Impact of Medical and Nonmedical Factors on Physician Decision Making for HIV/AIDS Antiretroviral Treatment [Bogart LM, et al. JAIDS 2000; 23: 396]: The authors from the University of Wisconsin Medical School conducted a survey to determine decision making regarding HAART. The data were collected from the membership of the Infectious Diseases Society of America using a random sampling. Results are based on responses from 495, which represents 53% of the 935 who received the survey. The questions concerned factors that influenced decisions regarding antiretroviral agents including medical findings such as viral load, nonmedical issues such as homelessness and guidelines, specifically the DHHS guidelines for HIV treatment. About 90% of the respondents were aware of the DHHS guidelines. Of those who used the CD4 cell count to determine the time to initiate therapy, 81% used the threshold of 500 cells/mm³. Of those who used viral load to make this decision, 64% used a threshold of 10,000 - 20,000 copies/mL. The number using viral load for this decision (402) was greater than the number using the CD4 cell count (285). Nonmedical issues that dissuaded respondents from prescribing HAART therapy were: if a patient missed his/her last three appointments (85%), a history of noncompliance with prior ART (92%), heavy alcohol use (85%), current heroin use (80%) and homelessness (62%). The authors conclude that life situations have a major impact on decisions regarding antiretroviral therapy despite numerous studies showing that physicians are poor at predicting adherence.
Comment: An interesting feature of the study that was the fact that 40% of respondents reported that they do not actually follow treatment guidelines. However, their responses to queries indicate that they seem to. The disparity is ascribed to the incorporation of nonmedical factors in the decision making process. Given the movement of the HIV epidemic to disenfranchised patients, it is clear that the physician respondents in this survey are likely to exclude a large number of patients from HAART based on decisions about "life situations." posted 7/19/2000