Three-quarters of clinicians in the US willing to prescribe early HIV treatment for the purpose of prevention

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 others.

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 start therapy.

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 partners.

“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.”

Kurth AE et al. Clinical practices and attitudes regarding early antiretroviral therapy in the US. J Acquir Immune Defic Syndr, online edition. DOI: 10.1097/QAD0b013e31826a184c, 2012.