TY - JOUR
T1 - Physician decisions to defer antiretroviral therapy in key populations
T2 - Implications for reducing human immunodeficiency virus incidence and mortality in malaysia
AU - Ferro, Enrico G.
AU - Culbert, Gabriel J.
AU - Wickersham, Jeffrey A.
AU - Marcus, Ruthanne
AU - Steffen, Alana D.
AU - Pauls, Heather A.
AU - Westergaard, Ryan P.
AU - Lee, Christopher K.
AU - Kamarulzaman, Adeeba
AU - Altice, Frederick L.
N1 - Funding Information:
We gratefully acknowledge the physicians who gave their time to participate in this study, the medical and research personnel at the Centre of Excellence for Research in AIDS and University of Malaya for their commitment to the study, and Paula Dellamura and the research personnel at the Yale AIDS Program for supporting this project. This work was supported by the National Institute on Drug Abuse (Grants R01 DA025943 and K24 DA017072 [to F. L. A.], K01 DA038529 [to J. A. W.], and K23 DA032306 [to R. P. W.]), the University of Malaya High Impact Research Grant (E-000001-20001; to A. K.), the National Institute of Allergy and Infectious Diseases and Fogarty International Center (Grant R25 TW009338; to G. J. C.), and Yale University
Publisher Copyright:
© The Author 2017.
PY - 2017
Y1 - 2017
N2 - Background. Antiretroviral therapy (ART) is recommended for all people living with human immunodeficiency virus (HIV), yet physician attitudes and prescribing behaviors toward members of key risk populations may limit ART access and undermine treatment as prevention strategies. Methods. Physicians in Malaysia (N = 214) who prescribe antiretroviral therapy (ART) responded in an Internet-based survey to hypothetical clinical scenarios of HIV patients, varying by key risk population and CD4+ T-cell count, on whether they would initiate or defer ART compared with a control patient with sexually acquired HIV. Results. The proportion of physicians who would defer ART in patients with advanced HIV (CD4 = 17 cells/μL) was significantly higher (P <.0001) for 4 key populations, including people who inject drugs ([PWID] 45.3%) or consume alcohol (42.1%), released prisoners (35.0%), and those lacking social support (26.6%), compared with a control patient (4.2%). People who inject drugs with advanced HIV (CD4 = 17 cells/μL) were 19-fold (adjusted odds ratio [AOR] = 18.9; 95% confidence interval [CI], 9.8-36.5) more likely to have ART deferred compared with the control. This effect was partially mitigated for PWID receiving methadone (AOR = 2.9; 95% CI, 1.5-5.7). At the highest CD4+ T-cell count (CD4 = 470 cells/μL), sex workers (AOR = 0.55; 95% CI,.44-.70) and patients with an HIV-uninfected sexual partner (AOR = 0.43; 95% CI,.34-.57) were significantly less likely to have ART deferred. Conclusions. Physicians who prescribe antiretroviral therapy in Malaysia may defer ART in some key populations including PWID and released prisoners, regardless of CD44 T-cell count, which may help to explain very low rates of ART coverage among PWID in Malaysia. Reducing HIV incidence and mortality in Malaysia, where HIV is concentrated in PWID and other key populations, requires clinician-level interventions and monitoring physician adherence to international evidence-based treatment guidelines.
AB - Background. Antiretroviral therapy (ART) is recommended for all people living with human immunodeficiency virus (HIV), yet physician attitudes and prescribing behaviors toward members of key risk populations may limit ART access and undermine treatment as prevention strategies. Methods. Physicians in Malaysia (N = 214) who prescribe antiretroviral therapy (ART) responded in an Internet-based survey to hypothetical clinical scenarios of HIV patients, varying by key risk population and CD4+ T-cell count, on whether they would initiate or defer ART compared with a control patient with sexually acquired HIV. Results. The proportion of physicians who would defer ART in patients with advanced HIV (CD4 = 17 cells/μL) was significantly higher (P <.0001) for 4 key populations, including people who inject drugs ([PWID] 45.3%) or consume alcohol (42.1%), released prisoners (35.0%), and those lacking social support (26.6%), compared with a control patient (4.2%). People who inject drugs with advanced HIV (CD4 = 17 cells/μL) were 19-fold (adjusted odds ratio [AOR] = 18.9; 95% confidence interval [CI], 9.8-36.5) more likely to have ART deferred compared with the control. This effect was partially mitigated for PWID receiving methadone (AOR = 2.9; 95% CI, 1.5-5.7). At the highest CD4+ T-cell count (CD4 = 470 cells/μL), sex workers (AOR = 0.55; 95% CI,.44-.70) and patients with an HIV-uninfected sexual partner (AOR = 0.43; 95% CI,.34-.57) were significantly less likely to have ART deferred. Conclusions. Physicians who prescribe antiretroviral therapy in Malaysia may defer ART in some key populations including PWID and released prisoners, regardless of CD44 T-cell count, which may help to explain very low rates of ART coverage among PWID in Malaysia. Reducing HIV incidence and mortality in Malaysia, where HIV is concentrated in PWID and other key populations, requires clinician-level interventions and monitoring physician adherence to international evidence-based treatment guidelines.
KW - Addiction
KW - Antiretroviral therapy
KW - HIV/AIDS
KW - Physician behavior
KW - Prisoner
UR - http://www.scopus.com/inward/record.url?scp=85014146341&partnerID=8YFLogxK
U2 - 10.1093/ofid/ofw219
DO - 10.1093/ofid/ofw219
M3 - Article
AN - SCOPUS:85014146341
SN - 2328-8957
VL - 4
JO - Open Forum Infectious Diseases
JF - Open Forum Infectious Diseases
IS - 1
M1 - ofw219
ER -
