National Survey Documents Gap in Quality of HIV/AIDS Care

WASHINGTON--One in four Americans starting treatment for HIV infection does not receive care that meets the most up-to-date and recognized standards, according to the results of the first National HIV/AIDS Treatment Survey.

The survey found that white males are likely to be treated by the physicians most experienced with HIV/AIDS and to receive care that follows the guidelines developed by the US Department of Health and Human Services (HHS), Paul A. Volberding, MD, professor of medicine, University of California, San Francisco, said at a news briefing.

Women and minorities, on the other hand, are likely to receive their care from physicians less experienced in treating HIV/AIDS, he said. They are also the groups likeliest to receive care that does not follow the guidelines.

These findings indicate the need for increased efforts to educate physicians and patients about optimal HIV care, said John G. Bartlett, MD, professor of medicine and chief, Division of Infectious Diseases, Johns Hopkins University.

The survey, conducted by the Louis Harris polling organization and supported by a grant from Merck, studied the prescribing practices of 476 physicians currently caring for HIV/AIDS patients. The group’s demographic characteristics match those of American physicians generally. Of these practitioners, approximately half are primary care doctors and the rest are specialists in various fields, 38% in infectious diseases.

The sample of physicians was broken into five tiers according to their experience treating HIV/AIDS, with the most experienced fifth currently treating, on average, 349 HIV-positive patients at any given time. These patients constitute an average of 53% of the top-tier physicians’ practices. The fifth of the physicians with the least experience treating HIV/AIDS have an average of 59 HIV-positive patients at any given time, and those patients constitute 7% of their practices.

The HHS Guidelines

The HHS guidelines closely resemble guidelines developed by other expert groups, Dr. Bartlett said, and they are recognized as representing the best expert consensus on treatment. The guidelines recommend how physicians should most effectively use the 11 anti-HIV drugs now available, specifying when treatment should start, with which drugs, and when treatment should be changed, and to which agents, according to each level of viral load and immune suppression.

In general, Dr. Bartlett said, the guidelines favor aggressive treatment as early as possible. The preferred regimen consists of a protease inhibitor and two nucleoside analog reverse transcription inhibitors. It is recommended for anyone with HIV/AIDS symptoms, as well as for HIV-positive individuals without symptoms who meet standards of viral load and immune suppression, he said.

The surveyed physicians often did not follow the guidelines in their clinical practice, Dr. Volberding reported. Only 60% of the physicians in the least experienced fifth prescribed the three recommended medications at the start of treatment, he said, adding that those physicians also tend to begin treatment at a later stage of infection.

Indeed, when the patients seeing the least experienced fifth of physicians first receive treatment, they have viral loads on average more than three times greater than the loads of patients seeing the most experienced fifth of physicians.

More than a third of women, 42% of African-Americans, and 43% of Hispanic HIV patients have developed symptoms by the time their treatment starts, as opposed to 27% of white men, Dr. Volberding said. The survey did not track patient outcomes, he added, but experience shows that delays in beginning treatment and failure to use the recommended regimen place patients at greater risk of disease progression and ultimate death.

Despite the failure of many physicians to include protease inhibitors in their initial prescriptions today, almost 100% of those surveyed, regardless of their experience level, stated that they intend to be doing so a year from now. Only 60% of those in the least experienced fifth report doing so now, however, as opposed to 88% of those in the most experienced fifth, Dr. Volberding said.

HIV/AIDS differs from other fields of medicine because of its very high "velocity of information," Dr. Bartlett noted, with knowledge being added continuously and guidelines changing every few months. There is not, however, any credentialling for treating HIV/AIDS.

Belonging to an active information network is vital to keeping informed about the latest developments, he said. To help clinicians from various specialties keep abreast, the HIV Medicine Association is now being formed, and other education efforts are also needed.

Barriers to Care

Although the survey did not explore the barriers keeping patients from treatment, Drs. Bartlett and Volberding agreed that such barriers exist. For example, the current, very demanding recommended regimen is extremely difficult for many people to maintain, including those who work or must travel. Easier and more convenient regimens are being developed, Dr. Volberding said.

The survey did not consider patients’ economic circumstances, but it did ask about insurance. The physicians in the top experience tier had the highest proportion of patients with private health coverage, and those in the bottom experience tier had the highest proportion of patients with public coverage. Economics and insurance might very well be the "most important factor" regarding barriers to care, Dr. Volberding said.