Objective: Recent advances in antiretroviral therapy have led to effective but increasingly complex strategies for the treatment of HIV infection. In a previous study, we demonstrated that physicians' experience in the care of patients with AIDS improves survival. We conducted this study to determine whether greater physician experience is associated with earlier adoption and appropriate use of new antiretroviral treatment regimens.
Design: Retrospective medical record review of a population-based sample of HIV-infected individuals who received antiretroviral treatment between December 1995 and May 1997 by primary care physicians practicing throughout the state of Washington. We classified antiretroviral regimens observed into one of four categories based on national treatment guidelines.
Results: The use of new antiretroviral treatment regimens significantly increased during the study period; 22% of patients were treated with a protease inhibitor (PI)-based regimen or an alternative PI-or nonnucleoside reverse transcriptase inhibitor (NNRTI)-based regimen between December 1995 and November 1996, compared with 57% between April and May 1997 (p < .001). After controlling for CD4 count and the calendar period of treatment, patients cared for by physicians with greater HIV experience were significantly more likely to receive PI-based regimens or alternative PI-or NNRTI-based antiretroviral regimens (p = .02). Use of PI-based regimens was also associated with lower CD4 count (p < .001) and treatment after January 1997 (p = .02), but independent of patient demographic characteristics and the geographic location of physicians' practices.
Conclusions: Greater physician experience in the care of persons with HIV infection is associated with earlier adoption of new antiretroviral treatment regardless of whether physicians practice in a rural or urban area.
Antiretroviral treatment strategies and clinical outcomes for persons with HIV infection are rapidly changing. The development of new classes of antiretroviral drugs (1,2), simultaneous advances in our understanding of viral dynamics (1,3-6) and the ability to measure plasma HIV-1 RNA level as a measure of an individual's risk of disease progression (7-12) and response to treatment (6,13) have led to more effective and increasingly complex strategies for use of antiretroviral medications in combination (14-18).
Physicians and their patients have had to assimilate and apply continuously emerging information about new antiretroviral medications and therapeutic approaches. In response to the rapid accumulation of scientific data and resulting uncertainty regarding the optimal approach to treatment, expert panels were convened by the International AIDS Society-USA, the National Institutes of Health (NIH), the U.S. federal Department of Health and Human Services (DHHS) and the Henry J. Kaiser Family Foundation in the United States, and the British HIV Association (BHIVA) in England to synthesize research advances and develop guidelines to aid clinicians and patients in making complex antiretroviral treatment decisions (19-27). Before evidenced-based guidelines were available, physicians could learn about advances in treatment from various sources including scientific meetings, medical journals, and in consultation with more experienced physicians caring for persons with HIV disease.
In a previous study, conducted before potent combination antiretroviral therapy was available, we demonstrated that physicians' experience in the care of persons with AIDS was associated with survival among their patients (28). As antiretroviral treatment becomes increasingly complex, physicians' level of HIV expertise may have an even greater impact on patient outcomes. We hypothesized that physicians with greater experience caring for persons with HIV infection would be more likely to prescribe antiretroviral regimens consistent with the latest advances in treatment. In this study, we examined the changing pattern of antiretroviral treatment provided to a cohort of HIV-infected patients after the introduction of potent combination antiretroviral therapy to determine whether greater physician experience was associated with earlier adoption and appropriate use of new antiretroviral treatment regimens.