The vast majority of HIV-positive patients retain a trusting relationship with their HIV doctor after starting antiretroviral therapy, according to a French study published in the April 1st edition of the Journal of Acquired Immune Deficiency Syndromes.
But about 7% of patients lost trust in their doctor after starting treatment with anti-HIV drugs, and the investigators found that that this was associated with health beliefs, specifically that anti-HIV treatment was not beneficial, poor provision of information to patients, and life-style factors such as smoking.
Effective anti-HIV therapy now means that many, if not most, HIV-positive patients will have the chance of living a near-normal life-span. Patients and their doctors will have to develop a trusting relationship that could last decades. French investigators wanted to see the nature and evolution of the relationship between HIV-positive patients and their doctors and to see if they could identify any factors that could lead to a breakdown of trust.
A total of 1026 patients who started anti-HIV treatment that included a protease inhibitor between 1997 and 1999 were included in the study. They were followed for five years. On entry to the study, and then every four months, the patients completed a questionnaire and were asked to rate their level of trust in their doctor on a scale from 4 (“total confidence”) to 0 (“no confidence whatsoever”).
The investigators wanted to see if there were any factors associated with a loss of trust and therefore also included a range of questions on issues including lifestyle factors, such as smoking and drug use, health beliefs, and HIV treatment changes and side-effects.
On entry to the study, nearly all the patients (943, 96%), reported having a trusting relationship with their HIV doctor. No factors were associated with a lack of trust at this time.
The median duration of follow-up was 48 months, and during this period 68 patients (7%) reported having one or more breaks in trust in their relationship with their HIV physician. In 50% of cases trust was subsequently reestablished, but in 35% the breakdown in trust was permanent. Many patients (20, 29%) experienced a break of trust on the four months after antiretroviral therapy was started, but the proportion of patients reporting problems with trust steadily declined after that.
Investigators found that a number of factors were associated with a loss of trust. These included younger age (odds decreased with each one year increase in age), regular cigarette smoking, a perception that antiretroviral therapy was not beneficial , dissatisfaction with information provided by doctors, more antiretroviral-associated side-effects, and a low baseline CD4 cell count.
“It is important to underline that a large proportion of patients from the cohort reported having a trusting relationship throughout the entire first 5-year period of follow-up after being [antiretroviral therapy]”, comment the investigators, adding, “a trusting patient-provider relationship seems to be quite a stable characteristic.”
The investigators note the association between side-effects and loss of trust. They comment it “is essential to understand the process that leads to a break of trust…self-reported side-effects consist of a subjective evaluation and can be regarded as a good marker of patients’ difficulties in managing their treatment on a daily basis.”
They also note the association between smoking and a loss of trust, and suggest that this could be because of the attitudes of doctors towards smoking. The investigators comment, “pressure to change smoking habits could destabilize the patient-provider relationship.”
Preau M et al. Prevalence and predictors of deterioration of a trustful patient-provider relationship among HIV-infected persons treated with antiretroviral therapy. J Acquir Immune Defic Syndr 47: 467 – 471, 2008.