| Summary: | 碩士 === 國立臺灣大學 === 健康政策與管理研究所 === 105 === Background: According to Centers for Disease Control, a total of 32,237 human immunodeficiency virus (HIV)-positive cumulative cases have been reported in Taiwan as of June 2016, and the number of live patients (including those with Acquired Immune Deficiency Syndrome [AIDS]) is 26,898, while there are about 2,000 new cases every year. Among live patients approximately 5,000 did not receive treatment, accounting for around 20-30% of all live patients. To increase the number of HIV-positive patients who receive treatment is therefore an important issue. According to epidemiological literature, the early use of antiretroviral drugs can effectively reduce the amount of HIV virus in the body, enhance patient immunity and significantly contribute to health and better quality of life. In addition, comparing with those who do not receive treatment, the infectious ability of HIV-positive patients who receive stable treatment and have non-detectable level of virus amount reduce significantly. In 2015, the World Health Organization (WHO) released the latest guidelines on the treatment of HIV/AIDS. The most vital change is to loosen the recommended therapeutic range for adults. The original criterion was that antiretroviral treatment was recommended for patients with a level of CD4+ cells less than 500 cells/μL, and this was changed to “all HIV-positive patients should be treated (regardless of the level of CD4+ cells)”. This change would nevertheless significantly impact on decision-making about receiving treatment among patients. In recent years, the Joint United Nations Program on HIV and AIDS (UNAIDS) announced it goal to achieve “90-90-90” by 2020. That means by 2020, 90% of all people living with HIV will know their HIV status; 90% of all people with diagnosed HIV infection will receive sustained antiretroviral therapy; and 90% of all people receiving antiretroviral therapy will have viral suppression, to conform to the principle of “Treatment as prevention (TasP)”. Past international research on the factors influencing the decision to receive antiretroviral treatment has pointed out the importance of several factors, such as economic factors, individual factors, drug and medical beliefs, daily plans, and interpersonal relationships. Especially, the economic factors are shown to be particularly critical. In Taiwan, related previous studies have mainly focused on medication adherence rather than to decision to receive and initiate treatment. At the same time, the Taiwanese government has implemented the policy of comprehensive subsidy of the anti-retroviral drugs, which would not only eliminate the economic barriers to receiving treatment but also make different considerations among HIV-positive patients regarding receiving treatment from those shown in international research results.
Object: The aim of this study was to understand factors influencing the decision to receive or refuse antiretroviral treatment among patients with HIV in Taiwan.
Methods: We conducted a qualitative study to explore the factors influencing HIV-positive patients’ decision to receive or refuse antiretroviral treatment. By using in-depth interview method to collect data, we interviewed 21 HIV-positive patients and three medical professionals with snowball sampling and open recruitment. The inclusion criteria for HIV-positive patients included an age of 20 years or older and a confirmed diagnosis of HIV infection; those for medical professionals (infectious disease specialists or specialized case managers of HIV-positive patients) included an age of 20 years or older and past experiences of providing care for HIV-positive patients. The interviews were transcribed into verbatim transcripts and analyzed according to the open coding principle proposed by Strauss and Corbin (1997).
Result: Factors that affect the patients’ willingness to receive treatment could be assigned into three levels, i.e. individual, interpersonal, and environmental / structural levels. These factors would also evolve and change over the life course, namely an additional time dimension. At each of three levels, the most important factors were: (1) self-perceived health (individual level): patients judged their own health status according to their perception, feeling, or biologic substitute index (CD4+ cell number). When patients considered themselves healthy or in good health condition, or they tended to deny or ignore their own infection status, they would tend to decide not to receive treatment; (2) privacy protection issue (interpersonal level): most patients made efforts to hide their infection from being exposed to other people. However, the possession of antiretroviral medications, taking the medications in front of others, and the medical records are likely to expose their infection status. Therefore, they would refuse to receive treatment as a result of this concern; (3) medical service environment (environmental / structural level): experiences of interacting with medical professionals would impact on patients’ decision to receive treatment. Positive experiences, friendly environment, and good doctor–patient relationship would result in more trust in health care providers and allow them opportunities to discuss their concerns with health care providers; the process would then contribute to agreed and appropriate treatment plans for patients. On the contrary, negative experiences will lead to rejection toward health care system, loss of follow-up, and treatment refusal.
Conclusion: In this study we conducted in-depth interviews to identify major factors influencing the decision to receive antiretroviral treatment among HIV-positive patients in Taiwan and found the importance of self-perceived health, privacy concerns, and doctor-patient relationship. The economic factors that were emphasized in the international research had an impact only among a small number of disadvantaged patients. Regarding prevention and control strategies, we can strive to develop channels for unimpeded dissemination of information, an HIV friendly social atmosphere, good doctor-patient relationships, and adequate support for patients with a deprived socioeconomic condition, with an aim to help patients to develop a more comprehensive understanding into their health status based on unbiased information, the true impact of the virus on their health, and the benefits and and potential side effects of the treatment. It is expected that these strategies could reduce the barriers and enhance the willingness of receiving antiretroviral treatment among HIV-positive patients.
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