Would use of specialists improve patient care?
Many patients not given recommended treatments
Even patients fortunate enough to be able to afford new treatments are often not being prescribed the correct regimens, particularly if their providers are less experienced in HIV treatment. This finding from a national survey raises once again the question of whether HIV treatment should become a specialized field.
Results from the first National HIV/AIDS Treatment Survey found that one-quarter of patients who begin HIV treatment are prescribed therapy that doesn't follow guidelines published last year by the U.S. Department of Health and Human Services. Moreover, the survey found that physicians with the least experience in treating HIV were more likely to delay treatment and prescribed fewer anti-HIV drugs than recommended by the guidelines.
"It is clear that physicians who receive new information and education on an ongoing basis are more likely to adopt and apply these treatment guidelines," says Paul Volberding, MD, director of the AIDS program at the University of California at San Francisco. "Likewise, patients who are more familiar with the health benefits related to new treatments will more likely seek and receive the most aggressive care."
The survey, conducted by Louis Harris & Associates with a grant from Merck & Co., questioned 476 physicians who treated HIV patients between January and March of this year. The results showed that 88% of physicians who had the most experience with HIV care were most likely to prescribe regimens that contained a protease inhibitor, compared to 60% for those with the least HIV-treatment experience. Experienced providers also were more likely to initiate treatment with three rather than two drugs.The federal guidelines recommend initiating treatment with three-drug therapy that includes at least one protease inhibitor.
The survey also confirmed the fact that women and minorities were less likely to receive care from HIV-treatment-experienced physicians than white men. In addition, more women and minorities showed symptoms of HIV and had higher viral loads when they began treatment compared to white men. For all patients, the least experienced physicians waited to begin treatment until viral loads reached an average of 33,000 copies, compared to less than 10,000 for the most experienced physicians.
The finding highlights the obstacles to treatment that may contribute to the increased rate of AIDS mortality. "Many of the more experienced physicians are not always easily accessible to this growing segment of the population most affected by HIV," Volberding notes.
One conclusion from the survey is that more providers and patients need to be educated in the scientific justification for early, potent therapy. Toward that end, the International AIDS Society-USA has sponsored numerous HIV education programs. More recently, the Infectious Diseases Society of America is creating its HIV Medical Association. Chaired by Volberding and Constance Benson, MD, professor of medicine at the University of Colorado, the association will help define the level of experience and commitment needed for quality HIV care.
On the positive side, the survey found that more physicians intend to include protease inhibitors in initial regimens in the near future. Nonetheless, the survey fuels recent debate over whether HIV care has become so complex that it should be relegated to specialists.1 Adding to the complexity is the lack of clear data on the benefits of early therapy, experts say.
Indeed, the delay of therapy and the use of suboptimal treatment may better reflect a lack of empirical survival benefit from early treatment than lack of knowledge about its theoretical benefits, they say.
"I think that reluctance has been in patients where there is concern about adherence, and you don't want to throw at them your most potent regimen if they are not ready to take it every day on schedule for the rest of their life," says Neal Graham, MD, director of HIV programs for Glaxo Wellcome of Research Triangle Park, NC. "When I talk to physicians, that is the issue they have, although in my mind there is no question that if you treat early you will have much better results - better viral-load suppression and better comeback of the immune system."
Neal Nathanson, MD, the incoming director of the National Institutes of Health's Office of AIDS Research, notes that the evidence for early treatment is not as widely accepted as perhaps it should be. He attended a recent meeting of AIDS experts in the United Kingdom, and was surprised to find such marked differences in opinion about early treatment.
"There was a knock-down, drag-out confrontation in which the Americans were telling the English they were being totally irresponsible not to treat their patients early," he tells AIDS Alert. "And the English were saying, 'I don't believe it. I am going to hold off and wait until my patients get sick.'"
One of the arguments the British put forth for delaying treatment is the problem with compliance and the fact that patients who are sick are more motivated to comply, he adds.
Indeed, a survey on HIV treatment adherence released in June found that patients who feel well are least likely to comply with their regimens. Conducted by Community Prescription Service, a New York City-based prescription service owned and operated by HIV-positive people, the survey conducted interviews with 400 people being treated for HIV. It found that 44% of respondents with CD4 counts above 300 reported missing a dose in the past week, compared to 30% for those with CD4 counts below 300.
"The survey suggests that the more we are removed from our illness, the less concerned we are about being strictly adherent," says Stephen Gendin, president of Community Prescription Service. "What we are seeing is a disturbing gap between people's perception of successful adherence and reality."
The survey also found that younger patients were more likely to skip medication. Nearly 58% of respondents younger than 35 years were non-adherent, compared to 34% for those 35 and older.
The combination of adherence problems and controversy over early treatment is making it a difficult time for HIV treatment providers, experienced or not, to provide clear guidance, experts say.
"There are strong arguments for treating early, but they are science arguments based on laboratory studies," Nathanson says, "and I think what is happening is that there is this other view, which is based on tangible things, particularly pushed by the AIDS communities but also by a lot of physicians."
While there is still debate over how soon treatment should start, John Bartlett, MD, chief of infectious diseases at Johns Hopkins University in Baltimore and co-chairman of the committee that wrote the federal guidelines, states that the goal of complete viral suppression is one grounded in good scientific evidence. "Not suppressing viral replication to the greatest extent possible means patients are more likely to experience symptoms of HIV, and their risk of developing an AIDS-related infection may be increased," he says.
Reference
1. Zuger A, Sharp V. 'HIV specialists': The time has come. JAMA 1997; 278:1,131.
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