Insurance, Age, Time of Treatment Impact HIV Prophylaxis Compliance

A lack of insurance and being an immigrant were found to lower the likelihood that a patient will comply with a prophylaxis regimen designed to prevent infection after exposure to HIV.

Stefano Malinverni, MD

A new study, published in The Journal of Infection, shed light on which patients are most likely to follow through on a critical post-exposure intervention against HIV.

Researchers in Belgium, including Stefano Malinverni, MD, corresponding author, looked at 5 years of data from a Brussels clinic to determine which patients underwent the full course of non-occupational post-exposure prophylaxis (nPEP) following possible exposure to HIV. The treatment can be effective at stopping HIV infection, but compliance can be a challenge because the therapy must be started within 72 hours of exposure, and requires twice-daily pills for 28 days.

The research team found that having health insurance, being older, and being a man who has sex with men increased the odds that a patient took the full course of nPEP. Conversely, not having health insurance and being an immigrant decreased the likelihood that a patient carried through with the treatment.

Overall, of the 1881 patients who started nPEP treatment, about two-thirds (66%) completed the course, and 87% showed up for their first follow-up appointment.

Malinverni, a resident physician at St. Pierre University Hospital, in Brussels, said the study should help physicians understand the need to take an individualized approach when explaining the treatment to patients.

“Globally we think that tailoring the intervention to the needs of the patients helps in increasing compliance,” he told MD Magazine.

When facing a patient who fits the profile of someone unlikely to follow through with treatment, Malinverni said physicians ought to take extra time to explain the importance of the treatment, and also to attempt to address any common barriers.

“In other words, if cost of follow-up might be a problem the patient should be informed of the exact costs he/she might face, putting him/her in contact with a social worker to see whether he/she could benefit from any form of payment support,” he said. “If access to care is more hindered by atypical working schedules or other time constraints, atypical arrangements for follow-up should be discussed with the patient.”

Insurance coverage was found to be a significant determinant of compliance, and Malinverni said it would make sense that cost would be a major cause of noncompliance among that group. However, he said the data available in the study wasn’t sufficient to specifically explicate the link between insurance and compliance. He said it could also be related to other things that tend to be associated with having health insurance, such as greater health literacy, higher education, and employment.

The effect of not having health insurance on compliance was particularly high when the patient was exposed to HIV as a result of sexual assault.

In a surprising finding, the research team also found that the time when a patient was first treated could also play a major role in the likelihood that the patient complies with the nPEP course of treatment. Patients who sought out help during the daytime were significantly more likely to follow through on their course of treatment.

Malinverni said his team was intrigued by the findings and scrutinized the data closely to try to understand why. They hypothesize that fatigue might be the reason.

“Compliance drops if patients consults at night when most of the senior staff is absent but does not drop during daytime in weekends when most of the senior staff is absent,” he said. “We could therefore infer that the problem is not about experience of the provider of nPEP but rather fatigue.”

Malinverni noted that fatigue could impact both doctor and patient — the provider might be less likely to be diligent about explaining the importance of the treatment, and the patient might be less likely to fully comprehend the information.

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