WASHINGTON--One in four Americans starting treatment for HIV
infection does not receive care that meets the most up-to-date and
recognized standards, according to the results of the first National
HIV/AIDS Treatment Survey.
The survey found that white males are likely to be treated by the
physicians most experienced with HIV/AIDS and to receive care that
follows the guidelines developed by the US Department of Health and
Human Services (HHS), Paul A. Volberding, MD, professor of medicine,
University of California, San Francisco, said at a news briefing.
Women and minorities, on the other hand, are likely to receive their
care from physicians less experienced in treating HIV/AIDS, he said.
They are also the groups likeliest to receive care that does not
follow the guidelines.
These findings indicate the need for increased efforts to educate
physicians and patients about optimal HIV care, said John G.
Bartlett, MD, professor of medicine and chief, Division of Infectious
Diseases, Johns Hopkins University.
The survey, conducted by the Louis Harris polling organization and
supported by a grant from Merck, studied the prescribing practices of
476 physicians currently caring for HIV/AIDS patients. The
groups demographic characteristics match those of American
physicians generally. Of these practitioners, approximately half are
primary care doctors and the rest are specialists in various fields,
38% in infectious diseases.
The sample of physicians was broken into five tiers according to
their experience treating HIV/AIDS, with the most experienced fifth
currently treating, on average, 349 HIV-positive patients at any
given time. These patients constitute an average of 53% of the
top-tier physicians practices. The fifth of the physicians with
the least experience treating HIV/AIDS have an average of 59 HIV-positive
patients at any given time, and those patients constitute 7% of
The HHS Guidelines
The HHS guidelines closely resemble guidelines developed by other
expert groups, Dr. Bartlett said, and they are recognized as
representing the best expert consensus on treatment. The guidelines
recommend how physicians should most effectively use the 11 anti-HIV
drugs now available, specifying when treatment should start, with
which drugs, and when treatment should be changed, and to which
agents, according to each level of viral load and immune suppression.
In general, Dr. Bartlett said, the guidelines favor aggressive
treatment as early as possible. The preferred regimen consists of a
protease inhibitor and two nucleoside analog reverse transcription
inhibitors. It is recommended for anyone with HIV/AIDS symptoms, as
well as for HIV-positive individuals without symptoms who meet
standards of viral load and immune suppression, he said.
The surveyed physicians often did not follow the guidelines in their
clinical practice, Dr. Volberding reported. Only 60% of the
physicians in the least experienced fifth prescribed the three
recommended medications at the start of treatment, he said, adding
that those physicians also tend to begin treatment at a later stage
Indeed, when the patients seeing the least experienced fifth of
physicians first receive treatment, they have viral loads on average
more than three times greater than the loads of patients seeing the
most experienced fifth of physicians.
More than a third of women, 42% of African-Americans, and 43% of
Hispanic HIV patients have developed symptoms by the time their
treatment starts, as opposed to 27% of white men, Dr. Volberding
said. The survey did not track patient outcomes, he added, but
experience shows that delays in beginning treatment and failure to
use the recommended regimen place patients at greater risk of disease
progression and ultimate death.
Despite the failure of many physicians to include protease inhibitors
in their initial prescriptions today, almost 100% of those surveyed,
regardless of their experience level, stated that they intend to be
doing so a year from now. Only 60% of those in the least experienced
fifth report doing so now, however, as opposed to 88% of those in the
most experienced fifth, Dr. Volberding said.
HIV/AIDS differs from other fields of medicine because of its very
high "velocity of information," Dr. Bartlett noted, with
knowledge being added continuously and guidelines changing every few
months. There is not, however, any credentialling for treating
Belonging to an active information network is vital to keeping
informed about the latest developments, he said. To help clinicians
from various specialties keep abreast, the HIV Medicine Association
is now being formed, and other education efforts are also needed.
Barriers to Care
Although the survey did not explore the barriers keeping patients
from treatment, Drs. Bartlett and Volberding agreed that such
barriers exist. For example, the current, very demanding recommended
regimen is extremely difficult for many people to maintain, including
those who work or must travel. Easier and more convenient regimens
are being developed, Dr. Volberding said.
The survey did not consider patients economic circumstances,
but it did ask about insurance. The physicians in the top experience
tier had the highest proportion of patients with private health
coverage, and those in the bottom experience tier had the highest
proportion of patients with public coverage. Economics and insurance
might very well be the "most important factor" regarding
barriers to care, Dr. Volberding said.