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液思舒
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1 对六省艾滋病疫情及防治状况数据的社会性别分析报告广东广西云南河南湖北重庆 Gender Analysis of Data on HIV Epidemic and Response in Six Provinces Guangdong, Guangxi, Yunnan, Henan, Hubei and Chongqing 2010 年 11 月 28 日 November 28, 2010 中国疾控中心性艾中心政策信息室 Division of Policy Research and Information, NCAIDS, China CDC

2 对六省艾滋病疫情及防治状况数据的社会性别分析报告 2010 年 11 月 28 日在大多数社会中, 相对于男性, 妇女青年女性和女童更面临着权力不平衡机会不均等遭受歧视以及对其人权的侵犯, 妇女所处的不利的文化环境和偏低的社会经济地位等种种因素导致妇女更容易受到艾滋病的侵袭因此, 艾滋病流行中需要关注性别问题随着我国艾滋病流行模式逐渐转变为以性传播为主, 性别问题日趋成为艾滋病防治工作中不容忽视的问题之一但到目前为止, 从社会性别的视角分析艾滋病问题在我国尚不多见, 来自社会学界的分析研究也更多从定性的角度阐述了面临艾滋病问题的性别差异及女性对艾滋病的脆弱性, 但关于艾滋病与性别关系的定量研究在我国十分缺乏, 社会学研究揭示的现象未能得到来自定量研究数据的证实本次分析主要利用艾滋病现有数据信息系统, 从社会性别视角对广东广西云南河南湖北和重庆等六省的疫情和防治数据进行分析, 以期定量地反映艾滋病对女性的影响女性感染艾滋病的风险以及女性接受艾滋病预防检测治疗关怀等服务的现状通过分析, 得出如下初步发现 : 1 女性受艾滋病影响日益增大, 男女性别比例逐年缩小我国每年新报告的艾滋病病毒感染者中, 男性和女性的比例已从 20 世纪 90 年代的 5:1 上升到 2009 年的 2.3:1, 表明女性艾滋病疫情增长幅度相对男性更快来自广东广西和云南三省数据显示, 艾滋病病毒感染者和艾滋病人中女性比例分别从 2000 年以前的 12.54% 17.09% 15.5% 上升到 2009 年的 23.58% 31.64% 40.3% 这些数据说明, 那些既往艾滋病感染以男性注射吸毒者为主的地区, 女性感染者比例明显上升 2 经性途径成为女性感染艾滋病的首要途径, 流行模式的转变对女性的影响大于男性我国近年来流行模式发生了显著改变, 性传播已取代注射吸毒上升成为第一位的传播途径, 这种传播模式的变化对女性的影响更为突出全国数据显示, 在历年报告的女性艾滋病病毒感染者中, 经性途径感染比例已从 2000 年的 30.1% 上升到 2009 年的 77.4% 在本次分析所包括的重庆湖北广东广西和云南等省份女性经性途径感染的比例从 2000 年的 15.0%~41.6% 上升到 2009 年的 71.0%~85.7% 不等与此相对应, 男性经性途径感染比例从 2000 年的 7.3% 上升到 2009 年的 45.4%, 在部分地区, 男性感染者的主要传播途径仍然是注射吸毒 3 在部分地区, 配偶 / 固定性伴传播逐渐成为女性感染艾滋病病毒的主要途径, 应加强包括配偶告知在内的预防配偶间传播的相关干预措施婚内性传播对女性构成更大的威胁, 女性异性传播感染者中有 31.7% 报告是经配偶 / 固定性伴传播, 而男性异性传播感染者中这一比例为 6.8% 此外, 部分地区女性经配偶 / 固定性伴传播的比例呈明显上升趋势, 广东广西和河南女性感染者中经配偶 / 固定性伴传播的比例分别从 2001 年的 7.15% 16.67% 和 42.86% 上升到 2009 年的 49.75% 42.39% 和 60.77% 预防家庭内艾滋病病毒传播是预防女性经性传播的重要措施, 其中, 配偶告知作为一项减少家庭内二代 1

3 传播的重要策略尤其重要, 有研究显示我国感染者配偶告知比例较低, 配偶告知率不足 70%, 女性感染者的配偶告知率显著高于男性感染者的配偶告知率广东数据显示, 已婚感染者中, 女性感染者的配偶艾滋病病毒检测率为 45%, 远高于男性感染者的 19.7% 配偶检测率下一步应重点强化包括配偶告知在内的预防配偶间传播的干预工作 4 较大规模的女性面临着感染的风险和脆弱性具有艾滋病病毒感染风险的女性既包括本身有高危行为的女性, 例如暗娼和女性吸毒者, 也包括男性艾滋病病毒感染者或有高危行为男性的配偶暗娼 :2009 年疫情估计结果显示, 广东河南和湖北三省的暗娼人群规模在 40~80 万之间哨点监测结果显示, 六省暗娼最近一月商业性性行为中安全套坚持使用率在 68%~89% 之间, 不安全性行为比例较高女性吸毒者 : 女性吸毒者中以卖养吸比例高, 在其商业性性行为中不安全性行为比例也极高六省的女性吸毒者中有 17.31% 报告有过商业性性行为, 由于买性和卖性者间的经济地位悬殊, 女性无力要求安全性行为, 因此在商业性性行为中安全套坚持使用率仅为 28.01% 女性吸毒卖性者梅毒阳性率高达 10.44%, 而男性吸毒者梅毒阳性率仅为 2.84% 男性艾滋病病毒感染者配偶或异性性伴 : 全国已作病例报告的艾滋病病毒感染者和艾滋病人中, 男性感染者的已婚比例为 53.5%, 而男性感染者报告最近三个月与阴性配偶发生性行为时安全套坚持使用率仅为 48.9% 男男性行为者的配偶 : 估计广东河南和湖北三省男男性行为着规模在 422,691~857,300 之间, 对男男性行为者的哨点监测结果显示,14.6%~33.6% 的男男性行为者与女性处于在婚或同居状态, 哨点监测结果显示, 男男性行为者最近半年与异性发生性行为时安全套坚持使用率在 4.5%~41.4% 之间有文献显示, 随着年龄增大, 迫于社会对男性成家立业的期待和要求, 绝大部分男男性行为者最终都会与异性组建家庭男性流动人口配偶 : 根据 2007 年在广东广西湖南和四川四省进行的流动人口调查数据显示, 有 15.75% 的男性在最近一年发生过商业性行为, 这些购买性服务的男性中只有 35.2% 每次都使用安全套, 而 25.4% 从未使用过安全套 11.9% 的调查对象过去一年发生过临时性行为, 但只有 27.2% 的调查对象每次都使用安全套,29.0% 从未使用这些被调查的流动人口最近一次与其配偶或固定性伴发生性关系时安全套的使用率仅为 22.3% 流动人群的高危行为将其自身及其留守在农村的配偶都置于较高的艾滋病病毒感染风险之中 5 女性艾滋病知晓率低于男性, 应针对男女差异设计宣传材料开发和传播策略中国预防与控制艾滋病中长期规划 (1998~2010 年 ) 中期评估结果表明, 在全国艾滋病预防知识知晓率方面, 女性 (46.1%) 低于男性 (53.1%); 在农村, 女性知晓率更低, 男性为 48.3%, 女性仅为 39.9% 六省青年学生艾滋病哨点监测数据表明, 在艾滋病知晓率方面男性青年学生 2

4 优于女性, 分别为 84.52% 和 76.08%, 在安全套知识方面, 这种差异更大, 男性 87.5%, 高于女性 73.14% 男女认识的显著性差异其原因可能是在日常生活中男生获取相关知识的主动性大于女生, 同时社会传统习俗将性无知作为评定女性纯洁的标准, 针对女性的性禁忌也妨碍了她们接近有关资讯和获取相关信息 6 预防艾滋病病毒母婴传播项目覆盖面地区差异大, 部分地区艾滋病病毒检测阳性孕妇终止妊娠比例较高 2009 年, 广东省全省孕产妇艾滋病病毒检测率为 71.12%, 但地区间差异较大, 珠江三角地区估计在 90% 以上, 粤西地区为 40.94%; 山区为 39.74%, 粤东地区仅为 11.68% 导致这种地区差异的原因尚待进一步探讨, 可能与艾滋病病毒检测服务提供经济发展水平文化差异等因素有关河南省年间共检出艾滋病病毒抗体阳性孕妇 622 人, 其中 88.3% (549/622) 终止妊娠, 这一比例高于广东和湖北等省有必要进一步开展调查深入了解终止妊娠的原因, 是出于本人意愿, 还是由于信息不对称所致盲目决策或缺乏提供母婴阻断服务的能力等, 以为更好开展预防母婴传播工作提供数据支撑并为感染者女性提供全面的有关预防母婴传播的信息咨询和技术服务 7 对高危行为人群 / 艾滋病病毒感染者的干预治疗服务在可及性方面无明显性别差异, 但总体覆盖率偏低通过对比男性和女性在吸毒者美沙酮维持治疗覆盖率感染者随访服务覆盖率感染者 CD4 检测覆盖率艾滋病人抗病毒治疗覆盖率等各项指标的数据, 发现在多数指标上女性和男性间并无显著性别差异但必须注意到, 这些服务的覆盖面总体偏低, 存在较大的提升空间例如, 广东感染者 CD4 检测覆盖率无论男女均低于 45%; 吸毒者美沙酮维持治疗覆盖率在广东广西和河南三省均低于 10%, 最高的湖北也仅为 30.5%; 重庆和广西两省抗病毒治疗覆盖率均低于 48% 8 女性对相关服务的依从性好于男性, 应发挥女性的示范作用分析数据表明女性接受相关服务的依从性好于男性, 以抗病毒治疗队列保持率和美沙酮维持治疗队列保持率为例, 广东 5 年抗病毒治疗队列保持率女性为 72.5%, 高于男性的 53.8%; 云南美沙酮维持治疗保持率女性为 63.8%, 男性仅为 43.5% 数据分析结果提示, 为了进一步提升艾滋病相关服务的质量, 在加大服务覆盖面的同时, 可以发挥女性在相关服务依从性方面的良好示范作用 3

5 Gender Analysis of Data on HIV Epidemic and Response in Six Provinces Guangdong, Guangxi, Yunnan, Henan, Hubei and Chongqing November 28, 2010 In most societies, women and girls are more vulnerable than men and boys to the imbalance of powers, inequality of opportunities, social discrimination and violation of human rights. Unfavorable cultural environment, low socioeconomic status and other adverse factors increase the vulnerability of women to HIV infection. Currently, sexual contact has gradually become a primary mode of HIV transmission in China. Therefore, special attention should be paid to gender-specific issues in HIV/AIDS response. So far, however, HIV/AIDS epidemic is seldom analyzed from the perspective of gender in China. While there are many analysis and research in the field of sociology describing gender differences in vulnerability of women to HIV infection from the qualitative perspective, there is a dearth of quantitative data and analysis on relationships between HIV/AIDS and gender. There is hardly any quantitative research data that support the conclusions from sociological studies. This initiative leverages the existing HIV/AIDS information system to analyze HIV/AIDS epidemic and response data in six provinces (i.e. Guangdong, Guangxi, Yunnan, Henan, Hubei and Chongqing) from the perspective of gender, in an attempt to reflect the impact of HIV/AIDS on women, the risk and vulnerability of HIV infection among women and the access of women to HIV/AIDS prevention, testing, treatment and care services in a quantitative way. The primary analysis findings are shown below. 1. Women are increasingly affected by the HIV/AIDS epidemic, and the ratio of men to women is decreasing among people living with HIV (PLHIV). Among annual reported new HIV infections, the ratio of men to women decreased from 5:1 in 1990s to 2.3:1 in The proportion of female PLHIV increased from 12.54% in 2000 to 23.58% in 2009 in Guangdong, from 17.09% to 31.64% in Guangxi and from 15.5% to 40.3% in Yunnan. These data indicate that female PLHIV constitute an obvious increasing proportion in areas where injecting drug use was once the leading route of HIV transmission. 2. Sexual transmission has become the primary mode of HIV transmission, and affects more women than men. Significant changes have been witnessed in the patterns of HIV/AIDS epidemic. Currently, sexual transmission has become the primary mode of HIV transmission in most areas, which has predominant impact on women. As indicated by the national data, the proportion of women infected with HIV via 4

6 sexual transmission has increased from 30.1% in 2000 to 77.4% in In Chongqing, Hubei, Guangdong, Guangxi and Yunnan, the proportion of women infected with HIV via sexual transmission ranged from 15.0% to 41.6% in 2000 and from 71.0% to 85.7% in Similarly, the proportion of men infected with HIV via sexual contact increased from 7.3% in 2000 to 45.4% in In some areas, injecting drug use is still the primary mode of HIV transmission among men. 3. In some areas, HIV transmission from spouses/regular partners has gradually become the primary mode of HIV transmission among women. Interventions should be strengthened to prevent HIV transmission between spouses, including the disclosure of HIV status to spouses. Sexual transmission within marriage poses a great threat to women. 31.7% of women infected with HIV via heterosexual transmission reported they got the virus from spouses/regular partners, while the proportion was 6.8% among men. In addition, the proportion of women infected with HIV from spouses/regular partners was on an obvious increase in some areas. Specifically, the proportion increased from 7.15% in 2001 to 49.75% in 2009 in Guangdong, from 16.67% to 42.39% in Guangxi and from 42.86% to 60.77% in Henan. The prevention of household HIV transmission is an important strategy to protect women from HIV infection via sexual contact. Particularly, the disclosure of HIV status to spouses should be taken as an important measure to prevent secondary transmission within households. Studies show that the proportion of PLHIV who disclose their HIV status to spouses is less than 70%, with disclosure rate of women significantly higher than that of men. In Guangdong, the proportion of married HIV-positive women whose husbands received HIV test was 45%, significantly higher than 19.7% among women whose husbands are HIV positive. As the next step, interventions should be strengthened to prevent HIV transmission between spouses, including the disclosure of HIV status to spouses. 4. A large number of women are facing the risk as well as vulnerability to HIV infection. Women facing the risk of HIV infection not only include those with high risk behaviors, such as Commercial Sex Workers (CSWs) and female drug users, but also include spouses of HIV-positive men or men with high risk behaviors. Commercial Sex Workers: According to epidemic estimations in 2009, there were 400, ,000 CSWs in Guangdong, Henan and Hubei. As indicated by sentinel surveillance data, the rate of consistent condom use at commercial sex was 68%-89% among CSWs in the six provinces. A high proportion of CSWs were involved in unsafe sex. Female drug users: There were a high proportion of female drug users selling sex for money to buy drugs. The proportion of female drug users involved in unsafe commercial sex was also very high. In the six provinces, 17.31% of female drug users reported commercial sex. Due to a big gap in 5

7 economic status, female drug users had no ability to negotiate safe sex with clients. Consequently, the rate of consistent condom use at commercial sex was only 28.01% among female drug users. The prevalence rate of syphilis was 10.44% among female drug users involved in commercial sex, but only 2.84% among male drug users. Spouses or heterosexual partners of HIV-positive men: Among all reported PLHIV in China, 53.5% of HIV-positive men are married, but only 48.9% of them reported consistent condom use with negative spouses in the past three months. Spouses of men who have sex with men (MSM): It is estimated that there are 422, ,300 MSM in Guangdong, Henan and Hubei. As indicated by MSM sentinel surveillance data, 14.6%-33.6% of MSM were married or live with female partners. The rate of consistent condom use with female partners was 4.5%-41.4% among MSM in the past half year. Literature review indicated that most MSM would finally get married to women due to social pressure. Spouses of migrant men: According to the migrant survey in Guangdong, Guangxi, Hunan and Sichuan in 2007, 15.75% of migrants had commercial sex in the past year, but only 35.2% of them used condoms at commercial sex every time, and 25.4% of them never used condoms. 11.9% of migrants had casual sex in the past year, but only 27.2% of them used condoms at casual sex every time, and 29.0% of them never used condoms. The rate of condom use at last sex with spouses was only 22.3% among surveyed migrants. High risk behaviors of migrants put both themselves and their spouses left behind in rural areas at a high risk of HIV infection. In Guangdong for example, there was an estimated 12.8 million migrants according to 2008 Statistical Yearbook of Guangdong Province. The total population of the province was 95 million in the same year. 5. The proportion of women with correct knowledge about HIV/AIDS is lower than that of men. IEC strategies should be developed and disseminated, tailored individually for men and women. According to the mid-term evaluation results of China Medium and Long Term Plan for HIV/AIDS Prevention and Control ( ), the proportion of women with correct knowledge about HIV/AIDS was lower than that of men, respectively 46.1% and 53.1%. In rural areas, the proportion was 48.3% for men and 39.9% for women. According to the sentinel surveillance for young students in the six provinces, a higher proportion of male young students knew correct knowledge about HIV/AIDS than female young students, respectively 84.52% and 76.08%. In addition, 87.5% of male young students new correct knowledge about condoms, significantly higher than 73.14% among female young students. This may be because male young students have easier access to relevant knowledge in daily life. Moreover, social customs define "sex ignorance" as an important criterion for girls, and sex taboos also prevent girls to obtain relevant knowledge. 6

8 6. The coverage of PMTCT varies significantly in different areas. In some areas, a high proportion of HIV-positive pregnant women terminate pregnancy. In 2009, 71.12% of pregnant women received HIV test in Guangdong, but there were significant differences among areas, specifically over 90% in Zhujiang Delta region, 40.94% in western part, 39.74% in mountainous areas and 11.68% in eastern part. Further exploration will be conducted to find out reasons. Possible factors may include the inappropriateness of HIV testing services, economic dependence of women and other cultural factors. In Henan, a total of 622 HIV-positive pregnant women were detected from 2001 to 2009, of which 88.3% (549/622) terminated pregnancy. This proportion is higher than those in Guangdong and Hubei. It is necessary to investigate the reasons for pregnancy termination. Such termination may be the willingness of pregnant women, inappropriate decision made based on incorrect knowledge, and/ or inadequate PMTCT services. Operational research probing into these root causes will better inform the scale up of PMTCT and enable timely access of HIV-positive women to information, counseling, prevention and treatment services. 7. The accessibility of prevention and treatment services for most-at-risk populations and people living with HIV have no significant difference between men and women, but the overall coverage is low. There are no significant differences between women and men in most coverage indicators, such as the coverage of MMT among drug users, coverage of follow-up services among PLHIV, coverage of CD4 test among PLHIV and coverage of ART among AIDS patients. It must be noted that, however, the overall coverage of these services is low and there is room for improvement. For example, the coverage of CD4 test is lower than 45% for both men and women in Guangdong; the coverage of MMT among drug users is lower than 10% in Guangdong, Guangxi and Henan, with the highest coverage of 30.5% in Hubei; and the coverage of ART is lower than 48% in Chongqing and Guangxi. 8. Women have better adherence to HIV services than men. This should be showcased in scaling up coverage of services for men. Data analysis indicates that women have better adherence to services than men. Taking retention rate of ART cohorts and that of MMT cohorts as examples, the five-year retention rate of ART cohorts was 72.5% among women in Guangdong, significantly higher than 53.8% among men; and the retention rate of MMT cohorts was 63.8% among women and 43.5% among men in Yunnan. This should be leveraged in finding means to improve the quality and coverage of HIV/AIDS services for both men and women. 7

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38 1 2014 1 Vol. 38No. 1 January 2014 51 Population Research 2010 2010 2010 65 100028 Changing Lineal Families with Three Generations An Analysis of the 2010 Census Data Wang Yuesheng Abstract In contemporary