Weiser John, Brooks John T, Skarbinski Jacek, West Brady T, Duke Christopher C, Gremel Garrett W, Beer Linda
*Division of HIV/AIDS Prevention, Centers for Disease Control and Prevention, Atlanta, GA; †Survey Research Center, University of Michigan, Ann Arbor, MI; and ‡Altarum Institute, Ann Arbor, MI.
J Acquir Immune Defic Syndr. 2017 Apr 15;74(5):479-487. doi: 10.1097/QAI.0000000000001276.
HIV treatment guidelines recommend initiating antiretroviral therapy (ART) regardless of CD4 cell (CD4) count, barring contraindications or barriers to treatment. An estimated 6% of persons receiving HIV care in 2013 were not prescribed ART. We examined reasons for this gap in the care continuum.
During 2013-2014, we surveyed a probability sample of HIV care providers, of whom 1234 returned surveys (64.0% adjusted response rate). We estimated percentages of providers who followed guidelines and their characteristics, and who deferred ART prescribing for any reason.
Barring contraindications, 71.2% of providers initiated ART regardless of CD4 count. Providers less likely to initiate had caseloads ≤20 vs. >200 patients [adjusted prevalence ratios (aPR) 0.69, 95% confidence interval (CI): 0.47 to 1.02, P = 0.03], practiced at non-Ryan White HIV/AIDS Program-funded facilities (aPR 0.85, 95% CI: 0.74 to 0.98, P = 0.02), or reported pharmaceutical assistance programs provided insufficient medication to meet patients' needs (aPR 0.79, 95% CI: 0.65 to 0.98, P = 0.02). In all, 17.0% never deferred prescribing ART, 69.6% deferred for 1%-10% of patients, and 13.3% deferred for >10%. Among providers who had deferred ART, 59.4% cited patient refusal as a reason in >50% of cases, 31.1% reported adherence concerns because of mental health disorders or substance abuse, and 21.4% reported adherence concerns because of social problems, eg, homelessness, as factors in >50% of cases when deferring ART.
An estimated 29% of HIV care providers had not adopted recommendations to initiate ART regardless of CD4 count, barring contraindications, or barriers to treatment. Low-volume providers and those at non-Ryan White HIV/AIDS Program-funded facilities were less likely to follow this guideline. Among all providers, leading reasons for deferring ART included patient refusal and adherence concerns.
艾滋病病毒治疗指南建议，无论CD4细胞计数如何，在没有治疗禁忌证或治疗障碍的情况下，都应启动抗逆转录病毒治疗（ART）。2013年，估计有6%接受艾滋病病毒治疗的人未接受ART治疗。我们研究了治疗连续过程中出现这一差距的原因。
在2013年至2014年期间，我们对艾滋病病毒治疗提供者进行了概率抽样调查，其中1234人回复了调查问卷（调整后的回复率为64.0%）。我们估计了遵循指南的提供者的百分比及其特征，以及因任何原因推迟开具ART处方的提供者的百分比。
在没有禁忌证的情况下，71.2%的提供者无论CD4细胞计数如何都启动了ART。病例量≤20例与>200例患者的提供者启动治疗的可能性较小[调整后的患病率比值（aPR）为0.69，95%置信区间（CI）：0.47至1.02，P = 0.03]，在非瑞安·怀特艾滋病病毒/艾滋病项目资助的机构执业的提供者（aPR为0.85，95%CI：0.74至0.98，P = 0.02），或报告药物援助项目提供的药物不足以满足患者需求的提供者（aPR为0.79，95%CI：0.65至0.98，P = 0.02）。总体而言，17.0%的提供者从未推迟开具ART处方，69.6%的提供者为1%至10%的患者推迟，13.3%的提供者为超过10%的患者推迟。在推迟ART治疗的提供者中，59.4%在超过50%的病例中提到患者拒绝是一个原因，31.1%报告由于精神健康障碍或药物滥用而担心依从性，21.4%报告由于社会问题（如无家可归）而担心依从性，这些是在超过50%的推迟ART治疗的病例中的因素。
估计有29%的艾滋病病毒治疗提供者未采纳在没有禁忌证或治疗障碍的情况下无论CD4细胞计数如何都启动ART的建议。病例量少的提供者以及在非瑞安·怀特艾滋病病毒/艾滋病项目资助的机构的提供者遵循该指南的可能性较小。在所有提供者中，推迟ART治疗的主要原因包括患者拒绝和对依从性的担忧。
