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
Clinicians were recruited from centres
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 behaviours 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
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 behaviour 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
“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 favourable long-term benefit to their own health.”