Mainstreaming HIV services for men who have sex with men: the role of general practitioners.
Mainstreaming HIV services for men who have sex with men: the role of general practitioners.
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将针对男男性行为者的艾滋病毒服务纳入主流：全科医生的作用。
DOI：
10.1136/sextrans-2012-050626
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发表时间：
2012
影响因子：
3.6
通讯作者：
Tucker,JosephD
中科院分区：
文献类型：
--
作者：
Wong,WilliamCW;Kidd,MichaelRichard;Tucker,JosephD
世界各地的全科医生和其他初级保健医生在为男男性行为者提供高质量的艾滋病毒预防、检测和治疗方面具有很大的潜力，正如世卫组织最近的准则所倡导的那样。1随着艾滋病毒流行病在世界许多地方越来越集中于慢性病护理，一些初级保健问题成为艾滋病毒临床服务提供的首要问题。全科医生在提供艾滋病毒服务方面具有优势，因为他们的地位是值得信赖的、以社区为基础的、长期的病人倡导者。全科医生的培训和能力，使边缘化群体的人增加的可能性，全科医生可以提供MSM所需的，高质量的临床护理。男男性接触者的健康问题和求医行为与全科医生所见的其他男性基本上没有什么不同。呼吸道感染和高血压等常见问题的处理与其他男性相同。然而，男男性行为者也可能增加感染艾滋病毒、性传播感染（包括人乳头瘤病毒）、精神健康问题2 3以及吸毒和酗酒的风险。3最近关于性传播丙型肝炎感染的研究，特别是在艾滋病毒感染的男男性行为者中，已经描述了4，有肛交史的人更有可能获得肛门发育不良。5在年轻的男男性行为者中，欺凌和相关的心理压力是需要仔细考虑的重要健康问题。越来越多的证据表明，全科医生有可能直接提供艾滋病毒服务。一项系统性审查表明，与单独的专业护理相比，全科医生在艾滋病毒咨询、检测和治疗方面是有效的。6成本效益研究支持初级保健艾滋病毒服务提供模式。7与此同时，关于全科医生提供接触者追踪和艾滋病毒预防的数据较少，这两项活动在艾滋病毒专科诊所得到强调。进一步的培训和支持对于使广泛的全球方案指导的艾滋病毒服务取得成功至关重要，特别是在这些模式尚未建立的地方。男男性接触者，像其他病人一样，需要他们可以信任的全科医生，以便与他们选择的医生建立长期的关系。为男男性接触者服务的全科医生需要对同性恋生活方式持开放态度，或者至少对提出的有关性行为和男男性接触者文化其他方面的问题持中立态度。特别是在同性恋恐惧症根深蒂固的文化中，培养这种临床环境可能具有挑战性，需要强有力的宣传和新的规范。但这不应该分散向所有人提供高质量临床服务的重要性，无论性取向如何。男男性接触者的歧视和耻辱感，往往建立在个人经历，可以有力地破坏药物的依从性和挑战医患沟通。8全科医生对性的误解和未说出口的假设会造成护理方面的差距。为了弥补这一服务差距，有几种潜在的方法来推进MSM患者的初级保健艾滋病毒服务模式。在初次患者访视时，全科医生可以清楚地阐明他们对不歧视和保密的承诺。
General practitioners (GPs) and other primary care doctors around the world have a strong potential for providing quality HIV prevention, testing and treatment for men who have sex with men, as advocated by the recent WHO guideline. 1 As the HIV epidemic becomes more focused on chronic disease care in many parts of the world, a number of primary care issues come to the forefront of clinical HIV service delivery. GPs have advantages in providing HIV services because of their position as trusted, community-based, long-term advocates for their patients. The training and capacity of GPs to engage marginalised groups of people increase the likelihood that GPs can provide MSM with needed, high-quality clinical care. The health problems and health-seeking behaviours of MSM are fundamentally no different from other men seen by GPs. Management of common problems such as respiratory tract infections and hypertension is the same as for other men. Yet MSM may also have an increased risk of HIV, sexually transmitted infections including human papillomavirus, mental health problems2 3 and drug and alcohol use. 3 Recent research on sexually transmitted Hepatitis C infection, especially among HIV-infected MSM, has been described4 and individuals who have a history of anal sex are more likely to acquire anal dysplasia. 5 Among young MSM, bullying and associated psychological stress are important health issues that require careful consideration.An expanding evidence base demonstrates the potential for GPs to directly provide HIV services. A systematic review suggests that GPs are effective in HIV counselling, testing and treatment when compared to specialty care alone. 6 Cost-effectiveness studies favour a primary care HIV service delivery model. 7 At the same time, there are fewer data on GP provision of contact tracing and HIV prevention, two activities that are emphasised in specialist HIV clinics. Further training and support will be important for making widespread GP-directed HIV services successful, especially in places where these models are not well established. MSM, like other patients, need GPs they can trust in order to forge a longterm relationship with their chosen doctor. GPs serving MSM need to be open-minded to gay lifestyles or at least respond neutrally to issues raised about sexuality and other aspects of MSM culture. Especially in cultures where homophobia is deeply engrained, cultivating this clinical environment may be challenging and requires strong advocacy and new norms. But this should not distract from the importance of providing high-quality clinical services to all individuals, regardless of sexual orientation. MSM perceptions of discrimination and stigma, often founded in personal experiences, can powerfully disrupt medication adherence and challenge doctor-patient communication. 8 Misunderstandings and unspoken assumptions of sexuality by GPs can create gaps in care. To bridge this service gap, there are several potential ways to move forward a primary care HIV service model for MSM patients. At initial patient visits GPs could clearly articulate their commitment to non-discrimination and confidentiality.