Studies have found that within several months of initiating HIV treatment (ART) the amount of HIV in the blood usually falls to a very low level, so low that it cannot accurately be measured using routine laboratory tests. This low level of HIV is commonly called "undetectable." Achieving and maintaining an undetectable viral load helps to ensure better health. Furthermore, studies have found that people who take ART and achieve and maintain this degree of viral suppression do not transmit HIV to their sexual partners.
The dual effects of ART to improve the health of people with HIV and to help reduce the spread of HIV are so tremendous that the United Nations Joint Programme on HIV/AIDS (UNAIDS) has set goals to which cities, regions and countries can aspire by the year 2020. These goals are encompassed in the shorthand phrase 90-90-90:
- 90% of all people living with HIV will know their HIV status
- 90% of all people with diagnosed HIV infection will receive sustained antiretroviral therapy
- 90% of all people receiving antiretroviral therapy will have viral suppression
There are many steps necessary for people to achieve each target of 90-90-90 and to ultimately fulfill all of its goals. These steps are referred to as the "HIV cascade of care." Researchers are investigating these steps to assess if gaps are occurring and what can be done about them.
Researchers at the U.S. Centers for Disease Control and Prevention (CDC) and elsewhere have been analysing survey results from more than 1,000 healthcare providers to understand the reasons that they have not prescribed ART for their patients. Since 2012, leading HIV treatment guidelines in the U.S. have stated that doctors should offer ART to all HIV-positive people (regardless of their CD4+ cell count). The survey, which was sent out to participants between June 2013 and January 2014, uncovers some barriers that explain why not all patients have been prescribed ART. Common reasons disclosed by the doctors included: patient refusal, the presence of addiction and/or mental health issues, and social issues such as homelessness. The CDC researchers noted that these barriers can be overcome so that the health of HIV-positive people is improved and the spread of HIV is reduced.
The research team designed a survey and sent it to more than 1,000 healthcare providers working in over 500 clinics and hospitals in 16 states and one territory in the United States. A majority (75%) of the care providers were physicians (usually infectious disease specialists or family doctors) and the remaining were nurse providers and physician assistants. The survey had 61 questions and took about 30 minutes to complete.
Results -- Provider-Related Factors
Most providers (71%) disclosed that they initiated ART regardless of their patients' CD4+ cell count. Among the remaining 29% of providers, researchers found that the following factors were linked to them restricting initiation of ART depending on the CD4+ count of patients:
- having 20 or less HIV-positive patients in their care
- working at clinics or hospitals that did not receive federal funding from the Ryan White HIV/AIDS program
- disclosing that pharmaceutical companies' patient assistant programs "did not provide sufficient medication to meet their patients' needs"
Exploring Reasons for Deferring Initiation of ART
When the study team asked providers why they delayed or deferred initiation of ART in their patients, the major responses were as follows:
- patient refusal
- concerns about their patients' ability to take ART every day exactly as prescribed and directed because of "substance abuse or mental illness or social problems such as homelessness"
The CDC researchers noted that other surveys of HIV healthcare providers have also found that those with relatively small numbers of HIV-positive patients tended not to adhere to HIV treatment guidelines. To remedy this, they suggested that health authorities could help facilitate support and training of care providers. One possibility suggested by the CDC researchers was to pair these providers with "highly experienced providers." This type of service is available through specialty medical associations. They also said that the training arm of the Ryan White program provides "a national network of HIV experts offering education, clinical consultation and technical assistance."
Focus on Patients
The CDC researchers found that the most common reason that providers declined to prescribe ART was because patients refused to initiate it.
As part of a parallel project during the period that doctors were being surveyed, HIV-positive patients were interviewed about ART. The CDC found that there was a common reason patients gave for not initiating ART -- because of advice from their doctors.
Taken together, these reports from providers and patients seem contradictory. However, the CDC researchers point to another study in which pairs of doctors and their HIV-positive patients were separately interviewed about ART. Researchers made the following points from this study:
- "Many patients were not taking ART because they had internalized messages from their providers over time."
- Providers who "practiced patient-centered care often [downplayed] the offer of ART, at times unintentionally."
- "Patients reported that providers had not strongly advised them to take ART and many said that such a clear recommendation would be necessary [for them] to initiate ART."
To deal with the issues uncovered by the interviews with patients, the CDC researchers said: "Future HIV treatment and prevention guidelines should recommend that providers strongly advise all patients to initiate ART barring medical [reasons that it should not be initiated] or [other barriers]."
Addiction and Mental Health
According to the CDC researchers, "concern about the effects of substance abuse and mental health disorders on [patients' ability to take ART every day] was the second most common reason that doctors decided to defer prescribing the initiation of ART."
The researchers underscored that while addiction and mental health issues can affect adherence, they can also be treated and managed and their impact on adherence can be minimized.
Although care providers cannot resolve homelessness, the researchers noted that studies have found that some homeless people can have rates of adherence that are similar to people who are not homeless.
Bear in Mind
- The CDC survey of providers was done before the release of the groundbreaking results of the START study in mid-2015. In that study, researchers randomly assigned HIV-positive participants to either initiate ART immediately (regardless of CD4+ cell count) or delay initiation until their immune system was degraded. Analysis of the results of START showed that immediate initiation of ART was associated with improved measures of health and a reduced risk of infections and cancer. It is therefore possible that as the results of START continue to diffuse across networks of care providers, in the future more providers will strongly encourage initiation of ART as soon as possible.
- The CDC study was based on self-reported behaviour by healthcare providers. It is possible that some of them may have given inconsistent or incorrect information, as the researchers were not able to examine medical records or interview patients of these providers.
Regardless of these potential drawbacks, the CDC researchers have uncovered barriers to the wider use of ART that were present at the time of the survey. It is unlikely that these barriers have completely disappeared. In the quest to achieve the 90-90-90 targets, more attention will have to be paid to gaps within the HIV cascade of care.
Why some HIV-positive people may be reluctant to start therapy -- TreatmentUpdate 210
Going beyond current ideas about the cascade of HIV care -- CATIE News
Progress on Ontario's HIV care cascade -- CATIE News
Alberta -- Reducing deaths by strengthening the HIV Treatment Cascade -- CATIE News
Gaps in British Columbia's HIV treatment cascade -- CATIE News
Canada's progress towards global HIV testing, care and treatment goals -- CATIE News
The HIV treatment cascade -- patching the leaks to improve HIV prevention -- Prevention in Focus
The Engagement Cascade -- The Positive Side
Summary: Measuring Canada's Progress on the 90-90-90 HIV Targets -- Public Health Agency of Canada
90-90-90 -- An ambitious treatment target to help end the AIDS epidemic -- UNAIDS
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