Who Resists Starting ART Therapy for HIV?

A study found that the demographic characteristics of patients who failed to initiate ART within 2 years of entering care were not as important as clinical factors.

With the goal of preventing HIV transmission and disease progression, federal guidelines since early 2012 have suggested everyone who tests HIV positive should start on anti-retroviral treatment (ART).

Not everyone does. A new study concluded that its findings from data drawn from the pre-100% guideline era can be helpful in reducing the percentage of non-compliant patients now.

Unexpectedly, the study found that the demographic characteristics of patients who failed to initiate ART within 2 years of entering care were not as important as clinical factors.

“Higher CD4 count, lower viral load, and a prevalent AIDS diagnosis were clinical characteristics associated with delayed ART initiation," researchers wrote. "Gender, age, race/ethnicity, and HIV risk factors such as reported male-to-male sexual contact and injection drug use were not associated with delayed ART initiation.”

Over the 10-year study period, the only clinical factor associated with failure to initiate ART was lower viral load.

“Despite the known benefits of early antiretroviral therapy initiation, a lower viral load measurement may continue to be an important clinical characteristic in the more recent era with current ART initiation guidelines," researchers wrote. "These findings provide a target for closer monitoring and intervention to reduce disparities in HIV care."

The research was based on data for 4,907 HIV patients enrolled in 8 clinics across the country between January 2003 through December 2012 — for whom treatment was strongly-to-moderately recommended. All of the test subjects had not previously been on ART.

At the beginning of their inclusion in the study, these patients had CD4 counts of 350 cells/mm or below. CD4 cells are the white blood cells that kill infections like HIV. A normal count is considered to be in the 500 to 1,500 range. AIDS may be diagnosed when that count drops below 200.

Those with a CD4 count of at least 200 cells/mm at the beginning of their participation in the study were 1.3 times as likely to delay ART than those with counts of less than 200. From 2003 through 2012, 54.6% of the participants with CD4 counts less than 200 did not initiate ART.

Viral load is measured by the number of HIV RNA. A viral load is 10,000 HIV RNA per milliliter of blood and high load would be 100,000. At the beginning of their participation, patients with viral loads of less than10,000 were more likely to delay ART than those with a viral load of at least a 100,000. Across the entire study period, 26.3% of those with viral loads of 10,000 or less did not start ART and 37.3% of those with viral loads of 100,000 or more also were not ART initators.

An AIDS diagnosis also was not necessarily compelling in terms of many AIDS positive participants not initiating ART. In the group that started in 2003 to 2007, 64.3% did not begin ART. In the group that started participating in the study in the 2008 to 2012 period, 74.1% with AIDS diagnoses were not initiators.

“Though guidelines also recommended ART initiation for patients with an AIDS diagnosis, it is possible that our findings that a prevalent AIDS diagnosis was associated with delayed ART initiation could have resulted from a lower engagement in care,” researchers wrote.

Enrollment date was the only demographic factor that appeared to affect the willingness to start ART, according to the study.

Six percent of the participants who did not initiate ART within 2 years of enrolling died. In 2014, 12,333 people died of AIDs-related causes in the US, according to the US Centers for Disease Control and Prevention (CDC). ART has been credited increased longevity for people who are HIV positive, and making it more of a chronic condition than a terminal one.

"This prolonged delay in ART intiation among patients with moderate to strong recommendation under past guidelines suggests that treatment practice under current guidelines recommending therapy initiation to all HIV-seropositive patients should be carefully scrutinized," researchers wrote. "The tendency to delay therapy in those patients with lower viral load may still persist despite clear evidence of the benefits of immediate therapy initiation."

The study, "Risk factors for delayed antiretroviral therapy initiation among HIV-seropositive patients," was published online in PlosOne.

Related Coverage

Lesbian, Gay, Bisexual Adults Report Greater HIV Test Rates, Worse Health

One-third of Low Viral Load HIV Patients Avoid Treatment

5 HIV Breakthroughs Coming Down the Pipeline