Background: A healthcare associated infection (HCAI) is an infection which is acquired from any healthcare establishment or context. In Sweden, one HCAI costs 107 000 SEK for the Swedish healthcare, but 50 percent of those are avoidable. The two most common HCAI are surgical site infections and urinary tract infections. Aim: The aim of this study was to describe patients experiences of suffering from healthcare associated infections. Method: The study was literature-based. Eight qualitative articles from the year 2010 to 2022 were included in the result. The articles needed to be based on describing the patients experience or perspective of suffering from a healthcare associated infection. Infections who were acquired from society were excluded. Results: The analysis of the articles resulted in three main themes and was then divided into two subthemes each. Main theme ”healthcare is failing” describes patients experienced lack of information and lack of trust in the healthcare professionals. “Physical exertion” was described as aches and pains, as well as physical limitation. “Psychological suffering” described patients experience of negative emotions and deteriorating social relationships.  Conclusion: HCAI showed substantial consequences for the patients, from distrust of the healthcare system, to suffering within emotional aspects as well as physical aspects due to pain and physical limitations. For practical implications, the authors are of the opinion that distinct information is essential to enable patients' participation in their healthcare.

This descriptive research used the Health Belief Model (HBM) to assess HIV/AIDS knowledge, perceived severity, perceived susceptibility, and behavioral practices within the population throughout the State of Sonsonate, El Salvador. Geographic Information Systems (GIS) was also utilized to display the results of this population study. The study population was composed of 15-39 year olds consisting of a total sample size of 1,500 (250 participants from each of the six cities). The basis of this study was to evaluate where this population fit within the Health Belief Model (HBM) and also to practically represent the results pictorially. Also, this information was collected so that the government of El Salvador could see and understand where their educational deficits existed so that future programs could be established to alleviate these discrepancies. An instrument consisting of 65 items including demographics, knowledge, perceived severity, perceived susceptibility, and behavioral practices was used for the general population. The analysis of the data was two-fold using Geographic Information Systems (GIS) mapping and statistical analysis. GIS mapping was used to graphically pinpoint areas of knowledge deficit and misinformation about HIV/AIDS. Results were based on a general population of 1,454. Various indices were created to show the level of knowledge or frequency of safe behavioral practices. The Perceived Severity and Perceived Susceptibility sections were not aggregated into an index but rather treated as individual variables. An item analysis of the questionnaire found that on average the general population responded correctly to 78% of the knowledge questions. However, a total of 11 questions in the knowledge section had less 75% (n=385) of the general population answering correctly. Another 3 questions in the behavior section were also found to have less than 75% (n=385) indicating safe behavioral practices. Linear regression analyses were performed to explore correlations between the areas of demographics, knowledge level, perceived severity, and perceived susceptibility to safe behavior. GIS maps were created to pictorially show where this population's deficiencies were in regard to the HBM. This research helped to pinpoint where this population fits within the construct of the Health Belief Model so that future educational efforts can be targeted in geographic areas with the greatest need. This will help to move this sample toward behavioral change. / Ph. D.

The core of the dissertation lies in developing two novel systems bioengineering approaches, a synthetic Escherichia coli killer-prey microecology, and a combined infection-inflammation NET-array system, to investigate the role of the mechanochemical complexity of the microenvironment in driving the microbe-microbe and host-microbe interactions, respectively. Herein, the first part of the dissertation includes designing and engineering a synthetic E. coli killer-prey microecological system where we quantified the quorum-sensing mediated interactions between the engineered killer and prey E. coli bacterial strains plated on nutrient-rich media. In this work, we developed the plate assay followed by plasmid sequencing and computational modeling that emphasizes the concept of the constant evolution of species or acquired resistance in the prey E. coli, in the vicinity of the killer strain. We designed the microecological system such that the killer cells (dotted at the center of the plate) constitutively produce and secrete AHL quorum-sensing molecules into the microenvironment. AHL then diffuses into the prey cells (spread throughout the plate) and upregulates the expression of a protein that lyses the prey. Through time-lapse imaging on petri plates automated using a scanner, we recorded the "kill wave" that originates outside the killer colony and travels outward as the prey dies. We found that the prey population density surrounding the killer decreased in comparison to other locations on the plate far from the killer. However, some of the prey colonies evolve to be resistant to the effects of AHL secreted by the killer. These prey colonies resistant to the killer were then selected and confirmed by plasmid sequencing. Using this empirical data, we developed the first ecological model emphasizing the concept of the constant evolution of species, where the survival of the prey species is dependent on the location (distance from the killer) or the evolution of resistance. The importance of this work lies in the context of the evolution of antibiotic-resistant bacterial strains and in understanding the communication between the microbial consortia, such as in the gut microbiome. Further, the second part of the dissertation includes quantifying the interactions between immune cells (primary healthy human neutrophils) and motile Pseudomonas aeruginosa bacteria in an inflammation-rich microenvironment. Neutrophils, being the first responding immune cells to infection, defend by deploying various defense mechanisms either by phagocytosing and killing the pathogen intracellularly or through a suicidal mechanism of releasing their DNA to the extracellular space in the form of Neutrophil Extracellular Traps (NETs) to trap the invading pathogens. Although the release of NETs is originally considered a protective mechanism, it is shown to increase the inflammation levels in the host if unchecked, ultimately resulting in end-organ damage (especially lung and kidney damage), as with the severe cases of sepsis and COVID-19. In our work, we developed a combined infection-inflammation NET-array system integrated with a live imaging assay to quantify the spatiotemporal dynamics of NET release in response to P. aeruginosa infection in an inflammatory milieu at a single-cell resolution. Importantly, we found increased NET release to P. aeruginosa PAO1 when challenged with inflammatory mediators tumor necrosis factor-α (TNF-α) and interleukin-6 (IL-6), but not leukotriene B4 (LTB4), compared to the infection alone. Our device platform is unique in that the nanoliter well-assisted individual neutrophil trapping enables us to quantify NET release with single-cell precision. Besides, incorporating confined side loops in the device helped us study the role of mechanical confinement on NET release, showing reduced NET release from neutrophils confined in the side loops compared to the relatively wider chambers of our microsystem. In summary, our work emphasizes the importance of studying the heterogeneity of NET release in host defense and inflammation. In the future, our system can be used for screening novel neutrophil-based immunotherapies and serve as a valuable research tool in precision medicine. / Doctor of Philosophy / The microenvironment plays a vital role in shaping the interactions within microbes and between the host and the microbes. Microbes use quorum-sensing-based chemical signaling to adapt to the environmental stresses in a microecology (be it a soil microecology or the gut microbiome). They communicate with each other with the help of these chemicals to regulate their population density (to mutual benefit in the case of a biofilm formation or to compete for resources in the case of a predator-prey model). In the first part of the dissertation, we utilize this quorum-sensing approach to study the spatiotemporal dynamics of the interactions between two engineered killer and prey Escherichia coli bacterial strains on a nutrient-rich agar plate in real-time. We designed the microecological system such that the killer cells (dotted at the center of the plate) constitutively produce and secrete AHL quorum-sensing molecules into the microenvironment. AHL then diffuses into the prey cells (spread throughout the plate) and upregulates the expression of a protein that lyses the prey. We found that the prey population density surrounding the killer decreased in comparison to other locations on the plate far from the killer. Further, through sequencing, we found that some of the prey colonies acquired resistance to the effects of AHL secreted by the killer. We then developed a computational model that recapitulates our experimental results, emphasizing the concept of the constant evolution of species or acquired resistance. The importance of this work lies in using experimental and computational approaches to better understand the evolution of multidrug-resistant (MDR) bacterial strains. Next, we investigated the interactions between primary human neutrophils (first responding immune cell type to infection) and motile Pseudomonas aeruginosa bacteria in the second part of the dissertation, explicitly focusing on quantifying neutrophil extracellular traps (NETs) release. With increasing concerns regarding the role of the dysregulated NET release in exaggerated inflammatory responses in the host, it is imperative to quantify NET release precisely at a single-cell level in a controlled microenvironment. To this end, we engineered a combined infection-inflammation NET-array device with 1024 nanoliter wells per device and achieved single-cell level trapping of neutrophils in these wells. Our device platform is unique in that the individual wells of the device have constricted side loops, which helps us better understand the role of mechanical confinement on NET release from an engineering standpoint. We then used the NET-array system to quantify the spatiotemporal dynamics of NET release to P. aeruginosa in an inflammatory mediator-rich microenvironment. Importantly, we found heightened NET release to Pseudomonas aeruginosa PAO1 when challenged with inflammatory mediators tumor necrosis factor-α (TNF-α) and interleukin-6 (IL-6), but not leukotriene B4 (LTB4), compared to the infection alone. We also demonstrated reduced NET release from neutrophils confined in the side loops compared to the relatively wider chambers of our combined infection-inflammation microsystem. Especially with the increasing complexity of the intercellular cues at the site of infection, by integrating our microfluidic method with the conventional reductionist approaches, we can better solve the intricate puzzles of the immune cell decision-making processes at a single-cell level. Our study highlights the importance of fine-tuning NET release in controlling pathological neutrophil-driven inflammation.

No / Pseudomonas aeruginosa is a versatile pathogen associated with a broad spectrum of infections in humans. In healthcare settings the bacterium is an important cause of infection in vulnerable individuals including those with burns or neutropenia or receiving intensive care. In these groups morbidity and mortality attributable to P. aeruginosa infection can be high. Management of infections is difficult as P. aeruginosa is inherently resistant to many antimicrobials. Furthermore, treatment is being rendered increasingly problematic due to the emergence and spread of resistance to the few agents that remain as therapeutic options. A notable recent development is the acquisition of carbapenemases by some strains of P. aeruginosa. Given these challenges, it would seem reasonable to identify strategies that would prevent acquisition of the bacterium by hospitalised patients. Environmental reservoirs of P. aeruginosa are readily identifiable, and there are numerous reports of outbreaks that have been attributed to an environmental source; however, the role of such sources in sporadic pseudomonal infection is less well understood. Nevertheless there is emerging evidence from prospective studies to suggest that environmental sources, especially water, may have significance in the epidemiology of sporadic P. aeruginosa infections in hospital settings, including intensive care units. A better understanding of the role of environmental reservoirs in pseudomonal infection will permit the development of new strategies and refinement of existing approaches to interrupt transmission from these sources to patients.

Ventilator-associated pneumonia (VAP) has been attributed with lengthening patients' stay in the intensive care unit (ICU), is the leading cause of death among nosocomial infections, and leads to increased hospital cost. Various positional strategies in the prevention of VAP include head of bed (HOB) elevation, continuous lateral rotation therapy (CLRT), and kinetic bed therapy. However, poor compliance rates in critical care units have been reported. Mechanically ventilated patients develop nosocomial pneumonia at a rate 6 to 21 times greater than non-ventilated hospitalized patients. A HOB elevation of 30' to 45' and the turning of patients every two hours are two commonly accepted guidelines used to prevent respiratory compilations by facilitating the clearance of pulmonary secretions. Both HOB elevation and CLRT were explored as interventions that could be implemented to reduce the incidence of VAP. It is difficult to attribute reduced VAP rates to either modality alone. However, when HOB elevation and CLRT are utilized in concert with other modalities, clinically significant benefits become readily apparent. Implementation of both improves clinical outcomes. These modalities should not be considered as individual strategies to reduce VAP, but as part of a comprehensive approach to reduce the incidence of VAP and improve patient outcomes.

A review of literature related to community-acquired Clostridium difficile- associated disease (CA-CDAD) was conducted. Information was collected from Cumulative Index to Nursing and Allied Health (CINAHL) and MEDLINE-EBSCOhost databases. Clinical practice recommendations were obtained from the CDC. Studies were examined for epidemiology of infection due to C. difficile in the community and interventions to reduce transmission. Findings demonstrated a mirroring of to CA-CDAD to community-acquired Methicillin-resistant Staphylococcus aureus (MRSA). Multiple studies found underlying gastrointestinal disorders and use of cephalosporin antibiotics to be a risk factor. Another identified risk factor was use of gastric acid suppressive drugs. Also, no particular C. difficile strain was more likely to cause recurrence. Many positive cases for CA-CDAD lacked traditional risk factors such as recent antibiotic exposure. To reduce transmission of community-acquired MRSA the CDC recommends MRSA should be considered in the differential diagnosis of soft skin tissue infections. Clinicians should also collect specimens for culture and antimicrobial susceptibility testing from all patients with abscesses. The CDC recommends clinicians should teach their patients to limit transmission and ask about similar cases in household members and close contacts. Therefore, to reduce transmission of CA-COAD, Clostridium difficile- associated disease should be considered in the differential diagnosis of diarrhea. Clinicians should collect specimens for culture based on patient history & current clinical presentation for patients with diarrhea. It is important that patients be taught the proper hygiene and cleaning protocols to reduce transmission

[pt] A Organização Mundial da Saúde declarou que a resistência aos antibióticos é uma das 10 principais ameaças globais à saúde pública. Entre os fatores que causam a disseminação de bactérias multirresistentes está o uso excessivo de antibióticos em hospitais. Esta tese baseia-se na premissa de que é necessário usar dados históricos para melhorar a prescrição de antibióticos e, assim, reduzir o impacto da resistência em ambientes hospitalares. Seus objetivos específicos incluem a análise de dados para fornecer informações que possam apoiar a prescrição de antibióticos, evitando assim que as taxas de resistência permaneçam elevadas após a pandemia de COVID-19 e prevenindo futuras quebras de protocolo semelhantes.. A tese também investiga as diferenças de desfechos entre a apresentação de bactérias resistentes e não resistentes em infecções adquiridas na comunidade. Para alcançar esses objetivos, os métodos incluem ferramentas de análise de dados, como estatísticas descritivas e inferenciais, Regressão Logística, Mineração de Processos e Mineração de Texto. Os dados incluem informações sobre pacientes internados em Unidades de Terapia Intensiva em hospitais de uma rede privada localizados no Rio de Janeiro, Brasil. A tese é composta por três artigos e descreve ainda uma plataforma desenvolvida para apoiar a prescrição de antibióticos em hospitais. Os resultados da tese revelaram um aumento significativo no consumo de antibióticos durante a pandemia, especialmente durante o segundo e terceiro meses da doença no Brasil. Esse aumento, aliado à alta variabilidade nos tratamentos de pacientes com COVID-19, demonstra que a incerteza em relação à doença levou ao não cumprimento dos protocolos previamente estabelecidos. O meropenem, um antibiótico da classe dos carbapenêmicos, teve o maior número ajustado de doses prescritas para pacientes com COVID-19 nos hospitais analisados. O aumento na prescrição de carbapenêmicos provavelmente explica o aumento observado na resistência a esse antibiótico durante o surto de COVID-19. No período pós-surto, a taxa de resistência aos carbapenêmicos diminuiu, seguindo a queda no consumo desses antibióticos após os primeiros meses da pandemia. No entanto, mesmo com a diminuição, os níveis de resistência pós-surto permaneceram mais altos do que antes da pandemia. Além disso, observou-se que a pandemia alterou outro hábito dos médicos nos hospitais pois o número de exames por paciente aumentou durante a pandemia e, mesmo após o surto da doença, continuou mais alto do que antes da doença. A tese também demonstrou como ferramentas de Mineração de Texto podem ser utilizadas na etapa de tratamento dos dados, possibilitando a inclusão de mais informações nas análises. Constatou-se ainda que, embora um terço dos pacientes admitidos em unidades de terapia intensiva apresentassem bactérias resistentes, não houve evidência de que isso implicasse em maiores chances de mortalidade hospitalar ou sepse em comparação com pacientes com infecções comunitárias por bactérias não resistentes. / [en] The World Health Organization has declared that antimicrobial resistance is one of the top 10 global public health threats facing humanity. Among the factors that cause the dissemination of multidrug-resistant bacteria is the overuse of antimicrobials in hospitals. This thesis is based on the premise that it is necessary to use historical data to improve antimicrobial prescription and thus reduce the burden of antimicrobial resistance in hospital settings. Its specific goals include analyzing data to provide information that can support antimicrobial prescription, thus avoiding antimicrobial resistance rates remaining high after the COVID-19 pandemic and preventing future similar protocol breakdowns. It also investigates the differences in outcomes between presenting resistant vs. non-resistant bacteria in community-acquired infections. To achieve these objectives, the methods include data analysis tools such as descriptive and inferential statistics, Logistic Regression, Process Mining, and Text Mining. The data includes information on patients admitted to Intensive Care Units in hospitals from a private network located in Rio de Janeiro, Brazil. The thesis comprises three articles and describes a CDSS developed to support antimicrobial prescription in hospitals. The thesis s findings revealed a significant increase in antimicrobial consumption and high variability in treatments for COVID-19 patients. Specifically, meropenem, a carbapenem-class antimicrobial, presented the highest adjusted number of doses prescribed for COVID-19 patients in the analyzed hospitals. The escalation in carbapenem prescription probably explains the observed increase in carbapenem resistance during the COVID-19 surge. In the post-surge, the carbapenem resistance rate decreased, following the decrease pattern we found in carbapenem consumption after the first months of the pandemic. Even though there was a decrease in carbapenem resistance, the post-surge levels remained higher than before the surge. Besides, this thesis did not find an association between presenting with antimicrobial-resistant bacteria and higher chances of hospital mortality or sepsis in patients with community-acquired infections.

Yes / Hospital-acquired Acute Kidney Injury (H-AKI) is a common cause of avoidable morbidity and mortality. To determine if the patients’ vital signs data as defined by a National Early Warning Score (NEWS), can predict H-AKI following emergency admission to hospital. Methods: Analyses of emergency admissions to York hospital over 24-months with NEWS data. We report the area under the curve (AUC) for logistic regression models that used the index NEWS (model A0), plus age and sex (A1), plus subcomponents of NEWS (A2) and two-way interactions (A3). Likewise for maximum NEWS (models B0,B1,B2,B3). Results: 4.05% (1361/33608) of emergency admissions had H-AKI. Models using the index NEWS had the lower AUCs (0.59 to 0.68) than models using the maximum NEWS AUCs (0.75 to 0.77). The maximum NEWS model (B3) was more sensitivity than the index NEWS model (A0) (67.60% vs 19.84%) but identified twice as many cases as being at risk of H-AKI (9581 vs 4099) at a NEWS of 5. Conclusions: The index NEWS is a poor predictor of H-AKI. The maximum NEWS is a better predictor but seems unfeasible because it is only knowable in retrospect and is associated with a substantial increase in workload albeit with improved sensitivity. / The Health Foundation

人類免疫缺陷病毒 (HIV) 是人獲得性免疫缺陷綜合征 (愛滋病，AIDS) 的致病原，2010年全球有180萬人死於愛滋病，HIV/AIDS已成為全球健康的嚴重挑戰。人類免疫缺陷病毒與乙型肝炎病毒 (HBV) ，丙型肝炎病毒 (HCV) 的合併感染非常普遍，已演變成具有嚴重臨床後果的新健康問題。儘管對於人類免疫缺陷病毒的研究已有很大的進展，但由於受研究模型的限制，人體免疫系統對人類免疫缺陷病毒感染的應答，特別是對乙型肝炎病毒，丙型肝炎病毒與人類免疫缺陷病毒合併感染的免疫應答，仍值得進一步的闡明。 / 在本研究中，我們首先對深圳人類免疫缺陷病毒，乙型肝炎病毒，丙型肝炎病毒合併感染的流行情況進行研究。共選取914份人類免疫缺陷病毒感染者的血漿，經過對乙型肝炎病毒表面抗原 (HBsAg) 和抗丙型肝炎病毒抗體 (anti-HCV) 的檢測，發現10.9% (100/914) 的被檢測者是人類免疫缺陷病毒/乙型肝炎病毒合併感染，14.6% (133/914) 為人類免疫缺陷病毒/丙型肝炎病毒合併感染，3.7% (34/914) 為人類免疫缺陷病毒/乙型肝炎病毒/丙型肝炎病毒三重感染。多元邏輯回歸分析證明人類免疫缺陷病毒傳染的危險行為與合併感染顯著相關聯。大多數的人類免疫缺陷病毒/乙型肝炎病毒合併感染者都是通過性接觸感染人類免疫缺陷病毒，包括異性傳播與同性傳播 (95/100, 95%); 大多數的人類免疫缺陷病毒/丙型肝炎病毒合併感染者是靜脈注射吸毒者 (89/133, 66.9%); 人類免疫缺陷病毒/乙型肝炎病毒/丙型肝炎病毒三重感染者中，大多數是靜脈注射吸毒者 (28/34, 82.4%)。靜脈注射吸毒人群中，大部分是男性 (108/122, 88.5%)，約半數人的年齡介乎27至32歲 (56/122, 45.9%) 。有接近一半的經過血液和血液製品傳播人類免疫缺陷病毒的人是人類免疫缺陷病毒/丙型肝炎病毒合併感染者 (10/23, 43.5%) 。性別與人類免疫缺陷病毒感染的危險行為有顯著關係，大部份的靜脈注射吸毒者是男性。 / 進一步，我們利用酶聯免疫吸附測定法 (ELISA) 檢測深圳愛滋病陽性樣本血漿中白細胞介素27 (IL-27) 的濃度。結果顯示，對比健康參照者，人類免疫缺陷病毒單獨感染者，人類免疫缺陷病毒/乙型肝炎病毒合併感染者，人類免疫缺陷病毒/丙型肝炎病毒合併感染者的血漿IL-27濃度顯著升高。隨後我們進一步發現，人類免疫缺陷病毒單獨感染組，人類免疫缺陷病毒/乙型肝炎病毒，人類免疫缺陷病毒/乙型肝炎病毒/丙型肝炎病毒合併感染組之間的血漿IL-27濃度沒有顯著差異，而人類免疫缺陷病毒/丙型肝炎病毒合併感染組與人類免疫缺陷病毒/乙型肝炎病毒/丙型肝炎病毒三重感染組的血漿IL-27濃度差異顯著。我們還發現人類免疫缺陷病毒單獨感染組中，血漿IL-27濃度與CD4⁺ T 淋巴細胞數量顯著正相關 (r = 0.177, P = 0.034)。 / 我們進一步分析了人類免疫缺陷病毒和丙型肝炎病毒的病毒載量對血漿IL-27濃度的影響，發現HIV單獨感染組中人類免疫缺陷病毒載量與血漿IL-27濃度沒有顯著相關 (r = - 0.063, P = 0.679)，而人類免疫缺陷病毒/丙型肝炎病毒合併感染組中，人類免疫缺陷病毒載量與血漿IL-27濃度顯著正相關 (r = 0.362, P = 0.049)。人類免疫缺陷病毒/丙型肝炎病毒合併感染組中，人類免疫缺陷病毒載量與丙型肝炎病毒載量缺少顯著線性關聯 (r = - 0.072, P = 0.704)，而人類免疫缺陷病毒/丙型肝炎病毒合併感染組可根據人類免疫缺陷病毒與丙型肝炎病毒的病毒載量再細分成血漿IL-27濃度差異顯著的三組 (P = 0.014) ， 丙型肝炎病毒載量與血漿IL-27濃度缺少顯著關聯 (r = - 0.119, P = 0.530) 。 / 我們利用TaqMan®等位基因分型技術測定深圳男同性戀人群中IL-27 p28基因的單核苷酸多態性 (SNP)。結果顯示，人類免疫缺陷病毒感染組IL-27 p28 -964A/G 和4603G/A的基因型與健康男同性戀參照組的基因型沒有顯著差異， IL-27 p28 -964A/G 和4603G/A的等位基因比率也沒有顯著差異。結果也顯示，IL-27 p28 2905T/G的TG基因型可減少2.77倍的人類免疫缺陷病毒感染風險，等位基因G可減少2.72倍的人類免疫缺陷病毒感染風險。連鎖不平衡在IL-27 p28 -964A/G 和2905T/G 中存在 ( / 綜上所述， 在本研究中，我們首次調查了深圳人類免疫缺陷病毒，乙型肝炎病毒，丙型肝炎病毒合併感染的流行情況，並分析了合併感染的風險因素。 發現人類免疫缺陷病毒單獨感染者，人類免疫缺陷病毒/乙型肝炎病毒合併感染者， 及人類免疫缺陷病毒/丙型肝炎病毒合併感染者的血漿IL-27濃度比健康參照組顯著地升高；人類免疫缺陷病毒單獨感染組中，血漿IL-27濃度與CD4⁺ T淋巴細胞數量顯著正相關。人類免疫缺陷病毒/丙型肝炎病毒合併感染組中，人類免疫缺陷病毒載量與血漿IL-27濃度顯著正相關 (r = 0.362, P = 0.049)。分析深圳男同性戀人群IL-27 p28基因的單核苷酸多態性，發現IL-27 p28 2905T/G 與人類免疫缺陷病毒感染相關，GGG單型可降低男同性戀人群人類免疫缺陷病毒感染的風險。 / Human Immunodeficiency Virus (HIV) is the causative agent of Acquired Immunodeficiency Syndrome (AIDS); HIV/AIDS caused 1.8 million deaths world-widely in 2010 and became a major global health challenge. HIV co-infections with Hepatitis B virus (HBV), Hepatitis C virus (HCV) are common and have emerged into new health problems with severe clinical consequences. Since the discovery of HIV, massive progress in understanding of the pathogen has been achieved. Due to the restriction of research model, how human immune system responds to HIV infection, particularly, to HBV or HCV co-infections is still worthy further elucidation. / A cohort study was first conducted in Shenzhen regarding the seroprevalence of HBV, HCV infections among HIV-infected population. Totally 914 HIV positive individuals were recruited in the study and tested for HBsAg and anti-HCV antibodies. The results showed a 10.9% (100/914) HIV/HBV co-infection rate, 14.6% (133/914) HIV/HCV co-infection prevalence and 3.7% (34/914) HIV/HBV/HCV triple-infection prevalence. Multivariate logistic regression revealed that HIV transmission risk behavior was significantly associated with HIV, HBV, HCV co-infections. Most HIV/HBV co-infection cases got HIV through sexual contact including heterosexual and homosexual behaviors (95/100, 95%); while most HIV/HCV co-infection subjects were injection drug users (IDUs) (89/133, 66.9%). In the case of HIV/HBV/HCV triple-infection, IDUs accounted for a large ratio (28/34, 82.4%). Among IDUs, most of them were male (108/122, 88.5%) and nearly half were aged 27 to 32 years old (56/122, 45.9%). Near half people who got HIV through blood and blood products were HIV/HCV co-infected (10/23, 43.5%). Gender has a significant correlation with HIV risk behavior and most IDUs were male. / Next, we applied ELISA to test HIV positive clinical samples and proved that plasma interleukin-27 (IL-27) level was significantly elevated in HIV mono-infected, HIV/HBV co-infected and HIV/HCV co-infected subjects when compared with healthy controls. Later, we further revealed that plasma IL-27 titer was not significantly varied among HIV, HBV and HCV co-infections except between HIV/HCV co-infections and HIV/HBV/HCV triple-infections. We also observed a significant positive correlation between CD4⁺ T cell counts and plasma IL-27 titer within HIV mono-infected group (r = 0.177, P = 0.034). / We further analyzed the impact HIV and HCV viral loads on plasma IL-27 titer. We found there was no significant correlation between HIV viral load and IL-27 titer among HIV mono-infected individuals (r = - 0.063, P = 0.679); while a significant positive correlation was observed between HIV viral load and IL-27 titer in HIV/HCV co-infected individuals (r = 0.362, P = 0.049). In the case of HIV/HCV co-infection, there was no significant linear correlation between HIV and HCV viral loads (r = - 0.072, P = 0.704) but exist obvious subdivision of samples in terms of HIV and HCV viral loads with significant IL-27 titer variance (P = 0.014). No correlation was observed between HCV viral load and IL-27 titer (r = - 0.119, P = 0.530). / IL-27 p28 polymorphisms were genotyped with TaqMan® Allelic Discrimination Assay in Chinese men who have sex with men (MSM) population in Shenzhen and the results revealed that proportions of IL-27 p28 -964A/G and 4603G/A genotypes were not significantly different from the healthy controls; IL-27 p28 -964A/G and 4603G/A allele frequencies were similar between HIV positive MSM group and healthy control MSM group. Results also showed that for IL-27 p28 2905T/G polymorphism, TG genotype has a 2.77-fold decreased risk of HIV susceptibility and subjects with G allele has a 2.72-fold decreased risk of HIV susceptibility. Linkage disequilibrium (LD) coefficients were observed between IL-27 p28 -964A/G and 2905T/G ( / In conclusion, the seroprevalences of HBV and HCV infection among HIV positive population in Shenzhen were surveyed and risk factors associated with co-infections were analyzed. Plasma IL-27 titer was significantly elevated in HIV mono-infected, HIV/HBV co-infected and HIV/HCV co-infected individuals. IL-27 level was correlated with CD4⁺ T cell counts within HIV mono-infected people. A significant positive correlation was found between HIV viral load and IL-27 titer in HIV/HCV co-infected individuals (r = 0.362, P = 0.049). IL-27 p28 2905T/G was associated with individual susceptibility to HIV infection and haplotype GGG showed a protective role in restricting HIV infection in MSM population. / Detailed summary in vernacular field only. / Detailed summary in vernacular field only. / Detailed summary in vernacular field only. / Detailed summary in vernacular field only. / Detailed summary in vernacular field only. / Detailed summary in vernacular field only. / He, Lai. / "October 2012." / Thesis (Ph.D.)--Chinese University of Hong Kong, 2013. / Includes bibliographical references (leaves 135-155). / Electronic reproduction. Hong Kong : Chinese University of Hong Kong, [2012] System requirements: Adobe Acrobat Reader. Available via World Wide Web. / Abstract also in Chinese. / Abstract (English) --- p.iii / Abstract (Chinese) --- p.vi / Acknowledgements --- p.ix / Contents --- p.x / List of Tables --- p.xv / List of Figures --- p.xvi / Abbreviations --- p.xvii / Chapter Chapter 1 --- Introduction --- p.1 / Chapter 1.1 --- Human Immunodeficiency Virus --- p.1 / Chapter 1.1.1 --- HIV virology --- p.1 / Chapter 1.1.1.1 --- HIV structure and genome organization --- p.1 / Chapter 1.1.1.2 --- HIV life cycle --- p.3 / Chapter 1.1.1.3 --- HIV genotypes --- p.5 / Chapter 1.1.2 --- HIV epidemiology --- p.6 / Chapter 1.1.2.1 --- Global HIV epidemiology --- p.6 / Chapter 1.1.2.2 --- HIV epidemiology in China --- p.9 / Chapter 1.1.3 --- HIV pathogenesis --- p.13 / Chapter 1.1.3.1 --- Natural history of HIV infection --- p.13 / Chapter 1.1.3.2 --- HIV transmission --- p.15 / Chapter 1.1.3.3 --- HIV tropism --- p.17 / Chapter 1.1.4 --- Immune responses to HIV infection --- p.19 / Chapter 1.1.4.1 --- Innate immune response --- p.19 / Chapter 1.1.4.2 --- Adaptive immune response --- p.21 / Chapter 1.1.5 --- Diagnosis --- p.24 / Chapter 1.1.6 --- HIV prevention --- p.25 / Chapter 1.1.7 --- Anti-HIV therapy --- p.25 / Chapter 1.1.8 --- Hepatitis B virus, Hepatitis C virus infection --- p.26 / Chapter 1.1.8.1 --- HBV infection natural history, diagnosis, disease progression and epidemiology --- p.26 / Chapter 1.1.8.2 --- HCV infection natural history, diagnosis, disease progression and epidemiology --- p.30 / Chapter 1.1.9 --- HIV, HBV, HCV co-infections --- p.32 / Chapter 1.2 --- Interleukin-27 --- p.36 / Chapter 1.2.1 --- Biology of IL-27 --- p.36 / Chapter 1.2.2 --- IL-27 on immune system --- p.37 / Chapter 1.2.3 --- IL-27 anti-tumor properties --- p.38 / Chapter 1.2.4 --- IL-27 antiviral features --- p.40 / Chapter 1.2.5 --- IL-27 with hepatitis --- p.41 / Chapter 1.3 --- Single-nucleotide polymorphisms (SNPs) --- p.42 / Chapter 1.3.1 --- Types of SNPs --- p.43 / Chapter 1.3.2 --- Functions of SNPs --- p.43 / Chapter 1.4 --- Objectives of the study --- p.45 / Chapter Chapter 2 --- Seroprevalence of HBV, HCV infection among HIV positive individuals in Shenzhen --- p.52 / Chapter 2.1 --- Introduction --- p.52 / Chapter 2.2 --- Materials and methods --- p.54 / Chapter 2.2.1 --- Study participants --- p.54 / Chapter 2.2.2 --- Measure of HBV, HCV seroprevalence --- p.55 / Chapter 2.2.3 --- Statistical analysis --- p.60 / Chapter 2.3 --- Results --- p.61 / Chapter 2.3.1 --- HIV infection in Shenzhen --- p.61 / Chapter 2.3.2 --- Seroprevalence of HBV, HCV infection among HIV positive individuals in Shenzhen --- p.61 / Chapter 2.4 --- Discussion --- p.65 / Chapter 2.4.1 --- HIV infection in Shenzhen --- p.65 / Chapter 2.4.2 --- HIV, HBV, HCV co-infections in Shenzhen --- p.68 / Chapter 2.4.3 --- Limitations of the study --- p.71 / Chapter Chapter 3 --- Upregulation of Interleukin-27 titer in HIV infected persons --- p.78 / Chapter 3.1 --- Introduction --- p.78 / Chapter 3.2 --- Materials and methods --- p.80 / Chapter 3.2.1 --- Study participants --- p.80 / Chapter 3.2.2 --- Measure of HIV, HBV, HCV infection --- p.80 / Chapter 3.2.3 --- Detection of IL-27 in plasma --- p.81 / Chapter 3.2.4 --- CD4 counting --- p.84 / Chapter 3.2.5 --- Statistical analysis --- p.84 / Chapter 3.3 --- Results --- p.84 / Chapter 3.3.1 --- Demographics of study participants --- p.84 / Chapter 3.3.2 --- Upregulation of IL-27 levels in HIV infected persons --- p.85 / Chapter 3.3.3 --- Correlation of plasma IL-27 titer with CD4⁺ T cell count --- p.86 / Chapter 3.4 --- Discussion --- p.86 / Chapter Chapter 4 --- Impact of HIV, HCV viral loads on Interleukin-27 titer among Antiretroviral Therapy- Naïve HIV positive Chinese --- p.95 / Chapter 4.1 --- Introduction --- p.95 / Chapter 4.2 --- Materials and methods --- p.96 / Chapter 4.2.1 --- Study participants --- p.97 / Chapter 4.2.2 --- HIV, HBV and HCV Serological assays --- p.97 / Chapter 4.2.3 --- CD4 counting --- p.97 / Chapter 4.2.4 --- Detection of plasma IL-27 --- p.98 / Chapter 4.2.5 --- Quantification of HIV, HCV viral loads --- p.98 / Chapter 4.2.6 --- Statistical analysis --- p.102 / Chapter 4.3 --- Results --- p.102 / Chapter 4.3.1 --- Demographics of study participants --- p.102 / Chapter 4.3.2 --- Plasma IL-27 was elevated in HIV-positive persons --- p.103 / Chapter 4.3.3 --- Correlation of IL-27 titer and CD4⁺ T cell count --- p.103 / Chapter 4.3.4 --- Correlation of HIV viral load and IL-27 titer --- p.104 / Chapter 4.3.5 --- Correlation of HCV viral load and IL-27 titer --- p.104 / Chapter 4.4 --- Discussion --- p.105 / Chapter Chapter 5 --- Association of Interleukin-27 polymorphisms with the susceptibility to HIV infection in a Chinese men who have sex with men population --- p.116 / Chapter 5.1 --- Introduction --- p.116 / Chapter 5.2 --- Materials and methods --- p.118 / Chapter 5.2.1 --- Study participants --- p.118 / Chapter 5.2.2 --- HIV screening --- p.118 / Chapter 5.2.3 --- Genomic DNA extraction --- p.119 / Chapter 5.2.4 --- IL-27 p28 -964A/G, 2905T/G and 4603G/A genotyping --- p.120 / Chapter 5.2.5 --- Statistical analysis --- p.121 / Chapter 5.3 --- Results --- p.122 / Chapter 5.3.1 --- Demographics of study participants --- p.122 / Chapter 5.3.2 --- IL-27 genotypes and allele frequencies in HIV MSM and healthy MSM controls --- p.122 / Chapter 5.3.3 --- LD analysis and haplotype analysis --- p.123 / Chapter 5.4 --- Discussion --- p.124 / Chapter Chapter 6 --- Summary and perspectives --- p.130 / Chapter 6.1 --- Summary --- p.130 / Chapter 6.2 --- Perspectives --- p.132 / Bibliography --- p.135

介紹.與確診多年的HIV陽性男男性接觸者（MSM）相比，新確診的HIV陽性男男性接觸者（N-MSM）傳播HIV的危險性更高，承受更多的心理健康問題，但愛滋病相關知識相對缺乏。目前的研究已經描述了N-MSM的心理健康和危險行為情況，但關於二者影響因素的調查卻甚少，且暫無關於N-MSM獨特相關因素，如疾病認知，安全套使用認知，安全使用的社會道德等的研究报告。目前，中國只有少量關於HIV陽性MSM的研究，無關於N-MSM的研究。 / 目的.本研究的目的包括： 1）描述中國N-MSM的心理健康和危險行為情況；2）驗證疾病認知量表在N-MSM人群的適應性；3）探討N-MSM疾病認知與心理健康（自殺意念，抑鬱，自我歧視和創傷後成長）的關係，並進一步研究在認知表徵與心理健康結果關係中，情感表徵的仲介作用與交互作用； 4）探索疾病認知與心理因素（抑鬱、自我歧視和創傷後成長）對自殺意念的獨立作用與交互作用；和5）研究愛滋病傳播相關危險行為的多方面因素。 / 對象與方法：本研究採用橫斷面研究設計，對中國成都共225名N-MSM進行了面對面訪談和電腦輔助移動電話訪談。根據Moss-Morris的方法，驗證疾病認知問卷的信度及效度； 使用單變量、多變量及分層的logistic和線性回歸等方法進行資料分析。 / 結果.在225名研究對象中，48%有自殺意念和抑鬱表現，35%自我歧視得分較高，17%有積極的創傷後成長。N-MSM的危險行為普遍存在：31%在確診感染後發生過非保護肛交性行為，40%認為在未來6個月意願與HIV陰性男性發生非保護肛交性行為，20%在感染後想過故意將HIV傳染給別人。經驗證，疾病認知問卷在N-MSM中具有良好的心理測量特徵。疾病認知的多個維度，如情感反應和治療控制等，與心理健康結果顯著相關。在認知表徵與心理健康結果的關係中，情感表徵表現出強烈的仲介作用。兩個疾病認知維度（情感反應與治療控制）和兩個心理因素（抑鬱和創傷後成長）對自殺意念有獨立作用，但無交互作用。影響N-MSM危險行為的多方面因素包括安全套相關認知，情感因素，心理健康和社會道德。 / 結論.本研究結果顯示中國N-MSM心理健康問題和危險行為是普遍存在的。疾病認知與心理健康結果的顯著聯繫，提示了可以通過改善N-MSM的疾病認知從而減少該人群的心理健康問題；在HIV領域中，這是一個新的研究方向。在對N-MSM危險行為的幹預研究中，需考慮影響N-MSM的獨特因素，如安全套相關認知，情感反應和社會責任等。 / Introduction.Newly diagnosed HIV positive men who have sex with men (N-MSM) comprise a special subgroup of HIV positive MSM, as they have higher risks of transmission via anal sex, suffer from more mental health problems, and possess less knowledge of HIV/AIDS than those who have been diagnosed for many years. Previous studies have investigated the prevalence of mental health and risk behaviours among N-MSMs, while few studies have explored the risk factors associated with these health-related outcomes, particularly the factors unique to N-MSMs, like illness perception, cognitions regarding condom use, social morality of condom use, etc. China provides only limited data about HIV positive MSM, and no such data is about N-MSMs. / Objectives.The aims of the study were to 1) investigate the characteristics of mental health and risk behaviours among N-MSMs in China; 2) validate the revised illness perception questionnaire (IPQ-R) modified for N-MSMs; 3) examine the effects of patients’ illness perception on their mental health outcomes and determine the mediating or moderating effects of emotional representation on the associations between cognitive representation and mental health outcomes; 4) examine the main effects and interaction effects of illness perception and psychological variables on suicidal ideation; and 5) investigate the multidimensional factors associated with risk behaviours related to HIV transmission. / Subjects and Methods.A cross-sectional study was conducted in Chengdu, China. A total of 225 N-MSMs participated in this study. Both face-to-face and computer-assisted mobile phone interviews were applied. The methodology by Moss-Morris was used to validate IPQ-R among N-MSMs. Univariate, multivariate, hierarchical logistic, and linear regression methods were used for data analysis. / Results.Of all participants, 48% had suicidal ideation and depression, and 36% reported self-stigma, but only 17% experienced posttraumatic growth (PTG). Risk behaviours were prevalent: 32% had had unprotected anal intercourse (UAI) since HIV diagnosis, 40% had the intention to have UAI with HIV negative men in the coming 6 months, and 20% had had thoughts of transmitting HIV to others purposely since HIV diagnosis. The modified IPQ-R for N-MSMs was validated and found to have acceptable psychometric properties. Most dimensions of illness perception (such as emotional response, treatment control and consequences) were significantly associated with mental health outcomes. Emotional representation had strong mediation effects rather than moderator effects on the associations between cognitive representation and mental health outcomes. Two illness perception dimensions (emotional response and treatment control) and two psychological variables (depression and PTG) showed independent effects on suicidal ideation, but not interaction effects on suicidal ideation. Multidimensional factors, such as variables related to cognitions of condom use, emotional affect (feelings of guilt regarding HIV transmission to others), mental health, and social morality (perceptions regarding responsibility for condom use), were associated with risk behaviours among N-MSMs. / Conclusions.The results show that mental health problems and risk behaviours are prevalent among Chinese N-MSM. Illness perception has a strong influence on mental health outcomes, indicating a new direction for the reduction of mental health problems via the modification of patients’ illness perception. Multidimensional factors are associated with risk behaviours related to HIV transmission, such as cognitions of condom use, emotional affection and social morality, which are unique to HIV infectors and should be considered in the development of intervention programs among N-MSMs. / Detailed summary in vernacular field only. / Detailed summary in vernacular field only. / Detailed summary in vernacular field only. / Detailed summary in vernacular field only. / Detailed summary in vernacular field only. / Wu, Xiaobing. / Thesis (Ph.D.)--Chinese University of Hong Kong, 2012. / Includes bibliographical references (leaves 257-276). / Electronic reproduction. Hong Kong : Chinese University of Hong Kong, [2012] System requirements: Adobe Acrobat Reader. Available via World Wide Web. / Abstract also in Chinese. / Abstract (English) --- p.i / Abstract (Chinese) --- p.i / Acknowledgements --- p.iii / List of Contents --- p.v / List of Tables --- p.xi / List of Figures --- p.xv / Abbreviations --- p.xvii / Chapter Chapter 1 --- Introduction --- p.1 / Chapter 1.1 --- Background --- p.1 / Chapter 1.2.1 --- The importance of HIV positive men who have sex with men as a source of HIV transmission --- p.1 / Chapter 1.2.2 --- The importance of newly diagnosed HIV positive MSM (N-MSM) --- p.3 / Chapter 1.2.3 --- Knowledge gaps about N-MSM --- p.4 / Chapter 1.2.4 --- Illness perception as a relative new perceptive in HIV research --- p.5 / Chapter 1.2 --- Aims --- p.7 / Chapter 1.3 --- Structure of the thesis --- p.10 / Chapter 1.4 --- Summary --- p.15 / Chapter Chapter 2 --- Literature review --- p.16 / Chapter 2.1 --- HIV epidemic --- p.16 / Chapter 2.1.1 --- Global HIV/AIDS epidemic --- p.16 / Chapter 2.1.2 --- HIV/AIDS in China --- p.17 / Chapter 2.2 --- MSM and HIV --- p.22 / Chapter 2.2.1 --- HIV epidemic among MSM worldwide --- p.22 / Chapter 2.2.2 --- HIV prevalence and incidence among MSM in China --- p.24 / Chapter 2.2.3 --- Risk sexual behavior among HIV positive MSM and its determinants --- p.25 / Chapter 2.2.4 --- Mental health problems faced by HIV positive MSM --- p.31 / Chapter 2.2.5 --- Studies of PLWH in China --- p.38 / Chapter 2.3 --- Newly diagnosed HIV positive MSM (N-MSM) --- p.43 / Chapter 2.3.1 --- HIV transmission risk varies at different stages of HIV infection --- p.43 / Chapter 2.3.2 --- More risky sexual behavior among N-MSM --- p.45 / Chapter 2.3.3 --- More stress and lack of knowledge among N-MSM --- p.46 / Chapter 2.3.4 --- Definition of N-MSM --- p.47 / Chapter 2.3.5 --- Studies about N-MSM --- p.47 / Chapter 2.4 --- Self-regulation model and illness representation --- p.51 / Chapter 2.4.1 --- Self-regulation model --- p.51 / Chapter 2.4.2 --- Illness representation --- p.52 / Chapter 2.4.3 --- Application of illness representation in HIV research --- p.60 / Chapter 2.5 --- Audio computer-assisted self-interviewing (ACASI) --- p.61 / Chapter 2.5.1 --- Types of questionnaire deliver modes --- p.61 / Chapter 2.5.2 --- Comparisons of sexual behavior reporting between ACASI and other delivery modes --- p.63 / Chapter 2.5.3 --- Limitations of ACASI --- p.65 / Chapter Chapter 3 --- Subjects and Methods --- p.67 / Chapter 3.1 --- The study site --- p.67 / Chapter 3.2 --- Study population --- p.68 / Chapter 3.3 --- Recruitment of study participants --- p.68 / Chapter 3.4 --- Data collection procedure --- p.69 / Chapter 3.4.1 --- Face-to-face interview --- p.70 / Chapter 3.4.2 --- Computer-assisted mobile phone interview --- p.70 / Chapter 3.4.3 --- Service provision and incentives --- p.71 / Chapter 3.4.4 --- Sample size and the representativeness --- p.71 / Chapter 3.5 --- Quality control --- p.71 / Chapter 3.6 --- Establishment of the CAMP system --- p.72 / Chapter 3.7 --- Collaborator --- p.73 / Chapter 3.8 --- Measurements --- p.74 / Chapter 3.9 --- Statistical analysis --- p.83 / Chapter 3.10 --- Ethical approval --- p.85 / Chapter Chapter 4 --- Participant profiles --- p.86 / Chapter 4.1 --- Background --- p.86 / Chapter 4.2 --- Objectives --- p.87 / Chapter 4.3 --- Statistical analysis --- p.87 / Chapter 4.4 --- Results --- p.87 / Chapter 4.4.1 --- Background information --- p.87 / Chapter 4.4.2 --- Mental health outcomes --- p.88 / Chapter 4.4.3 --- HIV secondary transmission related behaviours --- p.90 / Chapter 4.4.4 --- Service utilization and quality of life --- p.94 / Chapter 4.5 --- Discussion --- p.95 / Chapter Chapter 5 --- Validation of the revised illness perception questionnaire among newly diagnosed HIV positive MSMs --- p.111 / Chapter 5.1 --- Background --- p.111 / Chapter 5.2 --- Objectives --- p.112 / Chapter 5.3 --- Modification and translation --- p.113 / Chapter 5.4 --- Statistical analysis --- p.114 / Chapter 5.5 --- Results --- p.116 / Chapter 5.5.1 --- Items of the main cognitive representation subscales --- p.116 / Chapter 5.5.2 --- Items of the emotional response subscale --- p.117 / Chapter 5.5.3 --- Items of the causal attribution subscale --- p.118 / Chapter 5.5.4 --- Examination of the identity subscale --- p.118 / Chapter 5.5.5 --- Descriptions of the derived subscales --- p.119 / Chapter 5.5.6 --- Inter-correlations among subscales --- p.119 / Chapter 5.5.7 --- External validity --- p.120 / Chapter 5.5.8 --- Associations between background variables and illness perception --- p.120 / Chapter 5.6 --- Discussion --- p.121 / Chapter Chapter 6 --- Relationships between illness perception and mental health outcomes among N-MSM --- p.132 / Chapter 6.1 --- Background --- p.132 / Chapter 6.2 --- Objectives --- p.134 / Chapter 6.3 --- Statistical analysis --- p.136 / Chapter 6.3.1 --- Analysis of the associations between illness perception and mental health outcomes --- p.136 / Chapter 6.3.2 --- Analysis of the mediation effects of emotional response on the associations between cognitive representation and health related outcomes --- p.137 / Chapter 6.3.3 --- Analysis of moderating effects of emotional response on the associations between cognitive representation and mental health outcomes --- p.139 / Chapter 6.4 --- Results --- p.140 / Chapter 6.4.1 --- Suicidal ideation --- p.140 / Chapter 6.4.2 --- Depression --- p.142 / Chapter 6.4.3 --- Self-stigma --- p.145 / Chapter 6.4.4 --- Posttraumatic growth --- p.147 / Chapter 6.5 --- Summary --- p.149 / Chapter 6.5.1 --- Associations between illness perception and health related outcomes --- p.149 / Chapter 6.5.2 --- Summary of the mediation effects of emotional response on the association between cognitive representation and health related outcomes --- p.150 / Chapter 6.5.3 --- Summary of the moderating effects of emotional response on the association between cognitive representation and health related outcomes --- p.150 / Chapter 6.6 --- Discussion --- p.151 / Chapter Chapter 7 --- The main and interaction effects of illness perception and other psychological variables on suicidal ideation among N-MSM --- p.177 / Chapter 7.1 --- Background --- p.177 / Chapter 7.2 --- Objectives and hypothesis --- p.179 / Chapter 7.3 --- Data analysis and results --- p.180 / Chapter 7.3.1 --- Associated factors of suicidal ideation in univariate analysis --- p.180 / Chapter 7.3.2 --- The associations between illness perception / psychological variables and suicidal ideation --- p.180 / Chapter 7.3.3 --- The independent effects of emotional response/treatment control and psychological variables on suicidal ideation --- p.182 / Chapter 7.3.4 --- Analysis of the interaction effects between illness perception and psychological variables onto suicidal ideation --- p.184 / Chapter 7.4 --- Discussion --- p.184 / Chapter Chapter 8 --- Risk behaviours related to HIV transmission and associated factors --- p.197 / Chapter 8.1 --- Background --- p.197 / Chapter 8.2 --- Objectives --- p.199 / Chapter 8.3 --- Statistical analysis --- p.202 / Chapter 8.4 --- Results --- p.203 / Chapter 8.4.1 --- Factors associated with having had UAI with men since HIV diagnosis --- p.203 / Chapter 8.4.2 --- Factors associated with intention to have UAI with HIV negative men in the coming 6 months --- p.205 / Chapter 8.4.3 --- Factors associated with having the thoughts of transmitting HIV to others purposively since HIV diagnosis --- p.206 / Chapter 8.5 --- Discussion --- p.207 / Chapter Chapter 9 --- Conclusions --- p.225 / Chapter 9.1 --- Summaries and interpretations of findings related to mental health --- p.225 / Chapter 9.1.1 --- Poor mental health status --- p.225 / Chapter 9.1.2 --- A validated revised illness perception questionnaire (IPQ-R) among N-MSM --- p.226 / Chapter 9.1.3 --- Strong associations between illness perception and mental health outcomes --- p.226 / Chapter 9.1.4 --- Significant associations between illness perception / other psychological variables and suicidal ideation --- p.227 / Chapter 9.2 --- Summaries and interpretations of findings related to risk behaviours --- p.228 / Chapter 9.2.1 --- Prevalent risk behaviours --- p.228 / Chapter 9.2.2 --- Factors affecting the risk behaviours related to HIV transmission and implications --- p.229 / Chapter 9.3 --- Service implications --- p.231 / Chapter 9.3.1 --- Intervention programs for reducing mental health problems --- p.231 / Chapter 9.3.2 --- Intervention programs for reducing risk behaviours related to HIV transmission --- p.233 / Chapter 9.3.3 --- Policy support in HIV prevention --- p.236 / Chapter 9.4 --- Study limitations --- p.238 / Chapter 9.5 --- Recommendations for future research --- p.239 / Chapter 9.5.1 --- Longitudinal studies --- p.239 / Chapter 9.5.2 --- Behavioural studies --- p.240 / Chapter 9.5.3 --- Intervention studies --- p.240 / Chapter 9.6 --- Conclusions --- p.241 / Chapter Appendix I --- Questionnaire for face-to-face interview --- p.243 / Chapter Appendix II --- Questionnaire for computer-assisted mobile phone interview --- p.254 / Reference --- p.257