Barriers to Universal Prescribing of Antiretroviral Therapy by HIV Care Providers in the United States, 2013–2014

Abstract

Introduction HIV treatment guidelines recommend initiating antiretroviral therapy (ART) regardless of CD4 cell (CD4) count, barring contraindications or barriers to treatment. An estimated 6% of persons receiving HIV care in 2013 were not prescribed ART. We examined reasons for this gap in the care continuum. Methods During 2013–2014, we surveyed a probability sample of HIV care providers, of whom 1234 returned surveys (64.0% adjusted response rate). We estimated percentages of providers who followed guidelines and their characteristics, and who deferred ART prescribing for any reason. Results Barring contraindications, 71.2% of providers initiated ART regardless of CD4 count. Providers less likely to initiate had caseloads ≤20 vs. >200 patients [adjusted prevalence ratios (aPR) 0.69, 95% confidence interval (CI): 0.47 to 1.02, P = 0.03], practiced at non–Ryan White HIV/AIDS Program-funded facilities (aPR 0.85, 95% CI: 0.74 to 0.98, P = 0.02), or reported pharmaceutical assistance programs provided insufficient medication to meet patients’ needs (aPR 0.79, 95% CI: 0.65 to 0.98, P = 0.02). In all, 17.0% never deferred prescribing ART, 69.6% deferred for 1%–10% of patients, and 13.3% deferred for >10%. Among providers who had deferred ART, 59.4% cited patient refusal as a reason in >50% of cases, 31.1% reported adherence concerns because of mental health disorders or substance abuse, and 21.4% reported adherence concerns because of social problems, eg, homelessness, as factors in >50% of cases when deferring ART. Conclusions An estimated 29% of HIV care providers had not adopted recommendations to initiate ART regardless of CD4 count, barring contraindications, or barriers to treatment. Low-volume providers and those at non–Ryan White HIV/AIDS Program-funded facilities were less likely to follow this guideline. Among all providers, leading reasons for deferring ART included patient refusal and adherence concerns.

Changing Clinician Practices and Attitudes Regarding the Use of Antiretroviral Therapy for HIV Treatment and Prevention

“…Our follow-up results regarding the percentage of providers who reported prescribing ART regardless of CD4 cell count (68%) were similar to the analogous population-based results from the Medical Monitoring Project surveying HIV clinicians from June 2013 to January 2014 (71%), 17 and those from a regional survey among infectious disease physicians in late 2013 (69%) 18 . However, our result (68%) was lower than the estimate from the September 2014 survey of infectious disease physicians in the US and Canadian Emerging Infections Network (87%) 19 .…”

Delivery of HIV Antiretroviral Therapy Adherence Support Services by HIV Care Providers in the United States, 2013 to 2014

“…A previous analysis indicated that providers with patient caseloads ≤20 were less likely to follow national and international guidelines for initiating ART. 28 These findings suggest that additional support for low-volume providers who manage antiretroviral treatment could be beneficial.…”

Qualifications, Demographics, Satisfaction, and Future Capacity of the HIV Care Provider Workforce in the United States, 2013–2014

“…It is well documented that providers with HIV caseloads in this range are less likely to follow antiretroviral treatment guidelines [20–22]. Among providers with caseloads of 21–50 patients, only 1 in 5 received assistance from an HIV expert, and of providers with the smallest caseloads (≤20 patients), just half received assistance from an HIV expert.…”