Assessing HIV/AIDS patients’ access to antiretroviral drugs using the healthcare accessibility framework: a cross-sectional study from Shandong, China | BMC Infectious Diseases

Assessing HIV/AIDS patients’ access to antiretroviral drugs using the healthcare accessibility framework: a cross-sectional study from Shandong, China | BMC Infectious Diseases

Study setting and participants

This is a cross-sectional survey conducted in three high-HIV burden cities located in eastern (Yantai), central (Jinan), and western (Heze) parts of Shandong Province. The designated hospital covers the vast majority of HIV/AIDS patients in the region. Taking into account the number of HIV/AIDS patients admitted by these hospitals and their willingness to participate, we used purpose sampling to select one designated hospital each in Yantai, Jinan, and Heze as the survey sites.

Stevens suggested that in studies analyzing influencing factors, the sample size should be determined based on the number of variables, and that at least 5 sample observations are needed per question. Given that the survey questionnaire designed for this study includes 51 questions, a minimum of 255 patients are required [17]. Considering potential invalid samples, the sample size was increased by 15%, resulting in a planned survey of 300 patients, with 100 questionnaires collected from each of the three designated hospitals.

The inclusion criteria for the participants are: patients who a) were confirmed positive for HIV RNA through HIV diagnostic testing; b) have been diagnosed for six months or longer and are receiving antiviral treatment; c) aged 18 or above; d) were willing to participate in the study and sign informed consent. We excluded patients who: a) were delirious or mentally abnormal; b) had cognitive disabilities. Information on cognitive disabilities was gathered from community health service center records.

Data collection

From August to December 2022, the researchers assisted by one physician from each designated hospital conducted a questionnaire survey. The questionnaire was designed based on previous studies and a focus group discussion with experts in clinical medicine and public health. Information collected included general demographic characteristics, utilization of health services, drug availability, disease burden in the past year, treatment compliance and so on. Before conducting the questionnaire survey, we uniformly trained the physicians who assisted us to ensure they had a consistent and accurate understanding of the questionnaire items. These physicians were responsible for ART treatment at the designated hospitals, helping us build trust with HIV/AIDS patients more quickly. We selected survey participants using a convenience sampling method, in which physicians explained the research purpose and questionnaire to HIV/AIDS patients. After obtaining informed consent, questionnaires were distributed. If patients had any questions, the physicians would explain to them.

Before starting the formal questionnaire, a pilot study was conducted in Jinan to test and improve the questionnaire. With the help of physicians, we conveniently sampled 10 patients at an HIV/AIDS designated hospital in Jinan to complete questionnaires after obtaining their informed consent. Their feedback, along with suggestions from physicians, was then used to revise the questionnaire for better readability and accuracy.

Variable definition and measurement

According to the Levesque framework, we defined specific variables related to the five abilities of HIV/AIDS patients to access ART drugs.

Ability to perceive relates to the fact that people facing health needs can actually identify the existence of some form of services and understand that these services have an impact on their health. This understanding could be facilitated by health information and other outreach activities [13]. In this study, the corresponding variable was respondents’ self-reported knowledge of HIV/AIDS progression and medication, evaluated using a 3-point scale.

Ability to seek is influenced by the degree of acceptability of services, which is determined by cultural and social factors [13]. The two variables we used to reflect this ability are whether you experience social discrimination and whether you do not choose to reimburse due to fear of privacy disclosure.

Ability to reach reflects the fact that being physically and timely reachable affects the accessibility of health services [13]. The corresponding variable was the number of hours spent each time buying drugs.

Ability to pay refers to the economic capacity to access services [13]. The corresponding variable was the incidence of catastrophic drug expenditures. We introduced the World Health Organization (WHO)-recommended concept of ‘catastrophic expenditure’ based on previous research [18,19,20]. We defined a household as incurring catastrophic drug expenditures when the annual out-of-pocket spending on antiretroviral drugs for HIV/AIDS patients equaled or exceeded 10% of the household’s total income.

Ability to engage in healthcare will be linked to patient participation in decision-making and treatment decisions, which are closely linked to the concepts of self-efficacy and self-management [13, 14]. In this study, we used the HIV Treatment Adherence Self-Efficacy Scale (HIV-ASES) score to reflect this ability. Treatment compliance was measured using the HIV-ASES [21]. Sun et al. have translated this scale into Chinese and verified that the Chinese version has high reliability and validity among people living with HIV in mainland China [22]. The scale uses a 12-item questionnaire to assess patients’ confidence in their ability to perform important treatment-related behaviors associated with their treatment plan. Each item is scored on a scale ranging from 1 (cannot do it at all) to 10 (certainly can do it). The total score of the scale is 120, and the higher the score, the greater the compliant self-efficacy. Based on previous studies, we defined a score > 110 as indicating high compliance and a score ≤ 110 as indicating low compliance [23].

In clinical practice, the CD4 + T-lymphocyte count has become the best indicator for staging HIV disease progression and guiding drug therapy. According to the WHO guideline [24], individuals with a CD4 cell count < 200 cells/µL are diagnosed with advanced HIV disease (AHD). We divided the participants into two groups based on their most recent CD4 cell count: those with a CD4 cell count < 200 cells/µL (stage 3 or 4) and those with a CD4 cell count ≥ 200 cells/µL (stage 1 or 2).

Data analyses

Descriptive statistics were calculated, with Chi-squared tests being used for categorical variables such as city, sex, place of residence, age group, years of formal education, marital status, and health insurance. Multiple logistic regression analysis was used to assess the impact of potential confounding variables. Initially, we identified influencing factors through multiple regression analysis, utilizing all socio-demographic information as independent variables and variables reflecting patients’ ability to access drugs as dependent variables. Subsequently, we conducted multiple regression analyses with CD4 cell count level as the dependent variable, and socio-demographic information and patients’ ability to access drugs as the independent variables, to explore the relationship between patients’ drug access and their CD4 cell count level. A collinearity test was conducted prior to performing the logistic regression. A P value < 0.05 was considered statistically significant.

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