愛滋病防治模式的運作 －從強效抗愛滋治療HAART相關的整體醫療照顧，到危險族群的介入

THE INTERVENING MODEL FOR THE PREVENTION AND CONTROL OF HIV/AIDS --- FROM INTEGRATED CARE OF HAART TO INTERVENTION OF HIGH RISK COHORTS

蔡季君(Jih-Jin Tsai)

指導教授 ： 陳田柏 ； 顏正賢

高雄醫學大學/醫學院/醫學研究所/博士(2006年)

https://doi.org/10.6832/KMU.2006.00043

摘要

總摘要

強效抗愛滋療法HAART (highly active antiretroviral therapy)是極有效能長期控制愛滋病毒之療法，但是病人之服藥遵從性(adherence)卻是決定成敗最重要之關鍵。臺灣自民國86年4月引進，由於剛開始藥物選擇有限，因此在標準HAART組合下，服藥次數複雜、藥顆多且副作用大，使得服藥遵從性相當困難。服藥遵從性又與藥物副作用、顆粒數與次數有關。而且病人心理層面之問題、服藥之動機皆是服藥遵從性之重要因素。因此自民國86年至90年間，如何選擇適當的HAART，如何處理副作用，到如何增加病人服藥遵從性，成為第一階段防治愛滋的首要難題；因為成功的治療，可以降低傳播速率，而且因為有效且免費，鼓勵病人就診，成為防疫的重點。病人的湧現，但相對的相關醫療團隊的協調不足，造成感染科醫師照顧的困難與窘境；因此相關的醫療團隊的願意加入協助成為防治愛滋的第二重要議題。而疾病造成病人的沉重之心理、社會壓力，亦影響接受治療意願及服藥遵從性，這是第三重要議題。因此第一階段的防治，針對HAART所衍生醫療層面及心理層面問題，需求一個完整醫療團隊的整體照顧。
本研究第二章接受強效抗愛滋療法 HAART之病人之整體照顧—從醫療層面到心理層面之評估與介入，是自民國88年至89年間，即是針對第一階段防治愛滋所遇到的難題的背景下所完成之研究，重點在解決臨床困境。發現不同HAART組合，產生不同的療效，也因急慢性副作用及服藥之便利性與否，因而服藥遵從性亦有差異。在此研究中也發現，逐漸浮現的長期副作用，將來可能使治療更加複雜化。在生活品質問卷、貝氏憂鬱量表及社會支持量表評估下，五成以上病人有憂鬱傾向；總觀交叉影響憂鬱及生活品質之因素為HAART副作用、罹病後工作或學業表現程度退步。精神科醫師的協助顯然有其必要。感染科於民國87年成立之病友會及設立的紅絲帶網站，也扮演與病人溝通與教育的相當重要的管道。而在感染科的努力下，也逐漸有精神科、皮膚科、胃腸科、外科、牙科、婦產科醫師的加入幫忙；於是屬於高醫完整醫療團隊的整體照顧終於成型。
自民國91年至92年間，一方面由於國外有HAART間斷性療法之初步報告，病人開始自行停藥；再加上HAART所造成之長期副作用，尤其是高血脂引發的心臟血管疾患及某些藥物引起的臉部脂肪萎縮，而使病人對HAART卻步，而該何時開始HAART 也令國內外專家漸趨保守，而不再是感染即早期使用--- 所謂Hit early、Hit hard。民國92年後SARS時期，愛滋患者驟增，尤其年輕患者、毒癮愛滋患者、婦幼愛滋患者，成為民國93年後至今相當嚴重的問題。第二階段防治愛滋的重點已由被動治療層面到須主動尋找危險族群及有效的介入。
在本研究第三章從愛滋病匿名篩檢諮詢到外籍新娘愛滋感染之研究，即應用民國93年剛通過美國FDA之快速檢驗--口腔唾液愛滋病抗體篩檢試劑OraQuick於部分匿名篩檢者及病人，並且應用至社區實施外籍新娘愛滋篩檢。發現口腔愛滋病抗體篩檢試劑的靈敏及專一性與血液ELISA檢驗方式相當，由於匿名篩檢ELISA檢驗工作天需3-5天，不僅受試者感到焦慮；難料愛滋病毒可能在此段時間經由性行為或其他管道造成傳播。而OraQuick，可以在20-40分鐘得知結果，再加上操作便利，適合將來使用於愛滋病匿名篩檢及醫護人員之針扎事件中對未知狀態之病人來源做快速檢驗。雖然在這一次外籍配偶(134人次)進行愛滋病抗體篩檢後並無發現HIV陽性個案，但透過我們的執行過程發現部份的外籍配偶相關政策值得檢討。
在本研究第四章，臺灣地區阿米巴痢疾感染在不同臨床族群與愛滋病毒感染者間之前瞻性血清盛行率研究，由近年來研究顯示愛滋病毒感染的男同性戀者，較易有高致病性阿米巴原蟲帶原率，如果藉由人與人的接觸和飲食污染，未來將會是公共衛生的一大威脅。因此，自民國89年至93年，以五年期間進行前瞻性血清致病性阿米巴抗體，以血清流行病學的方法，了解侵犯性阿米巴感染的盛行率與發生率。並自94年起迄今，同時利用特殊抗原檢驗，篩檢追蹤愛滋病毒感染者與尚未發生愛滋病毒感染的男同性戀者的糞便和血清檢體，以了解其帶原率。我們進行不同愛滋病毒感染風險族群的阿米巴血清流行病學調查。過去五年中我們針對持續收集的愛滋病毒感染者(667位)、到醫院接受愛滋病毒匿名篩檢者(1311位)、因腸胃病症到院就醫的非愛滋病毒感染者(616位)和接受健康檢查者(2500位)的血清檢體，進行阿米巴抗體檢驗，我們的結果發現這四族群的阿米巴抗體高效價(IHA titer ³128)的盛行率分別是：7.1%、2.5%、1.8%、0.1%。愛滋病毒感染者的阿米巴抗體高效價盛行率遠高於其他受試者族群。其中高效價盛行率最高的族群是30-39歲的男同性戀者，陽性率高達11.2%。未來針對醫事人員的持續教育和男同性戀者的衛生教育中，強調新的痢疾阿米巴的感染途徑，並且針對社區中散發的侵犯性阿米巴感染的對象流行病學調查中加入了性行為和接觸對象的追蹤。從持續進行中的計劃希望可以更加了解在高危險族群之阿米巴帶原率，以幫助後續臨床在治療此類病人之策略方針。並從侵犯性阿米巴患者找出愛滋感染高風險族群，視為愛滋病防治之重要一環；對於危險族群之持續不間斷之衛教諮商，仍是現階段對預防愛滋病與侵犯性阿米巴最重要的介入方法。

關鍵字

愛滋病毒感染 ； 強效抗愛滋療法 ； 服藥遵從性 ； 愛滋療法藥物副作用 ； 愛滋療法療效 ； 憂鬱 ； 生活品質 ； 愛滋病匿名篩檢諮詢 ； OraQuick檢驗 ； 外籍配偶 ； 愛滋病防治教育 ； 侵犯性阿米巴原蟲疾病 ； 痢疾阿米巴原蟲 ； 阿米巴原蟲感染 ； 台灣

並列摘要

English Abstract

The globally rapid surge of HIV/AIDS patients threatened and challenged the public health system. HAART (highly effective antiretroviral therapy) is the mainstay powerful therapy for HIV infection. Therapeutic adherence is the key factor contributing to its success. There are several factors affecting patients’ adherence, including the drug side effects, pill burden, dosing frequency, psychosocial problems and the motivation of taking drugs. We tried to find the optimal model for these problems and helped the patients tolerate long-term HAART medications without interruption. It belonged to an important part for HIV/AIDS prevention since it can reduce the infectivity of HIV.

On the other side, we should seek for the high risk cohorts with the tendency to acquire HIV. Through studies of anonymous voluntary counseling test, HIV screening of inbound foreign brides, seroprevalence of invasive amebiasis which homosexual males were prone to acquire, we regarded that actively finding out these high risk cohorts and giving them counseling/education for prevention of HIV/AIDS and sexual transmitted diseases (STDs) were the most important measures for intervention.

Up to Nov. 2000, we analyzed 88 patients under long-term HAART. The percentage of effective HAART, which was defined as viral load less than 500 copies/ml after six-month treatment, was 88.6% among these patients and that of strict control, which was defined as viral load less than 50 copies/ml after six-month treatment, was 50.5%. We analyzed 78 patients under three main HAART regimens, including 24 patients of PI (protease inhibitor)-based, 33 of NNRTI (Non-nucleoside reverse transcriptase inhibitor)-based and 21 of 3NRTIs (Nucleoside reverse transcriptase inhibitors) HAART. The patients treated with NNRTI-based HAART had significantly higher percentage of low viral (load less than 50 copies/ml) than those with PI-based HAART. The patients treated with PI-based HAART were significantly prone to develop drug adverse effects than those with 3 NRTIs and NNRTI-based HAART. The patients receiving these three HAART regimens all developed hyperlipidemia (ranging from 27.3% to 37.5%) and glucose intolerance (ranging from 4.2% to 6.1%).

We used the questionnaires which contained the following six items to approach the medical and psychological problems of these HIV-infected patients under regular HAART. (1) WHO-QOL-BREF (WHO quality of life in brief), Taiwan version, (2) BDI (Beck Depression Inventory), (3) Social support, (4) HAART adverse event recording, (5) HAART adherence, (6) HIV-related symptoms and signs. Of the 41 cases analyzed, 51.2% were under depression after HAART. Among them, 47.6% showed moderate to severe depression. HAART adverse effects and subjective feeling of regression either in work or in school were significant factors common in those after diagnosing or acquiring HIV/AIDS in our evaluation from QOL and BDI questionnaire.

Our studies addressed important medical support in every aspect for HIV patients. We should detect their depression as early as possible and if they are in moderate to severe status, we need to transfer them to the psychiatrist for appropriate intervention, either prescribing anti-depressants or applying psychotherapy. According to the correlated factors, we suggest the attending physician should discuss and explain in details to HIV cases about every aspects of the disease, including the drug adverse events and how to cope with them before initiating HAART. The fact of acquiring HIV infection cast great impact on patients either physically or mentally. Individual psychotherapy or group therapy should be delivered to the mal-adapted cases.

We have addressed the importance of HIV integrated care to cover the physical and psychosocial problems -- the organization of HIV care team consisting of physicians in every special field, nurses, social workers and case managers. We must offer any kind of support and help as possible and as best as we can. Our HIV cohort comprised 70% of young people. For them, to take HAART lifelong is not an easy task. To achieve the goal of persistent regular long-term HAART to our patients, we applied the individual case management, group education via the club activity and internet website which we started two years ago. The integrated effect of such care model reflected on the high percentage of successful treatment response and adherence in our cohort. It is worthwhile to promote such model to care HIV patients.

We undertook the project of HIV anonymous screening program of Department of Health (DOH) from 2000 to 2004. We offered the voluntary counseling testing (VCT) of HIV for the anonymous volunteers coming to our hospital for help, including education for safer sex practice and the free tests for anti-HIV ELISA and Western blot. We found 88 patients (4.5%) with HIV infection among 1950 anonymous volunteers. For HIV victims, we transferred them to our infection specialists for further management, granted them with the information about the supportive system from any hospital, community or society, and helped them to face coming problems, including medication, privacy, and employment. We also encouraged them to take their intimate sex partners for HIV testing. For anonymous volunteers of negative results, it didn’t mean they were really free of risks to acquire HIV infection, because they belonged to the high risk groups; therefore we focused on giving them the updated knowledge pertaining to the prevention of HIV/AIDS and STDs. We set up one telephone line only for them and maintained the website to let them keep in contact with our team and access any information or counseling conveniently but highly confidentially.

The result of anti-HIV ELISA test required 3 to 5 days. During the waiting period, the anonymous volunteers were frequently anxious about their results; on the other hand, there were always risks that HIV might be spread through sexual behaviors or other pathways during this period. In 2004, FDA of U.S.A. issued permit for OraQuick Rapid HIV-1/2 Antibody test which could be applied for the specimens in saliva, whole blood and serum. The practice of this test for saliva was very convenient and the result was available within 20-40 minutes. During the waiting period for the result, the staff could give them important knowledge for the prevention of HIV/AIDS and STDs at once.

Therefore, In Taiwan, we first applied this powerful tool for another DOH project of investigation of HIV status among the inbound foreign brides in 2004. This study focused on the investigation of HIV status among the inbound foreign brides in Kaohsiung City. We used both the HIV ELISA blood tests and the OraQuick test as the first step screening. Meanwhile, we delivered to them the important knowledge regarding the HIV/AIDS, STDs and safe sex practice. We also chose 30 anonymous volunteers and 40 HIV/AIDS cases under regular long-term treatment for the OraQuick test. The sensitivity and the specificity were 100%. 134 foreign brides were enrolled into this study. We hold 12 activities for HIV antibody screening and AIDS prevention education toward foreign spouses in church, primary school and community. The foreign spouses were mainly from Mainland China 47% (63/134) and Vietnam 47% (63/134), followed by Indonesia 2.2% (3/134), Philippines 1.5% (2/134), Cambodia 0.7% (1/134) and Thailand 0.7% (1/134). Their main occupation was housekeeper 79.9% (107/134). The average education level was low with 65.7% (88/134) below junior high school. During their daily practice, 53.7% (72/134) didn’t use condom and 43% (55/134) raised only one child. According to the questionnaire, the rate of their concurrent STDs was 14.6% (19/134), but no one was HIV-positive from our laboratory tests. Despite no HIV case were found from this study, we had found that the government policy in managing the foreign spouses required reform. We also strongly recommended the great potential of the OraQuick test to apply to the VCT for the convenience, time-saving and comparable sensitivity and specificity with HIV ELISA test.

From 2000 to 2004, we assessed the seroprevalence of Entamoeba histolytica infection using indirect hemagglutination antibody (IHA) assay among 667 HIV-infected persons (group 1), 1311 HIV-uninfected persons seeking anonymous HIV testing (group 2), 616 HIV-uninfected controls with gastrointestinal symptoms (diarrhea and/or liver abscess) seeking medical care (group 3), and 2500 healthy controls undergoing health check-up (group 4). An IHA titer greater than 128 was detected in 7.1% of group 1, 2.5% of group 2, 1.8% of group 3, and 0.1% of group 4 (p<0.0001). The highest seroprevalence (11.2%) was noted among HIV-infected persons who were men having sex with men (MSM) aged 30 to 39 years. Compared with persons with gastrointestinal symptoms, the adjusted odds ratio for having high IHA titers among HIV-infected persons was 3.206 (95% confidence interval, 1.433, 7.176) (p=0.005). These findings demonstrated that HIV-infected persons, especially MSM group aged 30 to 39 years, were at significantly higher risk of E. histolytica infection.

並列關鍵字

HIV-1 infection ； HAART ； Adherence ； adverse effects of HAART ； Efficacy of HAART ； Depression ； Quality of life ； Integrated care ； HIV anonymous screening test ； Voluntary counselling test ； Inbound foreign brides ； Oraquick test ； Taiwan ； Amebiasis ； Invasive amebiasis ； Seroprevalence of amebiasis

參考文獻

第一章

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