When ART became available in Canada and other high-income countries in 1996, regimens were complex -- they had specific food and water requirements, contained many pills, had to be taken up to three times a day on an exact schedule and had many side effects.
Surveys of HIV-positive people around that time found that there were at least the following barriers to starting treatment:
Nearly 20 years after ART became available, therapy is much simpler (often once a day and there are entire regimens available in one pill), safer and more effective. However, there are still HIV-positive people who do not wish to start therapy, though there are many benefits to starting early. At the level of the individual, early use of ART can reduce the amount of HIV in the body. This reduction in HIV helps relieve ongoing damage to the immune system, brain, heart, lungs, kidneys and other vital organs and systems. At the level of thousands of people in a city or region (what researchers call "population level"), taking ART every day exactly as directed and getting regular checkups for sexually transmitted infections helps to greatly reduce the future risk for spreading HIV. This is an important benefit for the community.
Researchers in the European Union and Australia conducted a survey of HIV-positive patients and their doctors about perceived barriers to starting ART. Analysis of the survey results suggest that in the current era barriers to initiating therapy still exist but are different from those of the late 1990s. A primary barrier among HIV-positive people today is that they may not feel sufficiently unwell and they lack serious symptoms that would hasten their entry to treatment. Major reasons by doctors for delaying the initiation of ART include that they perceived some of their patients to be suffering from a degree of depression, that there was active substance use and that patients did not understand the need to adhere to HIV medicines.
Between November 2011 and October 2012 researchers recruited 508 HIV-positive patients with the following average profile:
Most participants had none or very mild symptoms of HIV disease and were distributed into the following CD4+ cell count ranges:
During the same period, 114 doctors were recruited, 60% of whom had at least 10 years of experience treating people with HIV.
All participants were administered an extensive survey about perceived barriers to initiating ART.
The main reason that HIV-positive people gave for delaying the start of ART was as follows:
This reason was relatively common regardless of CD4+ cell counts.
Another answer was that they would delay starting ART until symptoms occurred.
Interestingly, researchers stated that 47% of respondents did not wish to start therapy because they did not want to be reminded about their HIV status. This wish was also relatively common regardless of CD4+ count.
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