Grimes Richard M, Grimes Deanna E
Department of Medicine, The University of Texas Health Science Center, Houston, TX, USA.
J Int Assoc Provid AIDS Care. 2013 May-Jun;12(3):185-94. doi: 10.1177/1545109712454334. Epub 2012 Aug 17.
This paper examines the scientific bases for the recommendations on readiness, trust, and adherence that were contained in 5 HIV treatment guidelines.
The authors reviewed the treatment guidelines of 5 internationally recognized expert panels, and 5 review articles on readiness, trust, and adherence to determine the evidence for the guidelines' recommendations. These review articles were assessed to determine whether they contained: 1) a definition of the concept, 2) a measure that predicted outcomes, or 3) evidence that a replicable intervention altered outcomes.
There is no good definition, measure, or evidence that readiness predicts adherence. There were no interventions that improved readiness in a clinically useful way. There was no good definition or measure of trust, nor was there evidence that patient trust predicts adherence or that interventions improve trust. It is not clear whether trust is a cause or an effect of clinical outcomes. There is agreement that adherence is defined as taking medications as prescribed. Six measures of adherence were found, and several studies showed that they correlated poorly when applied to the same sample of patients. Adherence interventions have had some success but are poorly described and idiosyncratic such that it is difficult to replicate them in other settings.
Research on readiness and trust are unlikely to yield useful results. Systematic, long term research on clinician-based adherence interventions must be done. A life-long process such as adherence to antiretroviral treatment is unlikely to be understood without having a long-term study of a cohort of patients taking these medications.
本文探讨了5份艾滋病治疗指南中关于治疗准备度、信任和依从性建议的科学依据。
作者查阅了5个国际认可的专家小组的治疗指南，以及5篇关于治疗准备度、信任和依从性的综述文章，以确定指南建议的证据。对这些综述文章进行评估，以确定它们是否包含：1）概念的定义；2）预测结果的指标；3）可复制干预措施改变结果的证据。
对于治疗准备度预测依从性，没有良好的定义、指标或证据。没有以临床有用的方式改善治疗准备度的干预措施。对于信任，没有良好的定义或指标，也没有证据表明患者信任能预测依从性或干预措施能改善信任。尚不清楚信任是临床结果的原因还是结果。人们一致认为，依从性的定义是按规定服药。发现了6种依从性指标，几项研究表明，当应用于同一组患者样本时，它们之间的相关性很差。依从性干预措施取得了一些成功，但描述不佳且具有独特性，因此难以在其他环境中复制。
关于治疗准备度和信任的研究不太可能产生有用的结果。必须对基于临床医生的依从性干预措施进行系统的长期研究。如果不对服用这些药物的一组患者进行长期研究，就不太可能理解像坚持抗逆转录病毒治疗这样的终身过程。
