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Barriers to Universal Prescribing of Antiretroviral Therapy by HIV Care Providers in the United States, 2013–2014

Weiser, John MD, MPH; Brooks, John T. MD; Skarbinski, Jacek MD; West, Brady T. PhD; Duke, Christopher C. PhD; Gremel, Garrett W. BS; Beer, Linda PhD

JAIDS Journal of Acquired Immune Deficiency Syndromes: April 15th, 2017 - Volume 74 - Issue 5 - p 479–487
doi: 10.1097/QAI.0000000000001276

Introduction: HIV treatment guidelines recommend initiating antiretroviral therapy (ART) regardless of CD4 cell (CD4) count, barring contraindications or barriers to treatment. An estimated 6% of persons receiving HIV care in 2013 were not prescribed ART. We examined reasons for this gap in the care continuum.

Methods: During 2013–2014, we surveyed a probability sample of HIV care providers, of whom 1234 returned surveys (64.0% adjusted response rate). We estimated percentages of providers who followed guidelines and their characteristics, and who deferred ART prescribing for any reason.

Results: Barring contraindications, 71.2% of providers initiated ART regardless of CD4 count. Providers less likely to initiate had caseloads ≤20 vs. >200 patients [adjusted prevalence ratios (aPR) 0.69, 95% confidence interval (CI): 0.47 to 1.02, P = 0.03], practiced at non–Ryan White HIV/AIDS Program-funded facilities (aPR 0.85, 95% CI: 0.74 to 0.98, P = 0.02), or reported pharmaceutical assistance programs provided insufficient medication to meet patients' needs (aPR 0.79, 95% CI: 0.65 to 0.98, P = 0.02). In all, 17.0% never deferred prescribing ART, 69.6% deferred for 1%–10% of patients, and 13.3% deferred for >10%. Among providers who had deferred ART, 59.4% cited patient refusal as a reason in >50% of cases, 31.1% reported adherence concerns because of mental health disorders or substance abuse, and 21.4% reported adherence concerns because of social problems, eg, homelessness, as factors in >50% of cases when deferring ART.

Conclusions: An estimated 29% of HIV care providers had not adopted recommendations to initiate ART regardless of CD4 count, barring contraindications, or barriers to treatment. Low-volume providers and those at non–Ryan White HIV/AIDS Program-funded facilities were less likely to follow this guideline. Among all providers, leading reasons for deferring ART included patient refusal and adherence concerns.

Supplemental Digital Content is Available in the Text.

*Division of HIV/AIDS Prevention, Centers for Disease Control and Prevention, Atlanta, GA;

Survey Research Center, University of Michigan, Ann Arbor, MI; and

Altarum Institute, Ann Arbor, MI.

Correspondence to: John Weiser, MD, MPH, Division of HIV/AIDS Prevention, Centers for Disease Control, 1600 Clifton Road NE, MS E46, Atlanta, GA 30329 (e-mail:

Funding for the Medical Monitoring Project is provided by the Centers for Disease Control and Prevention.

The authors have no funding or conflicts of interest to disclose.

The findings and conclusions in this report are those of the authors and do not necessarily represent the views of the Centers for Disease Control and Prevention.

The following are contributions of the authors to the study: J.W. contributed to study conception, data analysis, and wrote the article; J.T.B., J.S., and L.B. contributed to study conception and edited the article; G.W.G. and C.C.D. contributed to data analysis, writing, and edited the article; B.T.W. contributed to survey weighting, data analysis, writing, and edited the article.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Web site (

Received July 30, 2016

Accepted November 09, 2016

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