臺灣博碩士論文加值系統

背景：愛滋 (human immunodeficiency virus/ acquired immunodeficiency syndrome, HIV/AIDS)和梅毒具有相似的傳播模式，愛滋病個案管理照護模式強調加強衛教服務，鼓勵其採行安全性行為，以減少其感染其他性病之風險，而歷年來台灣梅毒通報人數逐年增加。本研究目的是檢驗接受愛滋病個案管理之HIV/AIDS患者，個管師於門診提供個別衛教諮詢次數與梅毒發生的相關性。
方法：本研究採回溯性世代追蹤研究，研究對象為2010至2015年參加北部某醫學中心愛滋病個案管理計畫初次收案之HIV/AIDS 成人患者共計553名，排除前一年及研究期間未追蹤梅毒血清檢查(RPR/VDRL或TPHA)及個案管理初次收案時梅毒為陽性者，病歷回顧495名個案，分析於2010至2017年發生梅毒感染的情形。以Kaplan-Meier計算梅毒的發生率，以Cox Proportional Hazard Regression Model分析愛滋病個案管理個別衛教諮詢次數與梅毒發生的相關性。無梅毒病史且個案管理初次收案時梅毒檢測陰性之351名個案，以GEE概化估計方程式推論愛滋感染者每三個月回診時有接受個案管理個別衛教諮詢相較未接受訪視衛教者，在三個月內Syphilis發生之差異。495名個案扣除23位女性愛滋感染者追蹤期間均未感染梅毒，計算472位接受愛滋病個案管理男性個案，以梅毒發生率估算愛滋感染者發生梅毒所需個管費、梅毒治療及住院醫療費用之成本效益比較。
結果：平均梅毒發生的時間在接受個案管理門診個別衛教諮詢次數1-4次者為3.654人年；5-8次者為4.698人年；9-12次者為6.547人年；13-16次者為6.788人年；17次以上者為7.606人年 (log-rank test p<0.05)。控制年齡、婚姻、收案時梅毒狀態，門診個別衛教諮詢次數5-8次者相較於1-4次者發生梅毒的風險比(Hazards ratio)為0.518 (95%CI, 0.336-0.798)；9-12次者相較於1-4次的風險比為0.191 (95%CI, 0.107-0.340)；13-16次者相較於1-4次的風險比為0.164 (95%C,I 0.094-0.284)；17次以上者相較於1-4次的風險比為0.068 (95%CI, 0.025-0.188)，門診個別衛教諮詢次數越多，發生梅毒的風險越低(p<0.05)。愛滋感染者每三個月回診時有接受個案管理個別衛教諮詢相較未接受個別衛教諮詢者，在三個月內Syphilis發生之OR為0.835，但未達顯著差異(p=0.529)。以複診個案管理費及梅毒發生後之治療相關費用估算一年總花費，每年諮詢四次較一次之個案管理費多1,274,400元；梅毒治療相關費用少874,531元，不足成本效益399,469元。
結論：對愛滋管理計畫之個案，接受越多次的個別衛教諮詢確實可延緩其發生梅毒的危險性，雖然衛教是否在三個月內並沒有顯著效果。此外，近年來強調以藥物來防止HIV病毒的傳播，但無法抑制其他性病的發生，雖然本研究以愛滋病個案管理管理費估算對梅毒發生不夠成本效益，但個管服務的成效另外也可能提高就醫比率、增加服藥遵從性等，藉由個別衛教諮詢強調安全性行為或降低其他性行為傳染病之個人式管理模式服務，仍是公共衛生上重要課題。

Background：HIV/AIDS and syphilis have similar modes of transmission. The AIDS case management care model emphasizes strengthening the education service and encouraging them to adopt safe sex in order to reduce their risk of contracting other sexually transmitted diseases. The number of syphilis notifications in Taiwan has been increassing year by year. The purpose of this study was to examine the association between the number of individualized counseling sessions provided by the case managers in the outpatient clinic and the occurrence of syphilis among HIV/AIDS patients who received case management.

Methods: This study used a retrospective cohort study design. The study population consisted of 553 adult HIV/AIDS patients who participated in the HIV/AIDS case management program in a medical center in northern Taiwan from 2010 to 2015. Those who were not tracked for their syphilis status and who tested positive on recruitment were excluded. The medical records were reviewed in 495 cases, and the syphilis infection occurred in 2010-2017. The incidence of syphilis was calculated by Kaplan-Meier, and the Cox Proportional Hazard Regression Model was used to analyze the correlation between the number of counseling sessions and the occurrence of syphilis. The generalized estimation equation (GEE) was used to examine whether individualized counseling during the recent 3-month period was associated with syphilis occurrence among the 351 participants who did not have previous syphilis history and were included in the case management for the first time. Of the 495 participants, none of the 23 females contracted syphilis in the follow up. Cost benefit regarding case management fee and syphilis medical acre was calculated among the 472 HIV/AIDS male cases.
Results: The average time to syphilis occurrence was 3.654 person years among those whose number of individualized education consultations being 1-4 times; 4.698 person years for 5-8 times; 6.547 person years for 9-12 times; 6.788 person years for 13-16 times; and 7.606 person years for 17 times or more (log-rank test p<0.05). Controlling age, marriage, and syphilis status at recruitment, the risk ratio of syphillis was 0.518 (95% CI, 0.336-0.798) for 5-8 times when compared with 1-4 times. The risk ratio of 9-12 times when compared with 1-4 times was 0.191 (95% CI, 0.107-0.340); the risk ratio of 13-16 times when compared with 1-4 times was 0.164 (95% CI, 0.094-0.284); the risk ratio of 17 or more times when compared with 1-4 times was 0.068 (95% CI, 0.025-0.188). The more individualized consultations in the outpatient clinic, the lower the risk of syphilis (p< 0.05). When the health education was in the recent three months, the syphilis risk was lower. The OR of Syphilis in the next three months was 0.835, but it did not reach statistical significance (p=0.529). The annual case management fee was NTD 1,274,400 more when heatlh education was 4 times compared to 1 time; medical cost for syphilis was NTD 874,531 less; and the cost-benefit was negative NTD 399,469.
Conclusion: For HIV/AIDS case management programs, the more individualized education consultations received, the risk of syphilis can be decreased, though the recency of individualized consultation session was not significant. In recent years, emphasis has been placed on the use of drugs to prevent the spread of HIV, but it has not been possible to suppress the occurrence of other sexually transmitted diseases. Although it is not cost-beneficial in terms of syphilis occurence, the HIV/AIDS case management could have other benefit such as increase in seeking medical care and drug adherence. Individualized health counseling that emphasizes safe sex and reduces other sexually transmitted diseases is still an important issue in public health.

目錄
論文電子檔著作權授權書............................. i
論文審定同意書................................... ii
中文摘要....................................... iii
英文摘要........................................ vi
目錄.......................................... viii
圖目錄........................................... x
表目錄...................................…..... xii
第一章 緒論.......................................1
第一節、研究背景及重要性............................1
第二節、動機.......................................3
第三節、研究目的...................................5
第四節、名詞界定...................................6
第二章 文獻探討....................................7
第一節、安全性行為及愛滋感染者之常見性病..............7
第二節、HIV/AIDS和梅毒共同感染.....................10
一、 HIV/AIDS和梅毒共感之相關性.................10
二、 HIV/AIDS和梅毒共感之發生率.................11
三、 HIV/AIDS合併梅毒感染之影響因子..............12
四、 HIV/AIDS感染梅毒之臨床表現..................14
五、 HIV/AIDS感染早期梅毒對CD4和HIV病毒量的影響...15
六、 HIV/AIDS感染神經性梅毒的影響................15
七、 梅毒的診斷與HIV/AIDS感染梅毒之治療.......... 16
第三章 研究方法....................................28
第一節、研究設計及研究對象..........................28
第二節、研究工具及資料收集......................... 29
第三節、研究倫理.................................. 32
第四節、資料分析.................................. 33
第四章 研究結果................................... 37
第一節、研究對象基本特性分佈........................37
第二節、存活分析推論門診個別衛教諮詢次數對梅毒感染之變化 45
一、梅毒設限資料涉險率、存活率及發生率.................45
二、Kaplan-Meier推論門診個別衛教諮詢次數對梅毒感染之影響47
三、整體Cox Proportional Hazard Regression Model....63
第三節、GEE（Generalized Estimating Equation；GEE）概化估計方程式推論門診個別衛教諮詢對梅毒感染之變化............. 65
第四節、門診個別衛教諮詢次數與HIV門診次數之關聯性.......69
第五節、愛滋病個案管理在梅毒感染之成本分析............. 71
第五章 討論.........................................75
第一節、愛滋病個案管理照顧與梅毒發生之分析..............75
第二節、愛滋病個案管理門診個別衛教諮詢次數對梅毒感染之分析76
一、以存活分析推論門診個別衛教諮詢次數對梅毒感染之討論 76
二、以GEE推論門診個別衛教諮詢對梅毒感染之討論.......... 77
第三節、愛滋病個案管理在梅毒感染之成本分析討論..........78
第六章 結論與建議................................... 79
第一節、結論....................................... 79
第二節、研究限制.................................... 81
第三節、未來研究建議................................ 82
參考文獻.......................................... 84


表目錄
表一 愛滋病個案管理初次收案時梅毒檢測陰性之人口學特質 40
表二 存活分析--設限資料涉險率、存活率及梅毒發生率 45
表三 不同年齡分組與梅毒發生之時間的平均數與中位數分析 47
表四 不同教育程度分組與梅毒發生之時間的平均數與中位數分析...50
表五 不同職業分組與梅毒發生之時間的平均數與中位數分析......52
表六 不同婚姻狀態分組與梅毒發生之時間的平均數與中位數分析...54
表七 HIV感染危險因子-性行為對象分組與梅毒發生之時間的平均數與中位數分析..............................................56
表八 不同個管師分組與個案梅毒發生之時間的平均數與中位數分析 58
表九 收案時梅毒狀態分組與梅毒發生之時間的平均數與中位數分析 59
表十 追蹤結束前訪視次數分組與梅毒發生之時間的平均數與中位數分析
.....................................................61
表十一 以Cox模型分析各危險因素與發生梅毒風險率之關聯性..... 63
表十二 不同年齡分組與梅毒發生之比較.......................65
表十三 不同教育程度分組與梅毒發生之比較...................66
表十四 不同婚姻狀態分組與梅毒發生之比較.................. 66
表十五 不同HIV感染危險因子-性行為對象分組與梅毒發生之比較...67
表十六 每三個月門診個別衛教諮詢分組與梅毒發生之比較....... 67
表十七 多變項分析每三個月門診個別衛教諮詢有無之分組與梅毒發生之比較..................................................68
表十八 收案日至追蹤結束前最後一次訪視日期之感染科HIV門診(非0BS)有執行衛教諮詢之百分比與接受門診個別衛教諮詢次數之相關係數分析 .....................................................69
表十九 依個案管理現有規模一年不同諮詢次數下發生梅毒之成本花費估算....................................................74
 
圖目錄
圖一 研究對象追蹤圖....................................37
圖二 不同年齡分組與梅毒發生時間之存活曲線圖.............. 48
圖三 性別分組與梅毒發生時間之存活曲線圖................. 49
圖四 不同教育程度與梅毒發生時間之存活曲線圖...............51
圖五 不同職業與梅毒發生時間之存活曲線圖.................. 53
圖六 不同婚姻狀態與梅毒發生時間之存活曲線圖.............. 55
圖七 HIV感染危險因子-性行為對象狀態分組與梅毒發生時間之存活曲線圖.................................................. 57
圖八 不同個管師分組與個案梅毒發生時間之存活曲線圖........ 58
圖九 收案時梅毒狀態與個案梅毒發生時間之存活曲線圖 ....... 60
圖十 追蹤結束前訪視次數分組與個案梅毒發生時間之存活曲線圖..62
圖十一 收案日至追蹤結束前最後一次訪視日期之感染科HIV門診(非0BS)有執行衛教諮詢之百分比與接受門診個別衛教諮詢次數之相關性分布圖 .....................................................69

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