The purpose of the proposed study is to investigate the processes by which patients decide whether to accept or reject their medical provider's recommendation to begin anti-retroviral therapy (ART). ART has dramatically extended the lives and reduced the suffering of people with HIV, but many clinically eligible patients refuse ART. Others stop ART without notifying their medical providers. There is some evidence that interpretive schemas and cognitive distortions may play a role in decision-making about ART. Schemas and cognitive biases may affect ART decision-making if they distort individuals' perceptions of risks, benefits, outcome probabilities, and the credibility of health information sources. Additionally, patients and medical providers may use different health criteria for deciding when ART should be initiated. The proposed study will examine how these processes affect decisions about ART in a sample of 150 persons with HIV who are patients in an inner-city clinic serving a largely disadvantaged, African-American population. Subjects will complete a structured interview and a battery of questionnaires examining their beliefs about health, illness, and HIV at baseline and at 6- and 12-month follow-up. Medical variables such as lab values and opportunistic infections will be recorded from electronic clinical databases. Questionnaire responses and medical factors will be used to predict acceptance of ART or change in intentions towards ART during the follow-up period. Questionnaire measures will also be used to examine differences between patients who overtly refuse ART and those who refuse ART covertly, e.g., by self-discontinuing ART. It is hypothesized that interpretive biases will play a significant role in ART decision-making, and that patients will weigh symptoms and other observable indices of health as more important to ART decision-making than lab values. It is also hypothesized that patients who overtly refuse ART will display a higher level of psychosocial functioning and more trust in the health care system than those who covertly reject ART. ? ?
To the extent that interpretive schemas and cognitive distortions lead persons with HIV to reject ART for reasons which are not empirically supported or are based on misconceptions, this represents a significant source of preventable morbidity and mortality related to HIV. Inadequate medical treatment results in higher viral loads, and therefore greater infectivity. If combined with decreased prevention behavior, which has also been found to be linked to mistrustful schemas about HIV, the result is likely to be greatly enhanced transmission of HIV to uninfected individuals. ? ? ?
