- 學位論文
台灣桃園地區男性愛滋病毒感染者與性病及人類乳突病毒相關疾病之研究
The Study on the Relationship between HIV-infected Men and Sexually Transmitted Infections and Human Papillomavirus-related Diseases in Taoyuan, Taiwan
摘要
人類免疫不全病毒(human immunodeficiency virus；HIV，俗稱愛滋病毒) 及後天免疫不全症候群(acquired immunodeficiency syndrome；AIDS，俗稱愛滋病)，是二十世紀以來，全世界最重要的傳染病之一，估計超過八千萬人遭受感染，其中超過三千萬人已經死亡。台灣在2012年12月底，已累計二萬四千多人感染HIV。由於高效能抗病毒療法(highly active antiretroviral therapy；HAART，俗稱雞尾酒治療)奏效，愛滋病毒感染者的死亡率已降低，且健康狀況提升，能回復正常生活。愛滋病人回復健康之後，繼而性行為也恢復活躍。愛滋病毒感染者繼續感染性病(sexually transmitted infections；STIs)，意味著感染者仍從事危險性性行為，可能繼續傳播愛滋病毒，『安全性行為』面臨巨大的考驗。全世界最盛行的性行為傳染病是人類乳突病毒(human papillomavirus；HPV)，可做為性行為傳染病的指標。高致癌性人類乳突病毒的感染，會演變成子宮頸癌及肛門惡性腫瘤，而近年來愛滋病人發生肛門惡性腫瘤有增加的趨勢，而且不因使用高效能抗病毒藥物的影響而減少。因此，本研究目的有三，目的一是調查台灣愛滋病毒感染者的性病，與個案管理計畫(Case management；CM)介入的成效；目的二，調查在台灣的愛滋病毒感染者的人類乳突病毒感染的盛行率與危險因子；目的三，探討愛滋病毒感染者的肛門癌前病變。 目的一的研究方法，在台灣的衛生署署立桃園醫院，收錄2007-2010年間愛滋病毒感染者在該院的就醫相關資料，分析性病的發生率、是否與個案管理計畫與高效能抗病毒治療有相關連性。目的二的研究方法，為收集愛滋病毒感染者及其對照組的會陰拭子檢體，以聚合酶連鎖反應(polymerase chain reaction；PCR)及線性矩陣HPV分型，探討人類乳突病毒的盛行率，並分析相關因子。目的三的研究方法，是分析愛滋病毒感染者的肛門抹片，探討其異常率，與組織病理診斷的相關性。 研究結果發現，574位在桃園醫院治療與追蹤的愛滋病毒感染者，其性病發生率為8.6人次/100人年。男同性戀愛滋病毒感染者規律參與個案管理計畫但尚未服用高效能抗病毒藥物者，有最高的性病發生率，其風險對比值(hazard ratio；HR)為 2.58， 95%信賴區間(confidence interval；CI)為1.14–5.84 (p = 0.02)。本研究顯示，除了加入疾病管制局的個案管理計畫，還要進入高效能抗病毒治療，才會有效降低性病的發生率。 在305位男性同性戀的愛滋病毒感染者(研究組)與100位的對照組的研究中，人類乳突病毒在會陰部的陽性率研究組為45.3% ，對照組為18.0%。年齡大於三十歲與CD4+ T淋巴球(CD4+ T cells)小於200 cell/?愮者有較高的機會偵測到人類乳突病毒。 此外，230位愛滋病毒感染者的肛門細胞抹片，發現肛門細胞學異常(anal dysplasia)的比率高達23%，男同性戀、感染多型的致癌性人類乳突病毒，及擁有多重性伴侶的人是高危險族群，建議該危險族群應妥善利用肛門抹片與致癌性人類乳突病毒兩種篩檢方法，篩檢肛門癌前病變，以期早期發現，這也是未來，愛滋感染者癌症防治的重點。 愛滋防治隨著時代的變遷，年輕族群性行為模式丕變，愛滋防治的策略奏效與否可觀察感染者的性病發生率，而且個案管理計畫需加入高效能抗病毒治療始能奏效。另一方面，本研究探討本土愛滋病毒感染者的人類乳突病毒感染的流行病學，及男性愛滋病毒感者的肛門癌前病變的發生情形與提出篩檢建議，以建立早期發現早期治療的防治政策，在台灣的愛滋防治，開創新的觀點與防治策略，值得重視。
並列摘要
Human immunodeficiency virus (HIV) infection and acquired immunodeficiency syndrome (AIDS) had been the greatest challenge to the human beings since 20th century. Until now, more than 80 million people had been infected worldwide, and among them 30 million died because of HIV/AIDS. Currently there were more than 24,000 HIV-infected persons in Taiwan. After the introduction of highly active antiretroviral therapy (HAART), there were remarkable decrease of HIV/AIDS-related mortality, and also significant promotion of health status of HIV-infected people. This study explored the fields of the occurrence of sexually transmitted infections (STIs) and human papillomavirus (HPV) -related diseases among HIV-infected people. The first objective is to study the incidence of sexually transmitted infections occurred in HIV-infected people. The effects of case management program would be evaluated. The second objective is to study the HPV infection among HIV-infected people. The third objective is to explore the HPV-associated anal precancerous lesions in HIV-infected population. Between Jan. 2007 and Dec. 2010, HIV-positive patients who visited Taoyuan General Hospital, Taiwan, were enrolled. Sexually transmitted infections were recorded and the associated risk factors were analyzed. Also, HIV-positive men who have sex with men (MSM) and HIV-negative control were recruited for HPV tests. Genital swabs were collected, and then analyzed by linear array HPV genotyping tests. Finally, anal thin preparation Pap smears were analyzed. Correlations between anal Pap smear and anal biopsy were also evaluated. In this study, 574 HIV-infected patients were enrolled for STI study. The incidence of STIs was 8.6 times/100 patient-years. MSM with regular case management (CM) but no HAART had the greastest risk to develop STIs (HR 2.58, 95% CI, 1.14–5.84; p = 0.02). Patients who were enrolled to the CM programs and had initiated HAART had the lowest risk to developed STIs, compared to the others. We concluded that CM and HAART were equally important for HIV prevention. The prevalence of HPV infection among the 305 HIV-infected MSM and 100 HIV-negative control subjects were 45.3% for HIV-positive MSM, and 18.0% for HIV-negative counterparts, respectively. Subjects who were less than 30 years of age and had CD4 T+ cells of less than 200 cells/?愮 were associated with HPV infection significantly. We studied the anal cytology among 230 HIV-infected men, and revealed that 23% of subjects had anal dysplasia. Men who have sex with men, have multiple oncogenic HPV infections, and have multiple lifetime sexual partners were risk factors associated with anal dysplasia. Anal screening by cytology and oncogenic HPV detection were suggested for above population. In conclusion, corporation of HAART in the CM program is effective for STIs control in HIV population, HPV burden in the HIV-infected patients is heavy, and screening for anal precancer by anal cytology and oncogenic HPV detection is suggested.
參考文獻
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