Why patients (and doctors) choose not to start HIV treatment

[buginme2]

Even though US guidelines recommend that people begin HIV treatment regardless of CD4 count there are still many patients ( and doctors ) that are forgoing starting treatment. 

I assumed that its a "fear of side effects."  After all there are probably a 1000 threads on this forum of people scared to start treatment.  And, it turns out that this was the major reason for delaying treatment prior to the year 2006. 

Since 2006 however, it appears now that the most common reason people don't start treatment when guidelines recommend that they start is because people don't "feel sick."  Even patients whose CD4 counts are less than 350 (the group who need medication the most) still said the main reason for not starting was that they didn't feel sick and "I rely on my body to tell me when to start."

Doctors are not scoring any better;
When asked to assess whether HIV treatment guidelines were suitable for each patient, physicians thought recommendations were suitable for their patients 93% of the time. However, when asked if ART was currently indicated for each patient, physicians who had a patient with a CD4+ cell count below 500 said 51% of the time that they should start treatment; among patients with a CD4+ cell count between 350 and 499 specifically, only 43% of their physicians said treatment was indicated. Unsurprisingly, for patients with a CD4+ cell count over 499, their physicians thought they should start ART only 16% of the time.

The main reasons doctors gave for not initiating treatment was they felt their patients were "too depressed" to begin or they felt they hadn't known their patient long enough. 

I dont know, I find this all so incredible.  Its hard for me and my brain to wrap my head around. 

http://www.thebodypro.com/content/73033/why-patients-and-their-doctors-choose-not-to-start.html?ic=700100

[xrel0aded]

My CD4 is 539 and I would start treatment if I didn't have to treat syphillis+TB first...How annoying. That is interesting though. At first, my main concern were the side effects, now it's just wrapping my head around having to take it every day. I've realized i'll never be comfortable with that, so starting once everything else is in order! good read

[OCPozGuy]

Interesting article and discussion.

I was lucky, if one can be lucky getting their diagnosis in that my primary care physician was also one of the leading HIV specialists in the county I live in.  So, he already knew me etc.

My CD4 count at the time in 2008 was not at the level that one would be considered to start treatment but my Dr was in the "camp" of Dr's at the time that believed you hit it early and hit it hard because you only have one immune system and once it's beaten down it's hard to build it back up.

His first question to me was can I be adherent to the regimen and I think there is one of the biggest concerns of those Dr's that don't know their patients and we all know adherence is key to keep fighting the virus.

That is the biggest takeaway I get from that article.   

[Dr.Strangelove]

Very interesting article.
Especially the part about the patients. I would have also thought it was the fear of side effects that lets people delay their treatment start. Shocking to see that 'I'm not yet feeling sick' and 'Ill' listen to my body' seem to be valid reasons for patients to not go on meds!

As for the doctors, I am not so surprised. I guess it's not so unusual that they don't abruptly change their ways, when a new guideline is released (although maybe they should). But yeah, 'He's too depressed' and 'I don't know the patient well, yet' don't exactly sound like a valid reason to delay therapy.

My doctor is gay and negative but he told me during our first meeting, if he would ever contract HIV he would start right away.

[bocker3]

Very interesting article.
Especially the part about the patients. I would have also thought it was the fear of side effects that lets people delay their treatment start. Shocking to see that 'I'm not yet feeling sick' and 'Ill' listen to my body' seem to be valid reasons for patients to not go on meds!

I think that the "I'm not yet feeling sick" and the fear of side effects overlap significantly.  You sort of see this when people stop antibiotics because their infection feels better, but they are having GI issues (not a perfect analogy, but illogical thinking just the same).

M

[Jeff G]

Although it was many years ago one reason I delayed treatment was because of being intimidated and scared of the healthcare system .

When you begin trying to understand medicare and medicaid and ADAP it dawns on you that its going to be your life for a very long time . It didn't occur to me then that allot of the details of getting on treatment wouldn't be something I had to deal with every single day , it just seemed so big and scary and permanent at the time . Also ASO's have come a long way now at helping people along .

I cant keep up with my car keys these days but boy do I remember those days .   

[Miss Philicia]

substance abuse, homelessness, post-incarceration, unemployed long term -- there's a laundry list of things that folks below the poverty level deal with that most of our lily white middle class asses forget about, and I include myself in that. Some folks are more busy trying to find a place to live and stretch their money to feed five children.

[bufguy]

When I was diagnosed in 2008 I was fortunate enough to have had a doctor prescribe atripla right away. The recommendation back then was anyone below 350 should start yet my CD4 was 511.
He remarked that I was educated, I had good insurance and he was confident I would be adherent.....Great decision...no side effects, healthy, consistently undetecatble and CD4 count as high as 1000.