Patients’ Preferences regarding the Timing of Highly Active Antiretroviral Therapy Initiation for Chronic Asymptomatic HIV-1 Infection

Abstract

Objective In patients with a chronic asymptomatic HIV-1 infection and >200 CD4+ T-cells/μl, the optimal timing of highly active antiretroviral therapy (HAART) initiation is unclear. It involves a trade-off between a potentially reduced risk of mortality, when started earlier in the course of infection, and an earlier exposure to pill burden and potential toxicities. We investigated patients’ preferences for immediate HAART initiation relative to delaying HAART for 1 year. Methods Consecutive patients were asked for their preference during an interview. A hypothetical difference in 3-year mortality risk between both options was systematically varied between 0% and 10% to determine the threshold at which preference would switch to HAART initiation. Results About 30% of patients preferred HAART initiation even if the mortality risk would be equal for both options. Almost 25% always preferred delaying HAART even if this would result in a 10% greater mortality risk. Most treatment guidelines recommend delaying HAART >350 CD4+ T-cells/μl However, at a risk difference between starting and delaying HAART that corresponds with this CD4+ T-cell count, about 50% would prefer to start HAART immediately. Most guidelines recommend starting HAART below 200 CD4+ T-cells/μl However, at a risk difference between both options corresponding with this CD4+ T-cell count, about 40% preferred delaying HAART. Conclusions We found large variation in patients’ preferences. Some patients were more inclined to initiate HAART earlier than the recommended guidelines, whereas others were more inclined to delay HAART. These findings emphasize the need for shared decision-making when deciding on the most optimal timing of HAART initiation in chronic asymptomatic HIV-1 infection.

Role of time and delay in health decision making.

“…Because the standard gamble procedure involves comparisons of probabilities that can be confusing to participants, psychological and behavioral economic studies of health preferences have relied almost exclusively on variations ofthe TTO method (e.g., Chapman, 2002;Locadia et al, 2006). The TTO method assesses the length of time in good health that participants consider equivalent to a period of time in bad health, typically followed by death.…”

“…In a study of preferences for nonfatal health outcomes over three delay intervals (2-5, 6-9, and 10-13 years), 67% of participants had positive time perspectives, and the rest had zero or negative time preferences (van der Pol & Cairns, 2000). Another study showed that a sizable minority of HIV-positive patients wanted to start highly active antiretroviral therapy earlier than recommended by treatment guidelines, even though it often has severe side effects (Locadia et al, 2006). Negative time preferences have also been associated with accepting flu shots and perceiving health outcomes as more serious, whereas positive time preferences have been associated with older age (Chapman et al, 2001;Shleinitz, DePalo, Blume, & Stein, 2006).…”

Dynamics of Patient-Based Benefit-Risk Assessment of Medicines in Chronic Diseases: A Systematic Review

“…32,37,38,[75][76][77]80,[83][84][85][86]91,92,94,95,97 However, not expectantly, previous experience of side effects was associated with patients becoming more risk averse. 64,[101][102][103][104][105][106][107][108] A model depicting the inter-relationship and dynamic impact of disease severity, disease duration and treatment experience on patients' preferences and risk tolerance in chronic disease is represented in Figure 2.…”