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Initiating ART in Reluctant Patient
How I Approach Patients Who Are Reluctant to Initiate ART

Released: September 08, 2015

Expiration: September 06, 2016

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Although the guidelines for antiretroviral therapy (ART) in HIV-infected adults and adolescents issued by the DHHS recommend ART for all patients regardless of CD4+ cell count, they also emphasize that patients should be willing and able to commit to ART and should understand the associated risks and benefits of treatment, as well as the potential consequences of nonadherence. For this reason, the guidelines note that clinicians may elect to defer initiating ART on a case-by-case basis. In the case under discussion, a 35-year-old HIV-infected woman in good health with a CD4+ cell count of 995 cells/mm3 and HIV-1 RNA of 17,525 copies/mL is reluctant to initiate therapy. Of note, she is originally from South Africa and her husband died of multidrug-resistant tuberculosis (MDR-TB). She was diagnosed with HIV infection 3 years ago, and her CD4+ cell count has declined from 1175 cells/mm3 at the time of diagnosis. She has no children and no current sexual partners and has missed some appointments due to difficulty getting time off from work.

Empirical Evidence From the START Trial
Although there is certainly no urgency to starting ART in this patient, there are several reasons to continue working with the patient to convince her of the importance of initiating ART. To begin with, the recently completed START trial now provides conclusive evidence that starting ART in patients with CD4+ cell counts > 500 cells/mm3 prevents disease progression and reduces mortality. Of note, the majority of clinical events in the placebo arm occurred in participants with CD4+ cell counts > 500 cells/mm3, and many of the events were cases of TB. Given our patient’s history of exposure to MDR-TB, preventing TB is an important reason to begin ART. In addition, approximately one half of participants in the control arm of START had begun ART within 3 years of enrollment. The CD4+ cell decline in our patient, although not yet at a concerning rate, could be presented to her as evidence of the ongoing damage to her immune system caused by untreated HIV infection.

Treatment as Prevention
Another important point is the role of ART in preventing sexual transmission of HIV, as demonstrated in HPTN 052. Although our patient is not currently in a sexual relationship, sexual encounters may occur unexpectedly. Moreover, being on suppressive ART might provide the patient with greater confidence and reduced stigma associated with becoming involved in a sexual relationship, which is an important part of general health and well-being for most people in their mid-30s.

Benefits of Good Adherence
Lastly, although adherence is a concern, there are several first-line regimens that have a very low risk of antiretroviral drug resistance upon virologic failure, including the recommended regimens darunavir/ritonavir plus tenofovir DF/emtricitabine and the single-tablet regimen dolutegravir/abacavir/lamivudine. Moreover, the patient can be encouraged that if she does well on ART, she may be able to reduce the frequency of her clinic visits to just twice per year.

Successful treatment of HIV infection is a joint venture between patient and clinician. The most immediate goal with this patient is to develop rapport and trust while continuing to educate her about the benefits of ART and the reasons for initiating ART while she is still healthy.

Your Thoughts?
How do you engage patients who are reluctant to initiate ART? I encourage readers to post their thoughts and experiences in the comments section below. And if you want to learn more about how my colleagues and I make treatment decisions for patients such as the one discussed here, as well as in several additional patient scenarios, I invite you to attend an upcoming satellite at the Interscience Conference of Antimicrobial Agents and Chemotherapy titled, “How the HIV Experts Treat: Evidence-Based Strategies for Individualizing ART Regimens.” On Saturday, September 19, in San Diego, California, I will gather with my colleagues Eric S. Daar, MD; Joseph J. Eron, Jr., MD; and Sally Hodder, MD, for an interactive case-based discussion of how we select ART for treatment-naive and virologically suppressed patients.

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Have recent data from the START trial influenced how you counsel patients who are reluctant to initiate ART?
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