的进一步传播。有关于种族、民族与HIV感染之间的关系有待于进一步研究。④职业:相较于同年龄段在校学生而言,校外流动青少年及青年感染HIV的风险性增加[16]。HIV感染风险高的职业以农民与流动性大的职业为主,其中流动性大的职业主要包括出租车司机、小商贩、警务工作者、安保人员、性工作者、从事服务业者等[7, 60]。当校外青少年及青年从事上述工作时,其感染HIV的风险增加。
(2)行为学因素:①性行为:青少年及青年性行为发生率逐年增加,且更容易发生高危性行为,安全套使用率不高,增加了青少年及青年HIV感染的风险。青少年及青年发生过性行为的比例为31.8%~75.0%[21, 61-62],高危性行为发生率较高,如同时期拥有多个性伴的比例超过20.0%[62-63],商业性行为发生率超过25.0%[64],而发生性行为时的安全套使用率仅为52.7%~66.0%[21, 62, 65-66],大多数青少年及青年选择使用安全套的目的在于避孕,而非预防疾病[67]。上述性行为改变的原因与性开放、有限的性教育、寻找性伴途径发生改变有关[68]。②不良行为:吸烟、饮酒、毒品、药物及其他成瘾性物质的使用可推动青少年及青年不安全性行为的发生,从而增加HIV感染的风险[16-17, 49, 61]。当使用成瘾性物质与酒精时,尤其是在性行为发生前后使用时,青少年及青年发生高危性行为的风险可增加2.76倍(95%CI:1.88~4.05)[12]。此外,不良嗜好等因素被认为与青少年及青年初次性行为年龄逐渐减小有关[61]。
(3)HIV相关知识与风险感知因素:①HIV相关知识:文化程度低是HIV感染的高危因素,文化程度与HIV相关知识知晓率密切相关,文化程度低,则HIV有关知识相对缺乏,增加了HIV的易感性[45, 56]。有研究显示,青少年及青年HIV感染者的知识知晓率 < 70.0%,而对HIV有完全正确认识的比例 < 10.0%[46, 69];此外,HIV相关知识增加可提升检测意愿(OR=1.23,95%CI:0.75~2.02),有利于减少高危性行为(OR=4.73,95%CI:1.40~16.0),从而减少HIV感染的风险[66];但也有研究认为,知识与高危性行为之间不一定相关,原因与青年对新奇事物及刺激活动表现出极大的好奇心有关[49, 70]。②风险感知情况:因相关知识缺乏,青少年及青年缺乏对感染HIV可能性的正确认识,对HIV风险感知能力差,易于主动暴露于HIV易感环境中,增强青年人群的自我感知力,可预防HIV感染[71]。2014年的一项基于60所高校的研究显示,学生中超过40.0%认为HIV流行不严重,超过56.0%的学生从未关注过HIV[72]。杭州市青年学生中有近55.0%认为自身不具有感染HIV的风险[73]。即使高风险人群,如青年MSM中的风险认知意识也很低,只有不到10.0%关注过HIV感染,且多数具有错误认识[74-76]。HIV相关知识与自我风险认知二者相互作用,对HIV易感性产生了影响。
2.家庭因素:家庭环境与HIV感染相关[77]。家庭完整性、家庭经济情况、父母物质滥用会增加青少年及青年高危性行为的发生,从而影响HIV的易感性[7, 15]。
(1)家庭完整性:相较于家庭完整的青少年,父母离婚、丧偶分别可使青少年婚前性行为发生可能性增加5.11倍(95%CI:2.42~10.80)、3.52倍(95%CI:1.69~7.33)[47]。当孤儿离开被收养的寄养家庭后,其发生吸毒、性行为(OR=2.38,95%CI:1.18~4.80)、商业性行为的风险增加(OR=10.25,95%CI:2.02~51.95)[78]。家庭不完整对HIV的易感性因素产生影响,增加了感染HIV的风险。
(2)家庭经济情况:家庭经济状况不好的青少年及青年面临着更多性不平等、性暴力、退学的处境,尤其是女性的发生率可能更高[7, 49, 79],因此增加了女性青少年及青年商业性行为的发生(OR=25.41,95%CI:7.80~82.76)[80]。
(3)亲子间性教育:父母与子女避讳谈论有关性的话题可增加子代感染HIV风险,而全面的性教育与开放的亲子交流被证明可以减少与HIV感染相关危险性行为的发生[81-82]。亲子间有关STD话题的交流可以增加子女对HIV知识的了解与掌握(r=0.195,P < 0.01)[83],从而使之减少高危性行为的发生。
3.社会因素:
(1)社会环境:当今社会环境较为开放,青少年及青年更易接触到成瘾性物质与酒精,加之性观念开放,使得性行为发生的可能性增加,进而感染HIV的风险性增加[84]。此外,大众传媒与新媒体的推广对社会环境产生了影响。大众传媒与新媒体可向人群传播与HIV相关的知识,提升人群参与自愿检测的意愿[85-86]。但同时,大众传媒与新媒体所传播的具有性诱导影像增加了青少年及青年发生性行为的可能,尤其是发生高危性行为的可能性增加1.23倍(95%CI:1.13~3.12)[61, 87-88]。
(2)社会交往:人际关系对青少年及青年既有积极作用也有消极作用,具体表现形式可体现为同伴教育与同伴压力。通过同伴教育可以提高人群HIV相关知识知晓率、检测意愿和抗病毒治疗依从性[16, 66, 89]。但同时,伴随人际交往可带来同伴压力,同伴压力是发生高危性行为的一个危险因素(OR=6.97,95%CI:4.24~9.69)[49, 61, 90],进而增加了感染HIV的风险。有超过10.0%的青少年认为存在同伴压力促使高危性行为发生,超过45.0%的青少年认为同伴压力无法拒绝[61]。因此,当同伴发生高危性行为时,其自身发生高危性行为的可能性增加[79, 91]。此外,同伴压力作为一种社会风险,增加了人群不良行为的发生[92],进而影响了感染HIV的风险。
(3)地域情况:贫穷的地区、不良的人居环境使该人群更多地暴露在易感因素下。交通环境差、医疗条件不好地区的青少年及青年更易感染HIV[77, 93],居住距离城市近,是青少年及青年HIV感染的保护性因素(OR=0.39,95%CI:0.24~0.66)[52],与城市地区的青少年及青年对HIV知识知晓率更高(OR=0.16,95%CI:0.05~0.58)有关[94]。
四、小结综上所述,现今青少年及青年感染HIV的风险增加。尽管从总体来看,我国青少年及青年的感染处于低流行态势,但从我国青少年及青年HIV感染者报告数、病例报告占比、哨点阳性检出率变化趋势来看,该人群中的HIV感染有增加趋势。因此,应对青少年及青年HIV的感染情况加以关注,尤其需要关注该年龄段的学生人群。目前我国青少年及青年HIV感染发现途径以自愿咨询检测接受度较高,感染途径以性传播途径为主,其中的青年学生以同性性传播为主。影响青少年及青年HIV感染风险的因素主要可以分为3类,即个体因素、家庭因素及社会因素。在青少年及青年中,当年龄≥ 18岁、黑种人或高风险环境中的少数民族、辍学或从事流动性大的职业、文化程度低、HIV相关知识知晓率低、缺乏自我风险认知可增加其自身易感风险。同时,当发生高危性行为,以及在发生性行为前具有不良行为史者,更易感染HIV。家庭环境与青少年及青年高危性行为发生率有关,当生长于家庭不完整、家庭经济状况不好、缺乏家庭性教育的环境中,会增加其高危性行为及不良行为的发生,进而增加感染HIV的风险。此外,社会环境、社会交往、地区经济发展情况均对青少年及青年HIV易感性产生了一定影响。
目前国内有关青少年及青年HIV风险认知与HIV易感性之间的关联性研究较少,对国外研究中尚有分歧的观点研究较少,例如大众传媒与新媒体对HIV易感性的影响、同伴在HIV感染与防控中发挥的作用等。应加强对上述问题的进一步研究,从而降低青少年及青年感染HIV的风险。
利益冲突 所有作者均声明不存在利益冲突
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