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| |  US Physicians Appear to Lag in Prescribing Antiretrovirals at Higher CD4-Positive Cell Counts: Presented at IDSA By Ed Susman VANCOUVER -- October 26, 2010 -- Compliance with new guidelines for earlier antiretroviral HIV therapy is not enthusiastic among doctors in the United States, according to results of a survey presented here at the 48th Annual Meeting of the Infectious Diseases Society of America (IDSA). New US guidelines suggest that doctors initiate therapy in patients with CD4-positive counts less than 500 cells/mcL. Even in 2008 when this survey was conducted -- when it was recommended to treat if the CD4-positive count was below 350 cells/mcL -- about one-third of patients with HIV infection who were in care were not getting antiretroviral therapy. Of that one-third of patients, half would have been eligible for antiretroviral therapy under the guidelines at that time. About 75% of these patients would be eligible for antiretroviral therapy under current guidelines, noted Julia Dombrowski, MD, MPH, Public Health Services of King County HIV/STD Control Program, Seattle, Washington. “Antiretroviral therapy is substantially underused even for persons engaged in HIV care,” said Dr. Dombrowski, speaking at an oral presentation here on October 22. “The reasons for this underuse are incompletely understood.” Session moderator, John Zurlo, MD, Penn State Hershey Medical Center, Hershey, Pennsylvania, commented, “I am not sure that all clinicians have bought into the idea that one should start antiretroviral therapy early. We have had a lot of disagreements over time as to [when to] begin therapy.” Dr. Dombrowski added, “We have accumulating evidence that antiretroviral therapy can prevent HIV transmission, leading to a lot of interest in the potential of antiretroviral treatment as prevention.” Over the years, different strategies for starting therapy have been advanced ever since clinical trials in the mid-1990s showed that HIV replication could be suppressed to undetectable levels and that, if patients were adherent to their treatment regimens, the disease could pass from being rapidly fatal to being chronic but controlled. In her study, Dr. Dombrowski examined records from The Centers for AIDS Research Network of Integrated Clinical Systems, in 8 sites in the United States; all are centres of excellence in HIV care. “This is a database that captures rapidly changing clinical practice. This is not a study population,” she explained. In 2008, the database cohort included 4,765 patients, 77% of whom had been on antiretroviral therapy. Of the remaining patients who were antiretroviral-naïve, 439 (9%) had CD4-positive counts below 350 cells/mcL. Of the other 667 patients, 336 had CD4-positive cell counts between 351 and 500, and 331 had cells counts greater than 500 cells/mcL. Depending upon the institution in the database, the percentage of patients on antiretroviral therapy ranged from 60% to 78% of the HIV patients at those facilities. [Presentation title: Growth in the Population of Antiretroviral Therapy (ART)-Naïve Persons With High CD4 Counts: An Expanding Clinical and Public Health Dilemma. Abstract 809]
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