Capturing the paradigm shift in HIV treatment: changing attitudes in the choice of combination antiretroviral drugs by high HIV caseload Australian GPs (1996-1997)

Evolving views and practices of antiretroviral treatment prescribers in Australia

OBJECTIVE

To examine whether there have been recent changes in Australian antiretroviral treatment (ART) prescribers' perceptions and practices relating to early ART initiation, which was defined as commencing ART when a patient's CD4+ T-cell count approaches 500 cells/mm3 or immediately after a patient is diagnosed with HIV.

DESIGN, PARTICIPANTS AND SETTING

Self-completed, anonymous, cross-sectional surveys, targeting all ART prescribers in Australia, were conducted online in 2012 and 2013. The surveys included questions on prescriber factors, CD4+ T-cell count at which prescribers would most strongly recommend ART initiation, and perceived patient characteristics that could change prescribers' practices of early initiation of ART.

MAIN OUTCOME MEASURES

Proportions of ART prescribers recommending early ART initiation.

RESULTS

We analysed responses from 108 participants in 2012 and 82 participants in 2013. In both years, more male than female prescribers participated. The median age of participants was 49 years in 2012 and 50 years in 2013. In both rounds, over 60% had more than 10 years' experience in treating HIV-positive patients. More prescribers in 2013 stated that they would most strongly recommend early ART initiation compared with those in 2012 (50.0% [95% CI, 38.7%-61.3%] v 26.9% [95% CI, 18.8%-36.2%]; P=0.001). The prescribers' primary concern was more about individual patient than public health benefit. Out of 824 patients for whom ART was initiated, as reported by prescribers in 2013, only 108 (13.1% [95% CI, 10.9%-15.6%]) were given ART primarily to prevent onward HIV transmission. The number of patients for whom ART was initiated was significantly associated with prescribers' HIV caseload even after adjusting for prescriber type (adjusted odds ratio, 1.73 [95% CI, 1.47-2.03]; P<0.001); of the 37 who had initiated ART for 10 or more patients, 29 had a high HIV caseload. In 2013, 60 prescribers (73.2% [95% CI, 62.2%-82.4%]) reported that they routinely recommended ART to treatment-naive, asymptomatic patients with a CD4+ T-cell count of 350-500 cells/mm3.

CONCLUSION

Our findings show increasing acceptance of and support for early ART initiation primarily as treatment and not as prevention.

The association of perceived health, clinical status, and initiation of HAART (highly active antiretroviral therapy) in adolescents

PURPOSE

To examine factors associated with the initiation of highly active antiretroviral therapy (HAART) in adolescents to understand better how current National Institutes of Health (NIH) Guidelines are being used in practice.

METHODS

HIV infected and HAART-naive adolescents seen at 15 REACH clinical sites were selected. Repeated measures methodology using generalized estimating equations was applied to identify associations between subject demographic characteristics, risk behaviors, perceived health, and clinical status with the outcome measure of HAART initiation during the first 24 study months.

RESULTS

A total of 219 subjects were eligible for analysis; HAART was prescribed in 115 (53%). Significant univariate associations with HAART prescription included lower CD4(+) T cell counts (OR = 1.7, 95% CI: 1.1-2.6), higher viral loads (OR = 2.7, 95% CI: 1.5-5.0), and calendar year of HAART prescription (OR as high as 2.4, 95% CI: 1.1-5.2). Multivariate results showed that after controlling for CD4(+) T cell counts below 500 cells/mm(3), higher plasma HIV-1 RNA (<or=10,000 copies per ml), and temporal factors, having a high school diploma/GED but no further education (OR = 2.7, 95% CI: 1.3-5.5) and subject's perception of poor health status (OR = .987; 95% CI: .975- .999) were independently associated with prescription of HAART. HAART was most likely to be prescribed during the first half of 1998 in this cohort (OR = 10.8; 95% CI: 4.0-29.0).

CONCLUSIONS

In this first ever study of HAART prescription in adolescents infected with HIV, perception of poor health status and having a high school diploma/GED were independently associated with prescription of HAART suggesting that the personal decision to accept therapy is related to the belief that one's health is deteriorating and that the decision to prescribe therapy may be linked in some fashion to the prescriber's assessment of the patient's ability to master the regimen as well as clinical status.