Combination antiretroviral therapy: Health care providers confront emerging dilemmas

Abstract

Recent editorials, conferences and clinical practice articles have discussed providers' concerns and practices regarding prescribing antiretroviral combination therapy for HIV. We aimed to deepen our understanding of these largely anecdotal reports and of the challenges facing experienced HIV clinicians today using qualitative methodology. Eight focus groups using a structured discussion guide were conducted. Data were analyzed by constant comparative analysis and open codes. Participants were a diverse group of 23 physicians, eight nurse practitioners and four physician assistants with significant experience providing care to HIV-seropositive patients in various San Francisco Bay Area health care settings. The following major themes emerged from the data: (1) providers expressed new optimism about helping HIV-seropositive patients live; (2) the main factors affecting providers' decisions about when to start combination therapy were the risks versus benefits of delaying therapy, and patients' health status, readiness to adhere and treatment preferences; (3) providers lacked resources to prepare patients to begin therapy and enhance adherence; (4) providers varied regarding assessment of adherence; and (5) providers were anxious about making decisions under conditions of uncertainty and were concerned about patient health outcomes. We concluded that experienced HIV clinicians were hopeful and excited about their increasing ability to help patients. This hope, however, was tempered by scepticism about the future and by their daily struggles to make treatment decisions under conditions of great uncertainty. Without access to adjunct supports or a multidisciplinary team, providers may not be able to optimally assess and enhance antiretroviral medication adherence.

Uncertainty and ‘technological horizon’ in qualitative interviews about HIV treatment

“…For example, some patients want to be actively involved in their HIV care, in keeping with the focus on the relationship or partnership-centred HIV clinical care (Gerbert et al, 2000;Race, 2001b). Active involvement in treatment is also reflective of the notion that people affected by HIV have resisted and re-deployed medical power, for example by increasing access to treatment and user involvement in clinical research and practice (Epstein, 1996).…”

“…Uncertainties in treatment outcomes can be reflected in self-reported stress and anxiety among clinicians (Williams et al, 2004). Gerbert et al (2000) advocate for 'relationship-centred HIV clinical care' as a way of managing treatment uncertainty, both for the patient and the clinician.…”

Strategies to Promote Adherence to Antiretroviral Therapy Applied by Dutch HIV Nurse Consultants: A Descriptive Qualitative Study

“…A qualitative study of 23 physicians, eight nurse practitioners, and four physician assistants aimed to deepen understanding of the challenges encountered in HIV care (Gerbert, Bronstone, Clanon, Abercrombie, & Bangsberg, 2000). The authors described factors that needed to be considered before initiating ART, including readiness and pretreatment strategies to enhance adherence such as education, placebo trial medication runs, and identification of cues as a reminder.…”

Early initiation of highly active antiretroviral therapies for AIDS: Dynamic choice with endogenous and exogenous learning

“…Paradoxically, it is in the case where expectations about resistance are rather optimistic (the phenomenon will be limited) that differences in estimations of this phenomenon may be a factor of variability in optimal treatment initiation. Because these conclusions are quite counter-intuitive, they may help clarify current inconsistencies between recommendations and practical behaviors of HIV/AIDS clinicians and public health experts on the one hand, and the expressed set of preferences and expectations of these same decision-makers, on the other hand (Gerbert et al, 2000).…”