2025-01-012025-05-05https://scholars.lib.ntu.edu.tw/handle/123456789/728807子計畫一因危險性行為增加及型態改變，性傳染病自1990年代開始有增加的趨勢。男同性戀者、雙性戀者和其他男男性行為者(GBMSM)受到愛滋病毒(HIV)和許多其他細菌性傳染病的影響尤為顯著。隨著抗HIV藥物的進步及HIV暴露前預防性藥物(HIV PrEP)的使用，HIV傳播的風險已顯著降低，且其感染發生率亦同時下降。但其他細菌性性傳染病(包括梅毒、淋病、以及披衣菌)的發生率，仍繼續增加。此因缺乏性健康認知、社會污名化、篩檢涵蓋率不足、診斷工具有限、以及缺乏有效藥物或疫苗預防措施等因素所致。近年來使用doxycycline作為具風險性行為後細菌性傳染病的預防(doxycycline PEP)，其效果已獲得研究證實。然而在臨床情境中，關於doxycycline暴露後細菌性性傳染病預防的有效性與可行性的研究仍然相當稀少，且尚未能充分推廣至具風險性行為之個案。因此應針對具有風險性行為者，規劃合適的治療照護模式。本計畫將針對具有風險性行為者，建立完整的性傳染病預防及整合式醫療服務模式，包含性傳染病篩檢(包含愛滋病毒、梅毒、其他細菌性傳染病原、病毒性肝炎)、性傳染病治療與回診追蹤、推廣 HIV PrEP, doxycycline PEP, 和性傳染病相關疫苗施打。此外，我們將建立醫療院所跨院際與跨科別橫向合作模式，期能更廣泛提供風險族群合適且專屬之性傳染病照護模式。 子計畫二根據目前的「抗人類免疫缺乏病毒藥品處方使用規範」，台灣的HIV感染者可以選擇四種三合一單錠處方藥物（STR）或一種二合一單錠處方作為第一線治療。四種三合一藥物包括TAF/FTC/RPV （Odefsey）、TDF/3TC/DOR （Delstrigo）、ABC/3TC/DTG（Triumeq）、TAF/FTC/BIC（Biktarvy），而二合一藥物則是DTG/3TC （Dovato）。這些複方藥物主要包含核苷酸反轉錄酶抑制劑（NRTIs），並結合非核苷酸反轉錄酶抑制劑（nNRTIs）或嵌合酶抑制劑（INSTIs）。根據以往的研究，大多數患者的治療效果良好，但少數患者可能因服藥依從性不佳、藥物濃度不足或感染時已攜帶抗藥性病毒株，導致治療失敗。在未能有效控制病毒的情況下，感染者群體中可能會出現抗藥性突變，這可能會影響後續的藥物選擇。隨著接受抗病毒治療的人數增加，未來數十年內對有效治療方案的需求將持續增長，因此了解治療失敗中的抗藥性突變普遍性及其影響至關重要。本計畫旨在針對新診斷且尚未接受治療的HIV感染者提供抗藥性檢查，為後續藥物調整提供參考，並了解台灣抗藥性盛行率及其對新診斷患者治療效果的影響。我們將使用斯坦福大學的“HIV抗藥性數據庫”進行抗藥性基因型分析，分析藥物涵蓋第一線處方藥，包括反轉錄酶抑制劑（RTI）、蛋白酶抑制劑及嵌合酶抑制劑等三大類。我們期望此研究成果能了解台灣的原生性抗藥性盛行率，及第一線三合一或二合一複方藥物的治療效果。並對於治療失敗者，檢測其病毒的抗藥性，從而改善臨床治療，並為疾病管制署提供政策參考。 子計畫三隨著抗HIV藥物的進展，愛滋病毒感染者的存活率大大的增加。但若個案服藥順從性低，會導致病毒量無法控制、健康狀況不佳、甚至病毒產生抗藥性和/或增加HIV傳播的風險。在高效能抗病毒藥物的時代，影響服藥順從性的因子，分為四大類：個人、藥物相關、服務及結構上的因素、和其他因子。研究證實，能有效提高抗病毒治療藥物順從性的介入措施，有多種面向，包括提供教育、諮詢、家庭與社會支持、回饋和額外監督。透過各種3C電子產品所提供的服務及簡訊發送的資訊，可針對影響服藥順從性的多項因素進行介入，以改善藥物順從性。另外，透過與社區藥局合作，共同監督和提醒個案的領藥，亦可改善病患服藥順從性。根據2024年台大醫院困難個案問卷研究結果，多數(31.5%)表示沒有回診的原因是「沒有時間回診」，其次是因情緒低落憂鬱(23.6%)。至於為何想回診的原因，超過半數(65.4%)表示「自己該回來面對」，其次(22.0%)是「個管師、衛生所人員找我回診」。個案大部分(62.2%)漏藥的原因是「忘記服藥」，其次(21.3%)是「太累睡著」。本計劃為前瞻性研究，如果可行，將於114年院內開放視訊門診時，申請HIV感染者的視訊門診，先以提供感染科門診為主，發展平日上、下午的視訊門診，徵求有意願參加之感染科醫師，再依醫師意願排定班表，並協調愛滋病個案管理師跟診。此外，詢問符合收案條件之個案，是否願意參與視訊門診。若個案同意，依院內視訊看診和領藥相關流程，完成視訊診療。同時配合院內藥局發藥時間，協助個案順利取得藥物。此外，亦詢問個案是否願意加入每周五天的通訊設備視訊或錄影都治服藥，藉以提醒個案服藥，進而養成按時服藥的習慣。 子計畫四有鑒於全面HIV篩檢和治療，是全球控制HIV疫情努力的重點。即便國外內持續提倡HIV篩檢及暴露前HIV預防性投藥使用，風險族群仍無法適時獲得愛滋病相關教育訊息，導致無法早期發現，進而診斷延遲。在HIV PrEP使用者中，因個人、社會及結構性障礙，使欲使用HIV PrEP民眾無法獲得資訊，或PrEP使用者在中斷使用後而感染。本研究計畫旨在利用LINE官方平台及人工智慧技術，提升HIV篩檢的可近性、增強PrEP的服藥順從性，並構建高風險族群的個案管理模式。主要目標包括：(1) 透過LINE平台使風險族群便捷獲取HIV篩檢資訊並預約篩檢；(2) 提供PrEP使用者服藥提醒與智能回應系統，協助個案按時服藥，減少中斷服藥情形；(3) 建立個人化的介入措施，確保高風險行為者的健康需求，能得到持續的提供和追蹤。本計畫將發展LINE平台結合志能客服，提供24小時HIV篩檢、諮詢及PrEP使用支持，並針對願意合作的醫療單位，推廣相關資訊。藉由風險族群的同儕效應，擴大平台影響，提升HIV篩檢率與HIV PrEP知識普及度，從而有效降低HIV延遲診斷及藥物順從性的問題。此計畫亦將為性工作者、跨性別者及女性等高風險族群，提供更廣泛的愛滋病預防及治療資源，促進篩檢率提升和及早診斷治療。 子計畫五世界M痘疫情持續發展，傳染防治相關策略與執行效果是各界關注的主題。疫苗施打及減少與感染者之親密接觸，是預防M痘傳染最直接的策略。然而這些防疫行為受多重因素影響，包括個人人口學特性，及健康信念。國際研究雖已提出，個人特定M痘相關健康信念對防疫行為的潛在影響，但仍缺乏系統性縱觀健康信念如何驅動或阻礙實際行為之研究。本計劃欲以混合研究法探索多元性別族群對M痘相關之健康信念與需求，及其對於M痘相關防疫行為之影響。詳細目的包括：調查及分析M痘疫苗族群 (1)針對M痘之自覺罹患性(perceived susceptibility)及自覺嚴重性(perceived severity)、(2) 針對M痘相關防疫行為之自覺行動利益(perceived benefits)、自覺行動障礙(perceived barriers)、自我效能(self-efficacy)及行動線索(cues to action)、(3) 安全性行為與M痘疫苗接踵之執行率、(4) 自覺罹患性、自覺嚴重性、自覺行動利益、自覺行動障礙、自我效能及行動線索與安全性行為與M痘疫苗接種之相關性、(5) M痘疫苗相關經驗及需求。本團隊欲藉由鑲嵌式設計之混和研究(mixed-methods with embedded design) 達到上述目的。做法為先由台大感染科團隊，自曾就診病人中識別潛在研究收納者(即18歲以上符合接受公費M痘疫苗施打的民眾)，邀請其線上填答M痘相關健康信念與行為問卷，再從中依照研究參與者之意願，進行立意抽樣(purposeful sampling)，以進行接續之敘述性質性研究(Qualitative descriptive study)。質性研究之資料收集將以半結構式訪談調查研究參與者對於M痘防治的經驗、感受與需求。量性及質性部分預估收案數分別為112及20位。本計畫成果將提供多元性別族群對M痘相關健康信念與防疫行為執行之現況報告，並試圖找出其相關性，以建議更精準之防疫策略。質性資料將補足量性調查之不足，期待橋接現行策略與民眾需求之落差。Subproject One Since the 1990s, there has been an increasing trend in sexually transmitted infections (STIs) due to increased risk behaviors and changing patterns. Gay, bisexual, and other men who have sex with men (GBMSM) are particularly affected by HIV and many other bacterial STIs. With advancements in anti-HIV medications and the use of HIV pre-exposure prophylaxis (HIV PrEP), the risk of HIV transmission has significantly decreased, and its incidence has also declined. However, the incidence of other bacterial STIs (including syphilis, gonorrhea, and Chlamydia) continues to rise. This is due to factors such as lack of sexual health awareness, social stigma, insufficient screening coverage, limited diagnostic tools, and lack of effective medications or vaccine prevention measures. In recent years, the use of doxycycline as post-exposure prophylaxis for bacterial STIs after high-risk sexual behaviors (doxycycline PEP) has been proven effective in research. However, studies on the effectiveness and feasibility of doxycycline PEP in clinical settings are still rare and have not been sufficiently promoted to high-risk individuals. Thus, appropriate treatment and care models should be planned for those engaging in high-risk behaviors. This subproject will establish a comprehensive STI prevention and integrated medical service model for high-risk individuals, including STI screening (such as HIV, syphilis, other bacterial pathogens, and viral hepatitis), STI treatment and follow-up, promotion of HIV PrEP, doxycycline PEP, and STI-related vaccine administration. Additionally, we will establish an interdisciplinary collaboration model among different departments or medical institutions to provide more timely and specialized STI care models for high-risk groups. Subproject Two According to the current "Prescription Use Guidelines for ART," PWH in Taiwan can choose from four thriple-drug or one dual-drug single-tablet regimens (STRs) as the first-line treatment. The four thriple-drug STRs include TAF/FTC/RPV (Odefsey), TDF/3TC/DOR (Delstrigo), ABC/3TC/DTG (Triumeq), and TAF/FTC/BIC (Biktarvy), while the dual-drug STR is DTG/3TC (Dovato). These combination drugs mainly consist of nucleoside reverse transcriptase inhibitors (NRTIs) combined with non-nucleoside reverse transcriptase inhibitors (nNRTIs) or integrase strand transfer inhibitors (INSTIs). According to our previous studies, most patients respond well to treatment, but a small number may experience treatment failure due to poor medication adherence, insufficient drug concentrations, or infection with drug-resistant viral strains. Without effective viral control, drug-resistant mutations may emerge in the infected population, potentially affecting subsequent drug choices. As the number of people receiving ART increases, the demand for effective treatment regimens will continue to grow in the coming decades, making it crucial to understand the prevalence of drug-resistant mutations in PWH with treatment failures and their impact. This subproject aims to provide drug resistance testing for newly-diagnosed and untreated PWH to guide subsequent drug adjustments and understand the prevalence of primary drug resistance in Taiwan and its impact on treatment effectiveness in newly-diagnosed patients. We will use Stanford University's "HIV Drug Resistance Database" for genotypic resistance analysis, analyzing drugs covering the first-line prescriptions, including reverse transcriptase inhibitors (RTIs), protease inhibitors, and INSTIs. We expect the results of this study to provide insights into the prevalence of primary drug resistance in Taiwan and the effectiveness of the first-line triple-drug or dual-drug STRs. For treatment failures, we will test for viral drug resistance to improve clinical treatment and provide policy references for the Taiwan Centers for Disease Control. Subproject Three With the advancement of antiretrovial therapy (ART), the survival rate of people with HIV (PWH) has greatly increased. However, if patients have low medication adherence, it can lead to uncontrolled viral loads, poor health status, and even viral drug resistance and/or increased risk of HIV transmission. In the era of highly effective ART, factors affecting medication adherence are divided into four categories: personal, medication-related, service and structural factors, and other factors. Research has shown that effective interventions to improve ART adherence have multiple aspects, including providing education, counseling, family and social support, feedback, and additional supervision. Services provided through various 3C electronic devices and information sent via text messages can intervene in multiple factors affecting medication adherence to improve drug compliance. Additionally, collaborating with community pharmacies to jointly supervise and remind patients of medication pick-up can also improve patient medication adherence. According to the results of a 2024 questionnaire study on difficult cases at the National Taiwan University Hospital, the majority (31.5%) stated that the reason for not returning for follow-up was "no time for follow-up," followed by emotional depression (23.6%). As for reasons for wanting to return for follow-up, over half (65.4%) stated "I should come back to face it myself," followed by (22.0%) "case managers or health center staff found me for follow-up." The main reason (62.2%) for patients missing doses was "forgetting to take medications," followed by (21.3%) "too tired and fell asleep." This subproject is a prospective study. If feasible, when the hospital opens video consultations in 2025, we will apply for video consultations for PWH, initially focusing on providing infectious disease clinic consultations, developing weekday morning and afternoon video consultations, recruiting willing infectious disease physicians, and then scheduling according to physician availability, coordinating with HIV case managers for follow-up. In addition, we will ask patients who meet the inclusion criteria if they are willing to participate in video consultations. If patients agree, video consultations will be completed according to the hospital's video consultation and medication dispensing procedures. At the same time, we will assist patients in obtaining medications smoothly in coordination with the hospital pharmacy's dispensing times. Furthermore, we will ask patients if they are willing to join a five-day-a-week communication device video or recorded directly observed therapy (DOT) to remind patients to take their medications, thereby developing a habit of taking medication on time. Subproject Four Given that comprehensive HIV screening and treatment are the focus of global efforts to control the HIV epidemic, despite continued promotion of HIV screening and PrEP use domestically and internationally, high-risk groups still cannot timely access HIV-related educational information, leading to delayed diagnosis. Among HIV PrEP users, personal, social, and structural barriers prevent potential PrEP users from obtaining information or leading to HIV infection after discontinuation of PrEP use. This subproject aims to utilize the LINE official platform and artificial intelligence technology to improve the accessibility of HIV screening, enhance PrEP medication adherence, and construct a case management model for high-risk groups. The main objectives include: (1) Enabling high-risk groups to easily access HIV screening information and schedule screenings through the LINE platform; (2) Providing PrEP users with medication reminders and intelligent response systems to help patients take medication on time and reduce discontinuation; (3) Establishing personalized intervention measures to ensure that the health needs of high-risk individuals are continuously offered and monitored. This subproject will develop a LINE platform combined with chatbots to provide 24-hour HIV screening, counseling, and PrEP use support, and promote related information to willing medical units. By leveraging the peer effect of high-risk groups, the platform's influence will be expanded to increase HIV screening rates and HIV PrEP knowledge prevalence, thereby effectively reducing the delayed HIV diagnosis and improving medication adherence issues. This subproject will also provide more extensive HIV prevention and treatment resources for the high-risk groups, such as sex workers, transgender individuals, and women, promoting increased screening rates and early diagnosis and treatment. Subproject Five As the global Mpox epidemic continues to develop, prevention and control strategies and their implementation effectiveness are the topics of concern. Vaccine administration and reducing intimate contact with the infected individuals are the most direct strategies for preventing Mpox transmission. However, these preventive behaviors are influenced by multiple factors, including individual demographic characteristics and health beliefs. Although international studies have proposed the potential influence of specific Mpox-related health beliefs on preventive behaviors, there is still a lack of systematic research on how health beliefs drive or hinder actual behaviors. This subproject aims to explore the health beliefs and needs of diverse gender groups regarding Mpox and their impact on Mpox-related preventive behaviors using a mixed-method approach. Among the populations that Mpox vaccination is recommended, detailed objectives include investigating and analyzing their (1) perceived susceptibility and perceived severity regarding Mpox, (2) perceived benefits, perceived barriers, self-efficacy, and cues to action regarding Mpox-related preventive behaviors, (3) implementation rates of safe sexual behaviors and Mpox vaccine uptake, (4) correlations between perceived susceptibility, perceived severity, perceived benefits, perceived barriers, self-efficacy, cues to action, and safe sexual behaviors and Mpox vaccine uptake, and (5) Mpox vaccine-related experiences and needs. Our team aims to achieve these objectives through a mixed-method study with an embedded design. The approach involves the National Taiwan University Infectious Diseases team first identifying potential research participants (i.e., individuals aged 18 and above who are eligible for publicly funded Mpox vaccination) from their patients, inviting them to complete an online questionnaire on Mpox-related health beliefs and behaviors, and then conducting purposeful sampling based on participants' willingness to participate in a subsequent qualitative descriptive study. Data collection for the qualitative research will involve semi-structured interviews to investigate participants' experiences, feelings, and needs regarding Mpox prevention and control. The estimated sample sizes for the quantitative and qualitative parts are 112 and 20 participants, respectively. The results of this subproject will provide a status report on Mpox-related health beliefs and preventive behavior implementation among diverse gender groups and attempt to identify their correlations to suggest the more precise prevention strategies. The qualitative data will complement the quantitative survey, aiming to bridge the gap between current strategies and public needs.