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US HIV physicians routinely offering early ART but only a third have prescribed PrEP
Michael Carter, 2015-10-06 09:20:00
Most doctors at
the frontline of the HIV epidemic in the United States recommend early
antiretroviral therapy (ART) and many also believe they have a role in
providing pre-exposure prophylaxis (PrEP) to the uninfected partners of their patients living with HIV, according to research published in the online edition of Clinical Infectious Diseases. Overall,
87% of doctors recommended ART from the point of diagnosis and most
thought PrEP appropriate in some circumstances. However, only a third had
actually prescribed PrEP.
ART is an
important component of HIV prevention strategies. There is now overwhelming
evidence that virologically suppressive ART reduces the risk of HIV
transmission to negligible levels. PrEP has also been shown to substantially
reduce the risk of infection with HIV for at risk HIV-negative gay men and
guidelines have recommended early ART since 2012 and in May 2014 the Centers for Disease Control and Prevention (CDC)
released comprehensive guidelines concerning the use of PrEP.
before the release of these guidelines showed that few frontline doctors were
offering early ART and that even fewer had experience of offering PrEP.
Investigators wanted to see if this had now changed. They therefore surveyed
clinicians involved in the Emerging Infections Network, an association of
infectious diseases physicians in the US and Canada. In May 2014 members were
sent a questionnaire about use of early ART, their experience of PrEP and the provision
of other recommended HIV prevention interventions, for instance clean syringes
and opioid substitution for people who inject drugs.
Of the 1191 active
members in the network, 573 responded (48%). A total of 415 respondents (72%)
were HIV care providers.
majority of HIV providers (87%) indicated that they typically recommend ART
from the time of HIV diagnosis, irrespective of CD4 count. However, 11% said
they waited until a patient’s CD4 count dropped below 500 cell/mm3
and 2% delayed therapy until the 350 cell/mm3 threshold.
Lack of patient
readiness was the main reason (95%) why doctors would not initiate ART when a
patient had a CD4 count above 500 cells/mm3. Two-thirds would delay
therapy in the context of uncontrolled drug or alcohol abuse, 49% if a patient
would have problems meeting the cost of ART, and 45% when individuals had
untreated mental health problems.
The majority of
physicians (69%) believed that decisions about starting ART should be shared
between themselves and patients.
Turning to PrEP,
80% of providers said they would recommend PrEP if a patient living with HIV had a
detectable viral load, was unwilling to start ART and was in a sexual
relationship with a HIV-negative partner with inconsistent condom use.
Sub-optimal ART adherence by the partner with HIV was cited as a reason for
recommending PrEP by three-quarters of physicians, but only 33% endorsed the
use of PrEP in the context of an undetectable viral load.
where a mixed HIV status couple were trying to conceive, 24% of doctors
reported that in addition to ART for the partner with HIV, PrEP had also
been used. Approximately a fifth reported that couples had attempted to
conceive without the use of PrEP and 16% reported the use of sperm washing or
considered aspects of PrEP provision to be part of their clinical role. This
included counselling their patients who have HIV about PrEP (87%), offering
appointments to discuss PrEP with HIV-negative partners (71%) and prescribing PrEP
(68%). However, only 59% of physicians had actually talked to their patients
about PrEP, even fewer (41%) had offered appointments to HIV-negative partners
and less than a third (32%) had ever prescribed PrEP.
Half of physicians
would prefer that doctors and patients shared decisions about the use of PrEP
but 36% believed that patient preferences should guide decision making.
“Because only 59%
of the study sample had actually counseled HIV-infected patients about PrEP,
and only 1 in 3 respondents had prescribed PrEP to partners, clinicians may
still be missing opportunities to provide PrEP,” comment the authors.
When asked about
other recommended methods of HIV prevention, 80% said they had offered sterile
needles and 68% had offered opioid substitution therapy routinely. However, only 42%
thought that PrEP should be routinely offered to HIV-negative individuals who
inject drugs, and just 24% felt adequately prepared to prescribe PrEP to drug
deferred ART were less likely than providers who recommended early therapy to
believe that they had a role counselling their patients who have HIV about PrEP
(p = 0.002), discussing PrEP with partners (p = 0.02) or prescribing PrEP (p =
“The findings of
this study suggest that most infectious diseases providers who are HIV
specialists in the United States generally recommend early ART and that many
also perceive a role for themselves in providing PrEP to partners of their
HIV-infected patients. However, only 1 in 3 clinicians had prescribed PrEP to
partners, [and] many do not feel prepared to deliver protective interventions
to PWID,” conclude the authors. “Investing in interventions to optimize
practices among frontline infectious diseases specialists could have an appreciable
impact on the HIV epidemic.”