「愛滋病個案管理師計畫」對於HIV感染者性行為、服藥遵從性及健康狀況的影響

Abstract

背景：自抗愛滋病毒藥物(highly active antiretroviral therapy; HAART)引進，免費提供給國內HIV感染者後，HIV感染者預期壽命逐年增加，伺機性感染之比率及死亡率顯著下降，但相對地卻也由於感染者健康狀況的改善，因此導致不安全性行為（如：未固定性伴侶、未戴保險套與他人發生性行為）及對HAART藥物服藥遵從性不佳等情形之發生，因而造成愛滋病毒傳播，形成人類嚴重之威脅；有鑒於此，疾病管制局於2005年10月開始進行愛滋病個案管理試辦計畫，並於2007年1月擴大實施該計畫。本研究主要目的為了解台灣的『愛滋病個案管理師計畫』的介入，對於HIV感染者在性行為、服藥遵從性及健康狀況等方面是否有所影響，如有影響其改變型態分布與趨勢變化結果，同時亦探討個管計畫成效與研究對象社會人口學特質及行為特性之相關性。 方法：本研究為評價研究(evaluation research)，採取單組實驗設計方式，包含1次前測及2次後測，以2007年疾病管制局『愛滋病個案管理師計畫』資料庫為主要研究工具，並以2007年1月至12月加入疾病管制局『愛滋病個案管理師計畫』之連續就診3次（包含初診1次同時複診2次）且年滿15歲以上之HIV感染者為研究對象，研究方法除以群體層次分析方式，分別描述研究對象接受3次個管之不同行為面向及健康狀況面向整體結果分布外，並以個體層次分析方式，進行同一名個案接受3次個管前後行為及健康狀況變化之分析，最後則採多變量分析方式，藉以檢視個管計畫成效與研究對象個人特質（如：社會人口學及行為等）之相關性。 結果：研究結果發現研究對象經接受3次的個案管理後，在性行為、就醫行為、HAART服藥遵從及健康狀況等方面，均有正向之改善，且大部分的個案在初診及複診第1次之間的變化幅度較大，其中以性行為之「保險套的使用情形」變化最大，進步最為明顯，HIV感染者家人知情部分，改善情形則最少，顯示社會對於愛滋病的歧視及標籤化，很難單純經由個管計畫介入而獲得改善。此外，依多變量迴歸分析結果顯示，女性相較於男性、大學教育程度以上者相較於高中職教育程度者，以及異性間性行為者相較於同性及雙性間性行為者，於保險套使用行為之表現均較差，進一步研究結果亦發現，個案自覺健康狀況愈好且CD4值愈高，較容易發生性行為，個案自覺健康狀況愈差且CD4值愈低，則較不容易發生性行為。 結論：個案管理計畫的介入，使HIV感染者在行為及健康狀況等方面均有顯著且正向之改善，建議應加以推廣及宣導，讓更多HIV感染者早日加入個管計畫；而個管計畫的成效亦應進行更長期的評估及監測，以確保其成本效益；建議個管計畫未來應將醫院個案管理模式與其他社會資源服務及介入措施進行有效整合。

Background: Since the highly active antiretroviral therapy (HAART) was introduced and freely provided for HIV infected persons, their lives have been prolonged, and the opportunistic infections and death rate are also significantly reduced accordingly. However, parallel to this improvement of health status has been the increase of unsafe sexual behaviors (e.g. lack of fixed sexual partners, and sex without condom) and poor adherence to HAART, which pose serious threat to further HIV transmission. In response to this newly emerged hazard, the HIV Case Management Program (HIVCMP) has been launched by Taiwan CDC since October, 2005, and was greatly extended on January 2007. The purpose of this study is to assess the effects of HIVCMP on sexual behaviors, adherence to HAART, and health status among HIV positive clients in Taiwan, and, if any, what are the patterns and distributions of changes in these regards? Furthermore, in what ways are clients’ sociodemographics and behavioral characteristics associated with the effects of HIVCMP.

Method: This evaluation research applies a one group experimental design with one pre-test and two post-tests. Data for the study comes from the database of 2007 CDC HIV Case Management Program. Only clients 15 years and older and have made three consecutive visits (one baseline and two regular visits) were included in the study. In addition to describe the distribution of different aspects of behavior and health status outcomes at the group level in each visit, the data analysis also present behavioral and health status changes at the individual level. Finally, multivariate analyses were conducted to examine which individual characteristics (sociodemographics and behavioral) associated significantly to the program effects. Results: The initial stage of HIVCMP has shown significant effects on clients’ sexual practices, medical care visits, HAART adherence, and health outcomes, and a sharp improvement was found from the baseline to the first regular visit in virtually all behavioral and health outcomes. “Condom use,” among participants who reported having engaged in sexual behavior, in particular, improved most drastically. “Disclosure of HIV status to family member,” however, was least improved, indicating a profound social discrimination attached to HIV/AIDS that is hard to be tackled with by HIVCMP. Multivariate analysis through regression indicated that female, college education and beyond, heterosexual performed poorer in behavior related to condom use. Further analysis also showed that self-reported better health status and higher CD4 counts tended to practice sex, as compared to those who perceived poor health status and had lower CD4 counts.

Conclusion: The initial effects of HIVCMP on HIV clients’ behavior and health status were significant, supporting an extended outreach effort to recruit more HIV infected persons to participate. However, the effect should be monitored and assessed for a longer period of time to assure its sustainment and pursue cost-benefit as well. It is suggested that future HIV case management should be beyond medical model to integrate with other social services and interventions.