Beliefs about efficacy of HIV treatment predict which urban poor patients start antiretroviral therapy

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 Syndromes.

“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 the investigators.

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 reduces infectiousness.

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 housing.

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 antiretroviral treatment.

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 non-initiators.

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.”