為什麼愛滋感染者會延遲C型肝炎治療？
資料來源；基思·奧爾康 / 2022 年 7 月 26 日 /aidsmap / 財團法人台灣紅絲帶基金會編譯
圖片：Suzy Hazelwood/Pexels
根據美國訪談研究的結果，醫療保健提供者可能需要更加努力地與愛滋病毒和C型肝炎患者建立信任關係，同時更加關注克服對治療副作用的擔憂，以鼓勵不願開始治療的人服用C型肝炎藥物。
消除C型肝炎這一健康問題的主要障礙在於不願開始C型肝炎的直接抗病毒治療。與其他人相比，目前正在和以前曾吸毒者、無家可歸者和 CD4 計數低的 HIV 感染者等人開始C型肝炎治療的可能性更低，這需要更多有關人們為何延遲C型肝炎治療以及如何說服他們開始治療上的信息。
這項發表在《愛滋病與行為》上的美國研究調查了 2020 年和 2021 年美國康乃狄克州非裔美國人和拉丁裔愛滋病毒感染者開始接受C型肝炎治療的障礙。它是該州一項更大計畫的一部分，旨在促進HIV 感染者和C型肝炎患者的C型肝炎治療。
研究參與者是從為該州吸毒者提供愛滋病毒照護和服務的診所招募的。如果愛滋病毒感染者在診斷後延遲C型肝炎治療一年以上，他們就有資格參加這項研究。該研究招募了 21 人（12 人在過去一年接受治療，9 人未接受治療）進行採訪，採訪者在沒有結構化腳本的情況下探索了一組主題。採訪透過電話進行。
研究參與者的平均年齡為 59 歲，男女各佔一半。十名黑人，五名波多黎各人，五名白人和一名美洲原住民。 15 人有注射吸毒史，所有人都有藥物濫用史。除了一個人之外，所有人都在接受抗反轉錄病毒治療。自C型肝炎診斷後他們以往的 HIV 診斷的中位時間為25 年和 15 年。
採訪者在參與者的敘述中確定了他們選擇延遲C型肝炎治療的幾個關鍵主題。
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治療素養
參與者經常將缺乏症狀作為他們不需要治療的原因。他們還看到同齡人在沒有治療的情況下過著看似健康的生活，並得出結論認為他們不需要治療。
害怕副作用是避免治療的常見原因；參與者認為副作用可能很嚴重，並且副作用是任何藥物的必然結果。一位受訪者說：
「對於藥物我真的很有趣，有些東西我不會服用。因為副作用，我認為你是想殺了我」。
對治療期間需要戒酒或使用藥物的擔憂很常見。一些參與者推遲了治療，因為他們認為他們在治療期間需要戒酒，但他們覺得自己不能這樣做，而另一些參與者則擔心與直接作用的抗病毒藥物一起使用酒精或藥物會加重副作用或降低治療效果。
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複雜的壓力源
一些參與者在接受C型肝炎治療之前還存在其他他們認為需要解決的健康問題或生活問題。有些人擔心服用額外的藥物；其他人則認為他們需要處理住房或飲食問題，以便在開始治療之前建立一個安全的基礎，因為他們預計這會使人衰弱。
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同儕影響
同儕對干擾素治療副作用的看法也影響了考慮治療的意願。同儕經常對在使用藥物或酒精時進行直接抗病毒治療的可能性表示懷疑。
另一方面，最近接受治療的一些人表示，同伴完成治療的例子已經說服他們開始治療。一位說：
「我的朋友告訴我，我應該去做，因為它不是那麼難治療」。
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與醫療保健提供者間薄弱和短暫的關係
醫療保健提供者或多個提供者缺乏連續性已被證明是一些參與者的障礙。
「我過去每個月都來那家診所，每個月都是不同的醫生」。
對於其他人來說，由於他們接受愛滋病毒治療的經驗因而導矽他們對醫療保健提供者缺乏信任，影響了他們討論或考慮治療的意願。來自醫療提供者有關需要避免藥物（指濫用之藥物）或酒精使用的訊息也強化了對治療的消極態度。
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穩定和支持性的醫療保健提供者關係
四分之三開始治療的人是在與醫療保健提供者建立支持關係後開始治療的，後者將他們作為一個人肯花時間去了解他們並建立信任。支持性提供者肯花時間解釋C型肝炎和可用的治療方法，並允許參與者按照自己的節奏做出決定。一些參與者確信，如果出現任何副作用，他們可以停止治療，這讓他們有信心開始治療。
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建議
研究人員建議醫療保健提供者可以透過以下方式促進C型肝炎治療的採用：
• 提供有關副作用的詳細訊息以解決問題
• 獲取以前藥物副作用的完整歷史，以解決患者不信任的根源
• 透過針對藥物使用、藥物相互作用、依從性和再感染風險進行坦誠對話，消除酒精、藥物和C型肝炎治療無法混合的看法
• 與已經完成C型肝炎治療的人建立伙伴關係，以促進接受治療，例如透過演講活動、支持小組和一對一的參與。
參考文獻：
Brothers S 等人。針對採用直接作用的抗病毒藥物 (DAA) 治療C型肝炎的看法：對HIV/HCV 合併感染者延遲或拒絕治療的定性分析。 AIDS and Behavior，2022 年 7 月 1 日線上發布（開放獲取）。https://doi.org/10.1007/s10461-022-03749-8
Why do people with HIV delay hepatitis C treatment?
Keith Alcorn / 26 July 2022 / aidsmap
Suzy Hazelwood/Pexels
Greater efforts by healthcare providers to build trusting relationships with people with HIV and hepatitis C, together with a greater focus on overcoming concerns about treatment side effects, are likely to be needed to encourage people reluctant to start treatment to taking hepatitis C medication, according to the findings of a US interview study.
Reluctance to begin direct-acting antiviral treatment for hepatitis C is a major barrier to elimination of hepatitis C as a health problem. Current and former drug users, people who are homeless and people with HIV who have low CD4 counts are less likely to have started hepatitis C treatment than others, but more information is needed about why people delay hepatitis C treatment and how they might be persuaded to start treatment.
The US study, published in AIDS and Behavior, looked at barriers to beginning hepatitis C treatment among African American and Latino people living with HIV in the US state of Connecticut in 2020 and 2021. It formed part of a larger programme in the state to promote hepatitis C treatment among people with HIV and hepatitis C.
Study participants were recruited from clinics providing HIV care and services for people who use drugs in the state. People with HIV were eligible to join the study if they had delayed hepatitis C treatment for more than a year after diagnosis. The study recruited 21 people (12 treated in the past year, nine untreated) for interviews in which interviewers explored a set of themes without a structured script. Interviews took place by phone.
Study participants had a mean age of 59 years, with an even split between women and men. Ten were Black, five Puerto Rican, five White and one Native American. Fifteen had a history of injecting drug use and all had a history of substance use disorder. All but one was taking antiretroviral therapy. The median time since HIV diagnosis was 25 years and 15 years since hepatitis C diagnosis.
Interviewers identified several key themes in participants’ accounts of why they had chosen to delay hepatitis C treatment.
Treatment literacy
Participants often cited a lack of symptoms as a reason they didn’t need treatment. They also saw peers living apparently healthy lives without treatment and concluded that they did not need it.
A fear of side effects was a common reason for avoiding treatment; participants believed that side effects could be severe and that side effects were an inevitable consequence of any medication. One interviewee said:
“I’m real funny about medication, there’s some things I won’t take. Because of the side effects and I think you’re trying to kill me.”
Concerns about the need to abstain from alcohol or substance use during treatment were common. Some participants delayed treatment because they believed they would be required to abstain during treatment and did not feel able to do so, while others feared that using alcohol or drugs alongside direct-acting antivirals would make the side effects worse or diminish the effectiveness of treatment.
Complex stressors
Some participants had other health problems or life issues they felt needed to be dealt with before committing to hepatitis C treatment. Some had concerns about taking extra medication; others felt that they needed to deal with housing or diet issues to establish a secure grounding before starting treatment, as they expected it to be debilitating.
Peer influences
Peer perceptions of the side effects of interferon-based treatment also affected willingness to consider treatment. Peers often reinforced doubts about the possibility of taking direct-acting antiviral treatment while using drugs or alcohol.
On the other hand, some who had been treated recently said that the example of peers completing treatment had persuaded them to start treatment. One said:
“My friend told me that I should go do it because it ain’t that hard of a treatment.”
Weak and transitory healthcare provider relationships
A lack of continuity in health care providers or multiple providers had proved a barrier for some participants.
“Every month I used to come to that clinic, every month was a different doctor.”
For others, a lack of trust in their healthcare provider as a result of their experiences with HIV treatment affected their willingness to discuss or consider treatment. Messages from providers about the need to avoid drugs or alcohol also reinforced negative attitudes towards treatment.
Stable and supportive healthcare provider relationships
Three-quarters of those who initiated treatment did so after establishing a supportive relationship with a healthcare provider who took the time to get to know them as a person and built trust. Supportive providers invested time in explaining hepatitis C and the available treatment and allowed participants to make a decision at their own pace. Some participants were reassured that they could stop treatment if any side effects occurred, and this gave them confidence to start.
Recommendations
The study investigators recommend that health care providers can promote the uptake of hepatitis C treatment by:
•Providing detailed information about side effects to address concerns
•Taking a full history of previous medication side effects to address the roots of patient distrust
•Addressing perceptions that alcohol, drugs and hepatitis C treatment do not mix by having frank conversations about substance use, drug interactions, adherence and the risks of reinfection
•Building on peer relationships with people who have already completed hepatitis C treatment to promote the uptake of treatment, for example through speaker events, support groups and one-to-one engagement.
References
Brothers S et al. Perceptions towards HCV treatment with direct acting antivirals (DAAs): a qualitative analysis with persons with HIV/HCV co-infection who delay or refuse treatment. AIDS and Behavior, published online 1 July 2022 (open access).
https://doi.org/10.1007/s10461-022-03749-8