Krakower Douglas S, Beekmann Susan E, Polgreen Philip M, Mayer Kenneth H
Division of Infectious Diseases, Beth Israel Deaconess Medical Center.
The Fenway Institute, Fenway Health, Boston, Massachusetts.
Clin Infect Dis. 2016 Jan 1;62(1):99-105. doi: 10.1093/cid/civ736. Epub 2015 Sep 18.
US Public Health Service guidelines recommend early initiation of antiretroviral treatment (ART) for human immunodeficiency virus infection (HIV)-infected patients and preexposure prophylaxis (PrEP) as a prevention option for persons at risk for HIV acquisition. Before issuance of these guidelines, few clinicians reported prescribing early ART or PrEP.
The Emerging Infections Network, a national network of infectious diseases physicians in the United States and Canada, was surveyed in September 2014 to assess practices of adult HIV-care providers with early ART, PrEP, and other guideline-recommended HIV prevention methods.
Almost half of the 1191 active members invited (48.1%) participated; 415 (72.4%) were HIV-care providers. Most providers (86.5%) indicated that they typically recommended ART initiation at diagnosis, irrespective of CD4(+) cell count. However, for patients with a CD4(+) cell count >500/µL, clinicians would defer ART if patients did not feel ready to initiate ART (94.7%) or had uncontrolled substance abuse (66.0%). Many providers had counseled HIV-infected patients about PrEP for partners (59.0%) or offered visits for partners to discuss PrEP (40.7%), and 31.8% had prescribed PrEP. Clinicians who deferred ART were less likely to endorse and engage in aspects of PrEP provision.
Concordant with guidelines, most infectious diseases physicians recommend early ART, and many have experience with aspects of PrEP provision, suggesting recent evolution of clinician practices. Providers who defer ART are also cautious about PrEP. Interventions that help physicians motivate patients to initiate ART and identify missed opportunities to provide PrEP could enhance HIV prevention.
美国公共卫生服务指南建议，对于感染人类免疫缺陷病毒（HIV）的患者应尽早开始抗逆转录病毒治疗（ART），并将暴露前预防（PrEP）作为预防HIV感染高危人群感染的一种选择。在这些指南发布之前，很少有临床医生报告开具早期ART或PrEP处方。
2014年9月对新兴感染网络（美国和加拿大传染病医生的全国性网络）进行了调查，以评估成人HIV护理提供者在早期ART、PrEP及其他指南推荐的HIV预防方法方面的实践情况。
受邀的1191名活跃成员中近一半（48.1%）参与了调查；415名（72.4%）为HIV护理提供者。大多数提供者（86.5%）表示，他们通常建议在诊断时开始ART，无论CD4(+)细胞计数如何。然而，对于CD4(+)细胞计数>500/µL的患者，如果患者觉得尚未准备好开始ART（94.7%）或存在未得到控制的药物滥用情况（66.0%），临床医生会推迟ART。许多提供者已就为伴侣提供PrEP向HIV感染患者提供咨询（59.0%）或为伴侣安排就诊以讨论PrEP（40.7%），31.8%的提供者已开具PrEP处方。推迟ART的临床医生不太可能认可并参与PrEP提供的各个方面。
与指南一致，大多数传染病医生推荐早期ART，许多医生在PrEP提供的各个方面有经验，这表明临床医生的实践最近有所演变。推迟ART的提供者对PrEP也持谨慎态度。有助于医生激励患者开始ART并识别提供PrEP的错失机会的干预措施可能会加强HIV预防。
