Poor patients are more likely to start HIV therapy if they
believe that treatment will benefit their health, that they will be able to
maintain high levels of adherence, and that they are ready to start treatment,
investigators from San Francisco report in the online edition of the Journal of Acquired Immune Deficiency
“Among this sample of the urban poor living with HIV,
expectancies about ease of treatment, efficacy of treatment and reports of
readiness for treatment are sensitive predictors of treatment uptake,” comment
Improvements in HIV treatment and care mean that many
HIV-positive patients now have a normal life expectancy. There is also growing
evidence that virologically suppressive antiretroviral therapy significantly
However, large number of patients who could potentially
benefit from antiretroviral treatment are not yet taking therapy. One group of
patients in the US with poor treatment uptake is the urban poor. Many
individuals in this group face multiple barriers to the successful management
of their HIV infection. These include access to care, mental health problems,
homelessness, drug and alcohol use, financial difficulties, and unstable
Mistrust of the healthcare system, beliefs about the
efficacy of antiretroviral therapy, concerns about side-effects, and
reservations about personal abilities to adhere to treatment can also mean that
some patients do not start therapy.
Research conducted in other disease areas has shown that
patient beliefs about readiness to take therapy and expectations about
treatment outcomes influence the ulitisation of health services.
Therefore investigators from the University of San Francisco
designed a study to investigate the possible role of patients’ beliefs about
treatment on the subsequent uptake of antiretroviral therapy.
Their study sample comprised 88 individuals recruited in the
Tenderloin district of San Francisco. All were HIV-positive, and despite
meeting current US guideline criteria for the initiation of HIV therapy (a CD4
cell count below 500 cells/mm3), none were currently taking
Most (85%) of the sample were men, 47% were African
American, and their mean age was 44 years. Almost half reported an annual
income below $10,000, three-quarters reported ever being homeless, 53% a
lifetime history of injecting drug use, and 80% said they had been incarcerated
at some point.
“Persons with a history of incarceration may have
particularly challenging barriers to accessing treatment,” write the authors.
On entry to the study the patients completed a
questionnaire. This measured expectations about the ease of treatment (e.g.,
“Taking HIV medications on schedule would be easy for me.”), expectations about
the effectiveness of therapy (e.g., “HIV medications would help me live
longer.”), readiness to take treatment (e.g., “I am ready to take HIV
medications.”), and concerns about stigma (e.g., “I would not want people to
know that I am taking HIV medication.”.
Individuals had follow-up interviews at regular intervals
over a twelve-month period when they were asked if they had started
antiretroviral treatment. The investigators conducted an analysis to see if any
of their measures predicted which patients would initiate treatment.
Overall, 60% of patients started antiretroviral therapy.
There was no difference in the baseline median CD4 cell counts of the patients who started
treatment and those who did not (237 cells/mm3 vs. 248 cells/mm3).
Nor were there any significant demographic differences between initiators and
However, patients who believed that they would be able to
adhere to treatment were significantly more likely to start taking anti-HIV
drugs (p = 0.001), as were individuals who believed in the efficacy of
treatment (p = 0.03), and those who expressed confidence in their readiness for
therapy (p = 0.0008).
There was no evidence that concerns about stigma affected
the uptake of treatment.
“Next steps in this line of research are to determine
whether expectancy-based beliefs predict subsequent ART adherence and
persistence,” write the authors. They also believe that a further research
priority is “to see whether these beliefs are modifiable by interventions, and
to test whether such interventions can alter the trajectory toward more timely
initiation of stable, life-saving therapy for those who need it.”
The investigators conclude that improving treatment uptake
“is particularly important given the personal benefit and potential reduced
risk of transmission that appear to accompany early treatment of HIV.”