All patients had been under the care of their surveyed physician for at least 180 days. The median age was 37 and 84% were male. About 67% had been diagnosed between one and four years ago, while 28% had been diagnosed five or more years ago. In terms of transmission route, 67% contracted the virus via homosexual sex, 25% via heterosexual sex and 6% via needle sharing. The median viral load was 10,000 copies/mL.
The patients were broken down into three groups based on CD4+ cell count: 8% had below 350 cells/mm3, 27% had between 350 and 499, and 65% had greater than or equal to 500.
Generally, the physicians were well experienced in providing care for HIV: 59% had 10 or more years of experience, 19% had five to nine years of experience and 18% had one to four years of experience. Additionally, over 90% of the physicians had more than 50 patients under their care.
Previous survey data taken between 1996 and 2006 found that patients' main concerns were fear of side effects, high pill burden and problems integrating ART into everyday life. For physicians, treatment guidelines regarding ART initiation changed frequently during that period.
In the current study, after analyzing all questionnaire results, the researchers found that the most common reasons patients selected for not starting ART were "I rely on my body to tell me when to start," and "lack of symptoms." This was particularly true for the group with a CD4+ cell count below 350, arguably the patients that need antiretrovirals the most. Overall, 47% of all three CD4+ cell count groups stated that they "didn't want to think about HIV."
In terms of readiness, for the two groups with a CD4+ cell count below 500, 50% said they "were not ready" for treatment and about 33% were "ambivalent" toward it.
On the physician side, the main reasons for not starting a patient with a CD4+ cell count below 350 were the perception that the patient was too depressed and that the patient didn't understand "key disease issues." For the group with a CD4+ cell count between 350 and 499, physicians primarily withheld treatment because they felt they had not known the patient long enough or that the patient was too depressed to start medications. In the group with a CD4+ cell count over 499, physicians also commonly felt they had not known the patient long enough.
When asked to assess whether HIV treatment guidelines were suitable for each patient, physicians thought recommendations were suitable for their patients 93% of the time. However, when asked if ART was currently indicated for each patient, physicians who had a patient with a CD4+ cell count below 500 said 51% of the time that they should start treatment; among patients with a CD4+ cell count between 350 and 499 specifically, only 43% of their physicians said treatment was indicated. Unsurprisingly, for patients with a CD4+ cell count over 499, their physicians thought they should start ART only 16% of the time.
The study had some limitations, such as a low number of patients in the group with a CD4+ cell count below 350 and lack of analysis regarding potential cultural differences in this cross-continental survey. Nonetheless, these results shed light on some of the current thinking behind why HIV-infected patients and their physicians defer starting therapy. These reasons differ from those in the past, when toxicity and high pill counts were the main barriers to treatment initiation.
The researchers conclude that, particularly with changing guidelines and more patients being approached to start treatment, these new barrier patterns should be taken into consideration.
Warren Tong is the research editor for TheBody.com and TheBodyPRO.com.
Follow Warren on Twitter: @WarrenAtTheBody.
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