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BACKGROUND: Antiretroviral treatment (ART) improves the health and prolongs the lives of persons with HIV. The current U.S. HIV treatment guidelines support initiation of ART for persons with HIV for their personal health benefit and to prevent transmission of HIV infection. However, to maximize individual and public health benefits, high levels of adherence to ART are critical. This analysis examines the types of clinical and nonclinical barriers to ART initiation for clinically-eligible individuals, and the patient- and provider-related factors associated with these barriers among HIV-infected patients in Houston/Harris County, Texas.
METHODS: Data used for this analysis was based on a probability sample of HIV Care clinicians (HCC) in 13 outpatient facilities in Houston/Harris County, Texas surveyed between June and September of 2009. An inductive thematic approach was used to code clinicians’ responses to the open-ended question that asked the main reasons why they may delay initiating ART in patients who are clinically eligible. These resulted in the classification of the reasons into four main themes (behavioral, psychosocial, structural and clinical condition) and nine subthemes.
RESULTS: HIV care clinicians generally delayed ART for patients because of concerns about adherence. The nonclinical reasons given by HCC for delaying ART were related to behavioral (45.7%), psychosocial (28.3%), structural (13.0%) concerns. Only 13% of the HCC reported delaying ART because of the patients’ clinical conditions. Under behavioral concerns, 57.1% of the HCC reported patients’ refusal or none readiness and poor appointment adherence (28.6%) as the main reasons for delaying ART. Psychosocial concerns were mostly related to substance abuse (53.8%) and chaotic and unstable lifestyle (30.8%). HCC and patients characteristics were associated with nonclinical reasons for delaying ART among clinically eligible HIV-infected patients.
CONCLUSIONS: The findings highlight the fact that clinical guidelines are only a starting point for medical decision making and point to the important roles that patients themselves have to play. Clinicians access to referrals for other medical issues and support services, and patient treatment education may help to improve adherence and patient readiness for therapy.