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There is an overwhelming consensus
among clinicians who prescribe HIV treatment in the US that people who are
taking antiretroviral therapy are less likely to transmit HIV to their sexual
partners, according to results of a study published in the online edition of
the Journal of Acquired Immune Deficiency Syndromes. Results also showed that
over three-quarters of care providers would be willing to prescribe early
therapy to people with an HIV-negative partner for the purposes of prevention.
The study involved 165 prescribing
clinicians working at HIV clinics in the Bronx, New York, and Washington DC. It
was conducted in 2010 and 2011, well before the publication of the results of
the HPTN 052 study in the summer of 2012, which showed that virologically
suppressive HIV treatment reduced the risk of transmission by 96%. US HIV
treatment guidelines were updated in 2012 to endorse early treatment to reduce
the risk of transmission.
“This survey of HIV clinicians in
two US cities found most clinicians believe that ART [antiretroviral therapy]
can reduce HIV transmission, even before the results of HPTN 052 demonstrated
ART to be effective for this purpose, and before 2012 treatment guideline
changes recommending ART for patients at risk for HIV transmission,” write the
authors.
The research was conducted because
the investigators wished to establish the beliefs of prescribing clinicians
(doctors, nurse-practitioners and physician assistants) about the efficacy of
antiretroviral therapy when used as prevention and their willingness to
prescribe early treatment for individuals at risk of transmitting HIV to
others.
Clinicians were recruited from centers
participating in the HPTN 065 study, the main purpose of which is to evaluate
the feasibility of community-expanded testing, linkage to care and treatment
adherence as an HIV prevention strategy. The study does not involve early
initiation of HIV therapy for prevention purposes.
Participants completed an
internet-based survey. They had a median age of 46 years, 59% were women and
two-thirds were white. The clinicians were highly experienced and had been
caring for HIV-positive people for a median of 13 years. The overwhelming
majority of their patients (85%) were already taking antiretroviral treatment
and 6% of healthcare providers stated that all their patients were on therapy.
Overall, the clinicians showed an
interest in the HIV risk behaviors of their patients. Three-quarters indicated
that they regularly asked their patients about the HIV status of their sexual
partners; 97% always or often enquired about condom use; and two-thirds stated
that they enquired about injecting drug use.
Almost all (95%) of the clinicians
strongly agreed or agreed that “early initiation of ART can slow the spread of
HIV in a community by making patients less infectious to others”.
The participants were asked about
their current prescribing practices. Most (92%) stated that they initiated
treatment for the patient’s own health and based on the readiness of the
individual to start therapy.
A small proportion of clinicians
(15%) indicated that they recommended treatment at any CD4 cell count. The
majority (56%) indicated that their current practice was to suggest treatment
when a patient’s CD4 cell count fell below 500 cells/mm3.
A substantial majority (79%) of
clinicians said that they would be more likely to recommend starting HIV therapy,
irrespective of CD4 cell count, if a patient disclosed behavior that involved a
high risk of transmission. Three-quarters said they would be willing to offer
early treatment if a patient had a partner who was HIV-negative.
However, a substantial proportion of
clinicians had reservations about the early use of therapy. Just under half
(47%) had concerns that this could lead to resistance and 52% were concerned
about the risk of side-effects. A little under a third (30%) had concerns that
early treatment could result in the transmission of drug-resistant virus to sex
partners.
“There remains an inherent tension
in prescribing ART to individuals for a population-benefit, when the
risk-benefit profiles of multidecades-long treatment are not yet available,”
comment the investigators. “Nonetheless there is emerging evidence that ART
initiation at higher CD4 counts may have individual benefit.”
They conclude, “our findings suggest
that clinicians will need to continue to balance information regarding efficacy
of ART for prevention, with their duty to provide patients with interventions
that have a favorable long-term benefit to their own health.”
The Friends of AIDS Foundation is
dedicated to enhancing the quality of life for HIV positive individuals and
empowering people to make healthy choices to prevent the spread of the HIV
virus. To learn more about The Friends of AIDS Foundation, please visit: http://www.friendsofaids.org.
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