This article reviews an aspect of daily clinical practice which is of critical importance in virtually every clinical consultation, but which is seldom formally considered. Non-clinical influences on clinical decision-making profoundly affect medical decisions. These influences include patient-related factors such as socioeconomic status, quality of life and patient's expectations and wishes, physician-related factors such as personal characteristics and interaction with their professional community, and features of clinical practice such as private versus public practice as well as local management policies. This review brings together the different strands of knowledge concerning non-clinical influences on clinical decision-making. This aspect of decision-making may be the biggest obstacle to the reality of practising evidence-based medicine. It needs to be understood in order to develop clinical strategies that will facilitate the practice of evidence-based medicine

https://journals.sagepub.com/doi/pdf/10.1258/jrsm.2010.100104

Non-clinical influences on clinical decision-making: a major challenge to evidence-based practice.

OBJECTIVE To present a review of barriers impeding people living with HIV/AIDS in developing countries from accessing treatment, and to make recommendations for further studies. METHODS Electronic databases, websites of main global agencies and international AIDS conferences were searched for relevant articles published between 1996 and 2007. Articles were reviewed using the Andersen and May framework of access to health services and barriers were categorized as either population-level or health system-level barriers. RESULTS A total of 19 studies (7 articles and 12 abstracts) in English were reviewed. The barriers most frequently cited at the population level were lack of information about antiretroviral therapy (ART), perceived high costs for ART and stigma. Barriers most frequently cited at the health system level were long distance from home to the health facility, lack of co-ordination across services and limited involvement of the community in the programme planning process. CONCLUSIONS Dissemination of information about HIV/AIDS and alternative related care, and alternative health financing policies seem to be the most relevant policy measures to remove barriers. In view of the paucity of evidence on barriers to access to ART, research should address the relative importance of barriers, include a mix of qualitative and quantitative research methods and evaluate barriers in different settings.

https://onlinelibrary.wiley.com/doi/pdf/10.1111/j.1365-3156.2008.02091.x

Barriers to access to antiretroviral treatment in developing countries: a review

The rollout of antiretroviral therapy (ART) significantly reduced human immunodeficiency virus (HIV)-related morbidity and mortality, but good clinical outcomes depend on access and adherence to treatment. In resource-limited settings, where over 90% of the world’s HIV-infected population resides, data on barriers to treatment are emerging that contribute to low rates of uptake in HIV testing, linkage to and retention in HIV care systems, and suboptimal adherence rates to therapy. A review of the literature reveals limited evidence to inform strategies to improve access and adherence with the majority of studies from sub-Saharan Africa. Data from observational studies and randomized controlled trials support home-based, mobile and antenatal care HIV testing, task-shifting from doctor-based to nurse-based and lower level provider care, and adherence support through education, counseling and mobile phone messaging services. Strategies with more limited evidence include targeted HIV testing for couples and family members of ART patients, decentralization of HIV care, including through home- and community-based ART programs, and adherence promotion through peer health workers, treatment supporters, and directly observed therapy. There is little evidence for improving access and adherence among vulnerable groups such as women, children and adolescents, and other high-risk populations and for addressing major barriers. Overall, studies are few in number and suffer from methodological issues. Recommendations for further research include health information technology, social-level factors like HIV stigma, and new research directions in cost-effectiveness, operations, and implementation. Findings from this review make a compelling case for more data to guide strategies to improve access and adherence to treatment in resource-limited settings.

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Current strategies for improving access and adherence to antiretroviral therapies in resource-limited settings.

India's National AIDS Control Organization (NACO) provides free first-line antiretroviral treatment (ART) at government centers for people living with HIV. To assist in developing policies and programs to ensure equity in ART access, we explored barriers to ART access among female sex workers (FSWs) living with HIV in Chennai. Between August and November 2007, we conducted three focus group discussions and two key informant interviews. Data were explored using framework analysis to identify categories and derive themes. We found interrelated barriers at the family/social, health care system/programmatic, and individual levels. Major barriers included fear of adverse consequences of disclosure of HIV status due to stigma and discrimination associated with HIV and sex work, lack of family support, negative experiences with health care providers, lack of adequate counseling services at government centers and by outreach workers employed by nongovernmental organizations (NGOs), perceived biased treatment of FSWs who are not referred by NGOs, lack of adequate knowledge about ART, and fatalism. Barriers can be addressed by: creating effective measures to reduce stigma associated with HIV/AIDS and sex work at the familial, societal, and health care system levels; incorporating information about ART into targeted interventions among FSWs; training counselors at government hospitals and NGO outreach workers on treatment issues; improving infrastructure and staffing levels at government centers to allow adequate time and privacy for counseling; and implementing government mass media campaigns on ART availability. Finally, it is crucial that NACO begin monitoring ART coverage of FSWs and other marginalized populations to ensure equitable ART access.

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Barriers to free antiretroviral treatment access for female sex workers in Chennai, India.

Adherence to antiretroviral therapy (ART) and correlates of adherence and virologic suppression among human immunodeficiency virus (HIV)-infected persons receiving ART in private outpatient clinics in India is unknown. Between December 2004 and April 2005 persons receiving ART at 3 private clinics in Mumbai India were interviewed regarding HIV care and adherence to ART. Physicians also completed a survey for each participant. Quantitative HIV-1 RNA level was determined for 200 participants. Of 279 participants 73% reported >/= 95% adherence to ART. Adherence was positively associated with age >/= 50 years (adjusted odds ratio [aOR] 3.90) presence of comorbid conditions (aOR 1.92) medication selfefficacy (aOR 4.01) absence of pain in the past month (aOR 2.14) and support from family and friends (aOR 2.57). Lack of reminders from family members to take medication (aOR 0.27) was negatively associated with adherence. Of 200 participants 127 (63.5%) had virologic suppression (RNA level /=3 ART drugs (aOR 5.52) first ART regimen (aOR 3.28) adherence to therapy >/= 95% (aOR 5.70) female sex (aOR 3.19) and a physical component score >/= 50 (aOR 1.07). Self-reported adherence to ART in a sample of patients attending Mumbais private clinics was relatively high. However the fact that a detectable viral level was found in nearly 40% of patients suggests that second-line ART regimens as well as an emphasis on adherence and appropriate ART regimens in India is needed. (authors)

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Adherence to Antiretroviral Therapy and Virologic Suppression among HIV-Infected Persons Receiving Care in Private Clinics in Mumbai, India

India has approximately 5.2 million persons infected with HIV. Although antiretroviral therapy (ART) is being widely introduced in public clinics, many HIV-infected persons still seek care via the private sector. A cross-sectional survey was conducted in 2004 at six public and private sites to characterize the knowledge, attitudes, and practices (KAP) of ART among patients with HIV receiving care in India. Of 1667 persons surveyed, 609 (36%) had heard of ART and 19% of these persons reported that ART could cure HIV. Twenty-four percent reported that they were currently taking ART, with 18% of these patients not actually on ART according to their provider. Major barriers to taking ART were cost (33%), lack of knowledge of ART (41%), and deferral by physician (30%). More than half of all public and private patients had not heard of CD4 (57%) or viral load testing (80%), and even fewer had received these tests (32% and 11%, respectively). Private clinic attendees were almost 4 times more likely to be on ART ...

Sikhamani Rajasekaran

Papers

Knowledge, attitudes, and practices of antiretroviral therapy among HIV-infected adults attending private and public clinics in India.